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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 Cincinnati Metro Area - Kentucky/Indiana counties. 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $6900.00 (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 $6900.00 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. This plan has no deductible. During the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs have a $3 copay at a preferred pharmacy. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Essence Advantage Choice (PPO) plan offers a wide range of benefits with varying costs. You'll have no copay for primary care, preventive services, and home health services. However, you'll encounter copays for inpatient hospital stays, outpatient services, specialist visits, and other services like ambulance and emergency care. This plan also provides coverage for hearing, vision, and dental services, with some limitations. Hearing aids are covered up to $1000 per year, and vision includes eyewear with a combined maximum benefit of $200 annually. Dental services have an annual maximum benefit of $1,000.
Inpatient Hospital See details
Inpatient Hospital benefits for Essence Advantage Choice (PPO) include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, with a $375 copay for days 1-5 (Acute) or 1-6 (Psychiatric), and no copay for days 6-90 (Acute) or 7-90 (Psychiatric). Additional days for both Acute and Psychiatric are covered, while Non-Medicare-covered stays and upgrades for both are not covered.
Outpatient Services See details
Outpatient Services are covered by the Essence Advantage Choice (PPO) plan. Outpatient Hospital Services and Observation Services have a $325 copay, Ambulatory Surgical Center (ASC) Services have a $285 copay, and Outpatient Substance Abuse Services have a copay between $10 and $15 depending on the session type. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by 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 by the Essence Advantage Choice (PPO) plan. Ground and air ambulance services have a $290 copay, 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, and there is no coinsurance for any of these services. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Essence Advantage Choice (PPO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, occupational therapy with a $35 copay, physician specialist services with a $30 copay, and physical therapy and speech-language pathology services with a $35 copay. Individual and group sessions for mental health and psychiatric services have copays of $15 and $10, respectively. Other Health Care Professional services and Opioid Treatment Program Services have a minimum copay of $30 and $15, respectively. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive services include coverage for Medicare-covered services with no copay, as well as additional preventive services that require prior authorization and may have a copay. This plan also covers fitness benefits and remote access technologies, which may have a copay between $0 and $35.
Hearing Services See details
Hearing services include a $20 copay for hearing exams and fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered with a plan-specified amount, up to $1000 per year.
Vision Services See details
The Essence Advantage Choice (PPO) plan covers vision services, including routine eye exams with a $30 copay. Eyewear is covered with a combined maximum benefit of $200 per year for both in-network and out-of-network services, while contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames are covered with no limit. Upgrades are not covered.
Dental Services See details
Dental Services are covered, with a $1,000 annual maximum benefit. Medicare Dental Services have a $30 copay and require prior authorization, while other dental services including oral exams, dental x-rays, other diagnostic services, prophylaxis (cleaning), fluoride treatment, other preventive services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, as well as Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Essence Advantage Choice (PPO) plan with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits are covered by Essence Advantage Choice (PPO). Durable Medical Equipment (DME) has a 20% coinsurance, and Prosthetic Devices have a 20% coinsurance. Medical Supplies have a 20% coinsurance. Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance. Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for diagnostic procedures and tests with a copay between $0 and $30, diagnostic radiological services with a copay up to $200, therapeutic radiological services with 20% coinsurance, and outpatient X-ray services with a $30 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 not covered by the Essence Advantage Choice (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Essence Advantage Choice (PPO) plan, with a $0 copay for days 1-20 and a $184 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered. Prior authorization is required for this benefit.
Other Services See details
Other Services are not covered by the Essence Advantage Choice (PPO) plan. Specifically, acupuncture, over-the-counter items, meal benefits, Dual Eligible SNPs with Highly Integrated Services, 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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