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Essence Advantage Premier Plus (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Essence Advantage Premier Plus (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Essence Advantage Premier Plus (PPO) in 2025, please refer to our full plan details page.
Essence Advantage Premier Plus (PPO) is a PPO plan offered by Lumeris Group Holdings Corporation available for enrollment in 2025 to people living in St. Louis Metropolitan Area. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Essence Advantage Premier Plus (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 Premier Plus (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 Premier Plus (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $247.00. 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 $590.00 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 $1000.00 (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 $1000.00 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 Premier Plus (PPO) plan has a $590 deductible for prescription drugs. After you meet your deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For preferred generic drugs, you will pay a $3 copay at preferred pharmacies and a $20 copay at standard pharmacies. For preferred brand drugs, you will pay 46% coinsurance. Once your total yearly drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for your Part D covered drugs.
Additional Benefits
The Essence Advantage Premier Plus (PPO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a $500 copay per admission, while emergency services, primary care, and home health services have no copay. The plan also includes coverage for hearing, vision, and dental services, but with limitations on what is covered. Additional benefits include coverage for home infusion, dialysis, medical equipment, and diagnostic services, all with no copay. However, some services like outpatient substance abuse, cardiac rehabilitation, and skilled nursing facility services have specific limitations and prior authorization requirements. Other services such as acupuncture and over-the-counter items are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric, are covered with a $500 copay per admission or stay; additional days are covered, but non-Medicare-covered stays and upgrades are not covered. Prior authorization is required.
Outpatient Services See details
Outpatient Services are covered by Essence Advantage Premier Plus (PPO), including Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, and Outpatient Blood Services. Outpatient Substance Abuse Services are partially covered, with individual and group sessions not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Essence Advantage Premier Plus (PPO) plan, but requires prior authorization.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Essence Advantage Premier Plus (PPO) plan. All ambulance services are covered with prior authorization and no copay or coinsurance, but ground and air ambulance services are not covered, as well as all transportation services.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Services, Worldwide Emergency Coverage, and Worldwide Urgent Coverage are covered with no copay and no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care Physician Services, Occupational Therapy Services, Physician Specialist Services, Other Health Care Professional, Additional Telehealth Benefits, Opioid Treatment Program Services, and Physical Therapy and Speech-Language Pathology Services are covered; however, Routine Chiropractic Care, Individual Sessions for Mental Health Specialty Services, Group Sessions for Mental Health Specialty Services, Individual Sessions for Psychiatric Services, and Group Sessions for Psychiatric Services are not covered. Occupational Therapy and Physical Therapy and Speech-Language Pathology Services have no copay and no coinsurance.
Preventive Services See details
The Essence Advantage Premier Plus (PPO) plan covers preventive services, including Medicare-covered services, annual physical exams, and other preventive services, but some services like health education, in-home safety assessments, and counseling services are not covered. Some services, such as additional preventive services, require prior authorization.
Hearing Services See details
Hearing Services include routine hearing exams and fitting/evaluation for hearing aids with no deductible; routine hearing exams are unlimited, while fitting/evaluation for hearing aids are limited to 1 visit every two years. Prescription hearing aids are covered up to a maximum of $1000 every two years for both ears combined, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision Services are partially covered by the Essence Advantage Premier Plus (PPO) plan. Eye exams are covered, but routine eye exams are not. Eyewear is also covered, however, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are covered under the Essence Advantage Premier Plus (PPO) plan, but Orthodontic Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered. Prior authorization is required for Medicare Dental Services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and a coinsurance between 0% and 20%. The plan also covers Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, both with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered, with no copay and no coinsurance.
Medical Equipment See details
Medical Equipment benefits, including Durable Medical Equipment (DME) and Prosthetics/Medical Supplies, are covered with no copay and no coinsurance, but require prior authorization. However, Durable Medical Equipment for use outside the home, Prosthetic Devices, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Essence Advantage Premier Plus (PPO) plan, but Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services are not covered. There is no copay for the covered services.
Home Health Services See details
Home Health Services are covered by the Essence Advantage Premier Plus (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 technically covered, but none of the sub-services, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services, are covered. Prior authorization is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but additional days beyond Medicare-covered SNF and non-Medicare-covered SNF stays are not covered. Prior authorization is required, and there is no cost sharing on the day of discharge.
Other Services See details
Other Services are not covered, as the plan does not cover acupuncture, over-the-counter items, meal benefits, dual eligible SNPs, 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, or Self-Directed Personal Assistance Services. No authorization or referrals are required for these services.
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