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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 2026, 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 3 out of 5 stars in 2026.
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 $254.00. 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 $615.00 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 $2000.00 (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 $2000.00 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) Medicare plan features an annual prescription drug deductible of $615. Under this plan, Tier 1 preferred generic drugs are available with no copay when using a preferred pharmacy or standard mail order. For Tier 2 generic medications, you will pay a low $3 copay for a one-month supply at preferred pharmacies and standard mail order, or a $20 copay at standard pharmacies. Tier 3 preferred brand drugs have a $47 copay for a one-month supply at both preferred and standard pharmacies. Higher-tier medications require coinsurance, with Tier 4 non-preferred drugs carrying a 50% coinsurance and Tier 5 specialty drugs requiring a 25% coinsurance for a one-month supply.
Additional Benefits
The Essence Advantage Premier Plus (PPO) plan offers extensive coverage with no copays and no coinsurance for primary care, preventive services, outpatient hospital care, and home health visits. Inpatient hospital admissions require a $500 copay per admission with no coinsurance. Additionally, members can access skilled nursing facility care, dialysis, and emergency services with no copay and no coinsurance. However, this plan excludes several routine services, meaning routine dental care, routine vision exams, eyeglasses, and cardiac rehabilitation are not covered. Hearing services are covered with no copay for routine exams and up to $1,000 for prescription hearing aids every two years. For medications, Medicare Part B chemotherapy drugs have a 0% to 20% coinsurance, while Part B insulin requires a $35 copay and 0% to 20% coinsurance.
Inpatient Hospital See details
Essence Advantage Premier Plus (PPO) covers inpatient acute and psychiatric hospital stays with a $500 copay per admission and no coinsurance, subject to prior authorization. This benefit is partially covered, as unlimited additional days are included, but upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered by Essence Advantage Premier Plus (PPO) with no copay and no coinsurance for outpatient hospital, ambulatory surgical center, and blood services. For outpatient substance abuse, some services are covered with no copay or coinsurance, but individual and group sessions are not covered.
Partial Hospitalization See details
Essence Advantage Premier Plus (PPO) covers partial hospitalization services with no copay and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered under the Essence Advantage Premier Plus (PPO) with no copay and no coinsurance, requiring prior authorization. While some services are covered, ground ambulance, air ambulance, and health-related transportation services are not covered.
Emergency Services See details
Essence Advantage Premier Plus (PPO) emergency services are partially covered because worldwide emergency transportation is not covered. All other emergency, urgent, and worldwide emergency and urgent care services are covered with no copay and no coinsurance.
Primary Care See details
Essence Advantage Premier Plus (PPO) offers primary care, physical therapy, occupational therapy, and telehealth services with no copay and no coinsurance, although prior authorization is required for specialist visits. Podiatry is not covered, and while some chiropractic, mental health, and psychiatric services are covered, routine or other chiropractic care and individual or group therapy sessions are not covered.
Preventive Services See details
Essence Advantage Premier Plus (PPO) covers preventive services, such as annual physical exams and kidney disease education, with no copay and no coinsurance. However, additional preventive services are only partially covered, excluding health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs for chemotherapy-related hair loss, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access technologies, home and bathroom safety modifications, and counseling.
Hearing Services See details
Hearing services under the Essence Advantage Premier Plus (PPO) feature no copay and no coinsurance for covered services, which include unlimited routine hearing exams and one fitting evaluation every two years. Prescription hearing aids are partially covered with a $1,000 maximum benefit every two years, though OTC hearing aids as well as inner ear, outer ear, and over-the-ear prescription models are not covered.
Vision Services See details
Vision Services are covered by the Essence Advantage Premier Plus (PPO) with no copay and no coinsurance, but in practice, routine eye exams, other eye exams, and all eyewear options—including contacts and eyeglasses—are not covered.
Dental Services See details
Dental services under Essence Advantage Premier Plus (PPO) are partially covered, with Medicare-covered dental services available at no copay and no coinsurance, subject to prior authorization. However, routine and comprehensive dental services, including oral exams, cleanings, x-rays, fluoride, restorative work, and orthodontics, are not covered.
Home Infusion bundled Services See details
Essence Advantage Premier Plus (PPO) covers home infusion bundled services with no copay and no coinsurance, although prior authorization is required. Associated Medicare Part B chemotherapy and other drugs require no copay and a 0% to 20% coinsurance, while Medicare Part B insulin has a $35 copay and a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the Essence Advantage Premier Plus (PPO) plan with no copay and no coinsurance.
Medical Equipment See details
Essence Advantage Premier Plus (PPO) covers Durable Medical Equipment with no copay and no coinsurance, subject to prior authorization. Although some non-Medicare prosthetics, medical supplies, and diabetic equipment services are technically covered with no copay or coinsurance, specific sub-services including prosthetic devices, medical supplies, diabetic supplies, and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the Essence Advantage Premier Plus (PPO) with no copay and no coinsurance, although prior authorization is required. While some services are covered, diagnostic procedures, lab services, diagnostic radiological services, therapeutic radiological services, and outpatient X-rays are not covered.
Home Health Services See details
Essence Advantage Premier Plus (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Essence Advantage Premier Plus (PPO) plan, which excludes standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services.
Skilled Nursing Facility (SNF) See details
Essence Advantage Premier Plus (PPO) covers Skilled Nursing Facility (SNF) services with no copay and no coinsurance, although prior authorization is required. Admission is allowed without a prior three-day inpatient hospital stay, but additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other Services are not covered under the Essence Advantage Premier Plus (PPO) plan, as acupuncture, over-the-counter (OTC) items, and meal benefits are all excluded from coverage.
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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.
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