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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 Lexington and Louisville Metropolitan Areas. 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 $6150.00 (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 $6150.00 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 an enhanced alternative drug benefit. The plan has a deductible of $295. After the deductible is met, you will pay the following costs for drugs in each tier until your total drug costs reach $2000. For preferred generic drugs, you will pay a $3 copay at a preferred pharmacy and a $12 copay at a standard pharmacy. For standard generic drugs, the copay is $47 at both preferred and standard pharmacies. For preferred brand drugs, you pay 46% coinsurance, and for non-preferred drugs, you will pay 29% coinsurance. After your yearly out-of-pocket drug costs reach $2000, you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The Essence Advantage Choice (PPO) plan offers comprehensive coverage for a variety of healthcare needs. This plan includes coverage for inpatient hospital stays, with copays ranging from $315 to $375, depending on the service and the length of stay. Outpatient services, such as hospital visits and substance abuse treatment, have copays ranging from $10 to $295. Additional benefits include coverage for ambulance services with a $245 copay, emergency services with copays from $45 to $135, and a wide range of primary care and specialist services. The plan also covers vision, hearing, and dental services, along with home health and skilled nursing facility care. However, it's important to note that this plan does not cover cardiac rehabilitation, acupuncture, or certain other services.
Inpatient Hospital See details
Inpatient Hospital coverage under the Essence Advantage Choice (PPO) plan includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization. For Inpatient Hospital-Acute, you will pay a copay of $315 for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, you will pay a copay of $375 for days 1-4, and no copay for days 5-90. Additional days are covered for both services. 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 services, outpatient substance abuse services, and outpatient blood services. Outpatient Hospital and Observation Services have a $295 copay, Ambulatory Surgical Center Services have a $255 copay, and Individual and Group Substance Abuse Sessions have a copay between $10 and $15.
Partial Hospitalization See details
Partial Hospitalization is covered under the Essence Advantage Choice (PPO) plan, with a $45 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Essence Advantage Choice (PPO) plan. Ground and Air Ambulance Services have a $245 copay, with no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services under the Essence Advantage Choice (PPO) plan includes Emergency Services with a $135 copay, Urgently Needed Services with a $45 copay, and Worldwide Emergency Services. Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $135 copay, while 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 $35 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 $35 copay, and opioid treatment program services with a $15 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Essence Advantage Choice (PPO) plan covers preventive services, including Medicare-covered services with no copay. The plan also covers additional preventive services, with a copay for remote access technologies ranging from $0 to $35.
Hearing Services See details
Hearing Services include hearing exams with a $20 copay, as well as coverage for Routine Hearing Exams and Fitting/Evaluation for Hearing Aid with a copay of $20. Prescription Hearing Aids (all types) are covered, up to $1,000 per year, while Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear are not covered.
Vision Services See details
Vision services include coverage for eye exams with a $30 copay, and eyewear with a combined maximum benefit of $200 per year for both in-network and out-of-network services; contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are also covered. Upgrades are not covered.
Dental Services See details
Dental services are covered, including Medicare dental services with a $30 copay and other dental services with a $1,000 annual maximum benefit. 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 also covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay, with coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Essence Advantage Choice (PPO) plan. You will pay a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment coverage includes Durable Medical Equipment (DME) with a 20% coinsurance and Prosthetics/Medical Supplies with a 20% coinsurance, but does not cover Durable Medical Equipment for use outside the home. Diabetic Therapeutic Shoes/Inserts are covered with a 20% coinsurance, but Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with a minimum copay of $0 for Diagnostic Procedures/Tests and a maximum copay of $30, while Lab Services are not covered. Diagnostic Radiological Services have a maximum copay of $200, Therapeutic Radiological Services have 20% coinsurance, and Outpatient X-Ray Services have a $30 copay.
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 not covered by the Essence Advantage Choice (PPO) plan. This includes 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.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by 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 $184 per day; additional days beyond Medicare-covered SNF and non-Medicare-covered SNF stays are not covered.
Other Services See details
The Essence Advantage Choice (PPO) plan does not cover acupuncture, over-the-counter items, meal benefits, or Dual Eligible SNPs with Highly Integrated Services. Additionally, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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