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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 Little Rock Metropolitan Area. 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 $6500.00 (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 $6500.00 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 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For preferred generic drugs, you'll pay a $3 copay at preferred pharmacies and a $12 copay at standard pharmacies. Preferred brand drugs have a 46% coinsurance, while non-preferred drugs have a 29% coinsurance.
Additional Benefits
The Essence Advantage Choice (PPO) plan offers a range of benefits, including coverage for inpatient and outpatient hospital services, with varying copays. The plan also covers primary care, preventive, hearing, vision, and dental services, each with specific copay amounts. Additionally, the plan offers home health services with no copay, but does not cover other services like acupuncture, over-the-counter items, or meal benefits. This plan provides coverage for emergency services, ambulance services, and skilled nursing facilities, with specific copays or coinsurance amounts. Diagnostic and radiological services have copays, while medical equipment and dialysis services have a coinsurance. The plan also covers home infusion, cardiac rehabilitation services, and partial hospitalization.
Inpatient Hospital See details
Inpatient Hospital services are covered by the Essence Advantage Choice (PPO) plan, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with prior authorization required. For Inpatient Hospital-Acute, you will pay a $260 copay for days 1-4, and no copay for days 5-90, while for Inpatient Hospital Psychiatric, you'll pay a $300 copay for days 1-5, and no copay for days 6-90. Additional days for both are covered, but non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital and observation services have a $245 copay, ASC services have a $205 copay, and outpatient substance abuse services have copays of $15 for individual sessions and $10 for group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered by the Essence Advantage Choice (PPO) plan, with a $50 copay. Prior authorization is required.
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 $240 copay, and there is no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the Essence Advantage Choice (PPO) plan, with a $110 copay for Emergency Services and Worldwide Emergency Coverage, and a $40 copay for Urgently Needed Services. 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 for routine care, occupational therapy services with a $40 copay, physician specialist services with a $30 copay, and mental health specialty services with a $15 copay for individual sessions and a $10 copay for group sessions. The plan does not cover podiatry services. It also covers other health care professionals with a copay of $30, psychiatric services with a $15 copay for individual sessions and a $10 copay for group sessions, physical therapy and speech-language pathology services with a $40 copay, additional telehealth benefits, and opioid treatment program services with a $15 copay.
Preventive Services See details
The Essence Advantage Choice (PPO) plan covers preventive services, including annual physical exams, other preventive services, kidney disease education services, and other preventive services. Additional preventive services require prior authorization, and have a copay for Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline). The plan does not cover health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, 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 fitting/evaluation for hearing aids, as well as prescription hearing aids, with a maximum plan benefit of $1000 every two years for both in-network and out-of-network services; however, the plan does not cover prescription hearing aids for the inner ear, outer ear, or over the ear, nor does it cover OTC hearing aids.
Vision Services See details
Vision services include coverage for eye exams with a $30 copay, and routine eye exams once per year. Eyewear is covered up to a combined maximum of $200 per year for both in-network and out-of-network services, while contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are also covered. Upgrades are not covered.
Dental Services See details
The Essence Advantage Choice (PPO) plan covers dental services, with a $30 copay for Medicare Dental Services and a yearly maximum benefit of $1,100 for both in-network and out-of-network services. 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 are all covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B insulin drugs, there is a $35 copay, and a coinsurance between 0% and 20%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Essence Advantage Choice (PPO) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment is covered by the Essence Advantage Choice (PPO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, and Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a 20% coinsurance, while Diabetic Equipment is covered with a coinsurance for Medicare-covered Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic procedures and tests, with a copay between $0 and $30, and diagnostic radiological services, with a copay up to $200. Therapeutic radiological services have a 20% coinsurance, and outpatient X-ray services have a $15 copay. Lab services are not covered.
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. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover any of the sub-services, including Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Essence Advantage Choice (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $170. Additional days beyond Medicare-covered, and non-Medicare-covered stays for SNF 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 more. No referrals or authorizations are required for additional services.
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