A non-government entity
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 2026, 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 3 out of 5 stars in 2026.
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 $19.80. 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 $340.00 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:
Sign up for Essence Advantage Choice (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Essence Advantage Choice (PPO) plan features an annual drug deductible of $340. For Tier 1 preferred generic drugs, you will pay no copay when using a preferred pharmacy or standard mail order, while standard pharmacies charge a $4 copay for a one-month supply. Tier 2 generic drugs cost a low $3 copay for a one-month supply at preferred pharmacies and standard mail order, compared to a $12 copay at standard pharmacies. Tier 3 preferred brand drugs require a flat $47 copay for a one-month supply at preferred pharmacies, standard pharmacies, and standard mail order. For higher-tier medications, you will pay a 50% coinsurance for Tier 4 non-preferred drugs and a 29% coinsurance for a one-month supply of Tier 5 specialty drugs.
Additional Benefits
The Essence Advantage Choice (PPO) plan offers comprehensive coverage for core medical services, featuring no copays or coinsurance for primary care visits and preventive care. Specialist visits require a $30 copay, emergency services have a $150 copay, and outpatient hospital stays require a $375 copay. For inpatient hospital stays, there is no coinsurance, though members pay a $375 daily copay for the first several days of their stay. Supplemental benefits include dental care with no copay up to a $1,000 annual limit, as well as routine vision exams for a $30 copay and a $200 annual eyewear allowance. Hearing exams require a $20 copay, while prescription hearing aids are covered with no copay up to a $1,000 yearly limit. Furthermore, home health services require no copay, and skilled nursing facility stays feature no copay for the first 20 days.
Inpatient Hospital See details
Essence Advantage Choice (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $375 daily copay for days 1 through 7 of acute stays and days 1 through 6 of psychiatric stays, with no copay for remaining days. Unlimited additional days are covered, though prior authorization is required, and upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Essence Advantage Choice (PPO) covers outpatient hospital and observation services with a $375 copay per stay and no coinsurance, and ambulatory surgical center services with a $255 copay and no coinsurance. Outpatient substance abuse services require no coinsurance and a copay of $15 for individual or $10 for group sessions, while outpatient blood services have no copay or coinsurance.
Partial Hospitalization See details
The Essence Advantage Choice (PPO) plan covers partial hospitalization services with a $45.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Essence Advantage Choice (PPO) covers ground and air ambulance services with a $245 copayment and no coinsurance, though prior authorization is required. Routine transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Essence Advantage Choice (PPO) covers emergency services with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, and urgent care with a $45 copay and no coinsurance. Worldwide emergency and urgent services are also covered with a $150 copay and no coinsurance, although worldwide emergency transportation is not covered.
Primary Care See details
Essence Advantage Choice (PPO) covers primary care physician visits with no copay and no coinsurance, and specialist visits with a $30 copay and no coinsurance. Therapy and mental health services require copays ranging from $10 to $35 with no coinsurance, while podiatry and chiropractic services are not covered.
Preventive Services See details
Essence Advantage Choice (PPO) covers preventive services, including annual physical exams, kidney disease education, and diabetes self-management, with no copay and no coinsurance. While a fitness benefit is covered under additional preventive services, other options like health education, personal emergency response systems, and weight management programs are not covered.
Hearing Services See details
Essence Advantage Choice (PPO) covers routine hearing exams and fitting evaluations for a $20 copay and no coinsurance. Prescription hearing aids are partially covered with no copay and no coinsurance up to a $1,000 annual maximum, though OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Essence Advantage Choice (PPO) partially covers vision services, offering one routine eye exam per year for a $30 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible up to a $200 annual maximum for contacts and eyeglasses, while upgrades are not covered.
Dental Services See details
Essence Advantage Choice (PPO) covers Medicare-covered dental services with a $30 copay and no coinsurance. Other preventive and comprehensive dental services are covered with no copay and no coinsurance up to a yearly maximum of $1,000 for both in-network and out-of-network care.
Home Infusion bundled Services See details
Essence Advantage Choice (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other drugs require no coinsurance to 20% coinsurance, while Part B insulin drugs have a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the Essence Advantage Choice (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Essence Advantage Choice (PPO) partially covers medical equipment with no copay and a 20% coinsurance, though prior authorization is required. This benefit includes durable medical equipment, prosthetics, and diabetic therapeutic shoes, but diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by Essence Advantage Choice (PPO), as lab services are not covered. Covered diagnostic procedures require no coinsurance and a copay of up to $50, while radiological services require prior authorization and range from no copay for diagnostic radiology to a $30 copay for X-rays and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home health services are covered by the Essence Advantage Choice (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Essence Advantage Choice (PPO) with no coinsurance and a $15 copay, but require prior authorization. Although some services are covered, cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled nursing facility (SNF) services are covered by Essence Advantage Choice (PPO) with no coinsurance, featuring no copay for days 1 through 20 and a $184 daily copay for days 21 through 100 per stay. Prior authorization is required, and while a three-day prior inpatient hospital stay is not required, additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other Services are not covered under the Essence Advantage Choice (PPO) plan, meaning acupuncture, over-the-counter (OTC) items, and meal benefits are all excluded from coverage.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved