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Essence Advantage Choice (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Essence Advantage Choice (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Essence Advantage Choice (PPO) in 2025, please refer to our full plan details page.
Essence Advantage Choice (PPO) is a PPO plan offered by Lumeris Group Holdings Corporation available for enrollment in 2025 to people living in Southwest Missouri and Northwest Arkansas. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Essence Advantage Choice (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Essence Advantage Choice (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Essence Advantage Choice (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $295.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $5500.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $5500.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Essence Advantage Choice (PPO) plan has a $295.00 deductible for prescription drugs. After the deductible is met, you'll pay a copay or coinsurance depending on the drug tier and pharmacy used. For preferred generic drugs, you'll pay a $3.00 copay at a preferred pharmacy or a $12.00 copay at a standard pharmacy. Standard generic drugs have a $47.00 copay at both preferred and standard pharmacies. For preferred brand drugs, you'll pay 46% coinsurance, and for non-preferred drugs, you'll pay 29% coinsurance.
Additional Benefits
The Essence Advantage Choice (PPO) plan offers a wide range of benefits, including coverage for inpatient and outpatient services, with varying copays. You'll pay a $275 copay for inpatient hospital stays for days 1-5, and no copay for days 6-90. Outpatient services have a $210 copay, and primary care visits have a $20 copay. This plan also covers ambulance services, emergency services, and offers vision, hearing, and dental benefits. Hearing exams have a $20 copay, and vision exams have a $30 copay. Dental services include a $30 copay for Medicare dental, with additional coverage up to $1340 per year.
Inpatient Hospital See details
Inpatient Hospital benefits include Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization. For Inpatient Hospital-Acute, the copay is $275 for days 1-5 and no copay for days 6-90. For Inpatient Hospital Psychiatric, the copay is $295 for days 1-5 and no copay for days 6-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services for the Essence Advantage Choice (PPO) plan cover outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services, observation services, and ASC services have a $210 copay, while individual outpatient substance abuse sessions have a $15 copay, and group sessions have a $10 copay.
Partial Hospitalization See details
Partial hospitalization is covered by the Essence Advantage Choice (PPO) plan, but requires prior authorization. There is no information provided about the cost of this benefit, such as copays or coinsurance.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Essence Advantage Choice (PPO) plan. Ground and Air Ambulance Services have a copay of $240, and there is no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Essence Advantage Choice (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, while Urgently Needed Services have a $45 copay; all services have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Essence Advantage Choice (PPO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $40 copay, physician specialist services with a $30 copay, mental health specialty services with a copay of $15 for individual sessions and $10 for group sessions, physical therapy and speech-language pathology services with a $40 copay, opioid treatment program services with a minimum $15 copay, and additional telehealth benefits. This plan does not cover podiatry services.
Preventive Services See details
The Essence Advantage Choice (PPO) plan covers preventive services including annual physical exams and other preventive services. Additional preventive services require prior authorization, and may include a copay. The plan also covers Remote Access Technologies with a copay between $0 and $40, and Fitness Benefit. However, the plan does not cover Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services.
Hearing Services See details
Hearing services include hearing exams, with a $20 copay, and prescription hearing aids, with a maximum benefit of $1000 every two years, but do not cover OTC hearing aids, Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear.
Vision Services See details
Vision Services include eye exams with a $30 copay. Eyewear is covered with a combined maximum benefit of $300 per year, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Upgrades are not covered.
Dental Services See details
Essence Advantage Choice (PPO) offers dental services, including a $30 copay for Medicare dental services. Other dental services are covered with a maximum plan benefit of $1340 per year, and the plan covers oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. Other Medicare Part B drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Essence Advantage Choice (PPO) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment is covered under the Essence Advantage Choice (PPO) plan, with Durable Medical Equipment (DME) subject to 20% coinsurance and requiring prior authorization, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies are covered with 20% coinsurance, while Diabetic Supplies are not covered. Diabetic Therapeutic Shoes/Inserts are covered with 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures/tests with a copay between $0 and $30, and diagnostic radiological services with a copay of at most $200. Outpatient X-ray services have a $20 copay, and therapeutic radiological services have a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the Essence Advantage Choice (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan states that Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Prior authorization is required, and there is a copay for some services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Essence Advantage Choice (PPO) plan, but require prior authorization. There is no copay for days 1-20, and a $160 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services are not covered by the Essence Advantage Choice (PPO) plan, including acupuncture, over-the-counter items, meal benefits, and several other services. No authorization or referral is required for these services.
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