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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 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 Chicago Metropolitan Area. 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 $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 $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:
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Drug Coverage
The Essence Advantage Choice (PPO) plan features an annual prescription drug deductible of $340. For Tier 1 preferred generic drugs, you will pay no copay when using a preferred pharmacy or standard mail order, and a $4.00 copay for a one-month supply at a standard pharmacy. Tier 2 generic drugs cost a $5.00 copay for a one-month supply at preferred pharmacies and standard mail order, compared to a $12.00 copay at standard pharmacies. Tier 3 preferred brand drugs require a $47.00 copay for a one-month supply at both preferred and standard pharmacies. Tier 4 non-preferred drugs require a 50% coinsurance, while Tier 5 specialty drugs require a 29% coinsurance for a one-month supply across all pharmacy types. Ordering a three-month supply of Tier 2 or Tier 3 drugs through standard mail order offers lower copays than retail pharmacies.
Additional Benefits
The Essence Advantage Choice (PPO) plan provides comprehensive medical coverage with no copay and no coinsurance for primary care visits, while specialist visits require a $30 copay. For hospital stays, inpatient care carries a $325 daily copay for the first seven days and no copay for days eight through 90, whereas outpatient hospital services require a $395 copay. Emergency room visits have a $150 copay, which is waived if you are admitted, and urgent care services are available for a $65 copay. This plan also includes key auxiliary benefits, such as dental care with no copay up to an $850 annual maximum and eyewear coverage with no copay up to a $200 yearly limit. Hearing services feature a $20 copay for routine exams and no copay for prescription hearing aids up to a $1,000 limit every two years. Additionally, home health services require no copay, while durable medical equipment is covered with no copay and a 20% coinsurance.
Inpatient Hospital See details
Essence Advantage Choice (PPO) partially covers inpatient acute and psychiatric hospital stays, which require prior authorization and cost a $325 daily copay for days 1 to 7 and no copay for days 8 to 90. There is no coinsurance for the first 90 days, but a 50% coinsurance applies for days 91 and beyond, while 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 $395 copay and no coinsurance, and ambulatory surgical center services with a $295 copay and no coinsurance. Outpatient substance abuse services require no coinsurance with a $15 copay for individual sessions and a $10 copay for group sessions, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered under the Essence Advantage Choice (PPO) plan with a $65.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Essence Advantage Choice (PPO) covers Medicare-covered ground and air ambulance services with a $280 copay and no coinsurance, though prior authorization is required. Transportation services are not covered under this plan, including trips to plan-approved or any health-related locations.
Emergency Services See details
Emergency services are covered by Essence Advantage Choice (PPO) with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours, while urgently needed services require a $65 copay and no coinsurance. Worldwide emergency and urgent care are partially covered with a $150 copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Essence Advantage Choice (PPO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $30 copay and no coinsurance. Physical and occupational therapies are covered with a $40 copay and no coinsurance, while podiatry and routine chiropractic services are not covered.
Preventive Services See details
Essence Advantage Choice (PPO) covers preventive services, such as annual physical exams, kidney education, and various screenings, with no copay and no coinsurance. Additional preventive services are partially covered with no copay and no coinsurance for a memory fitness benefit, but health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, remote access technologies, home safety modifications, and counseling are not covered.
Hearing Services See details
Essence Advantage Choice (PPO) partially covers hearing services, offering routine exams and fitting evaluations for a $20 copay and no coinsurance. Prescription hearing aids are covered with no copay and no coinsurance up to a $1,000 maximum benefit every two years, but OTC hearing aids and inner ear, outer ear, and over-the-ear prescription devices are not covered.
Vision Services See details
Essence Advantage Choice (PPO) covers one routine eye exam per year with a $30 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay or coinsurance up to a $200 annual maximum for contacts and eyeglasses, with no deductibles required, though upgrades are excluded.
Dental Services See details
Essence Advantage Choice (PPO) covers preventive and comprehensive dental services with no copay and no coinsurance, up to a combined yearly maximum of $850 for both in- and out-of-network care. Medicare-covered dental services are also covered with a $30 copay and no coinsurance.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Essence Advantage Choice (PPO) with no copay and no coinsurance, though prior authorization is required. Covered Medicare Part B chemotherapy, radiation, and other drugs carry no copay and 0% to 20% coinsurance, while Part B insulin requires a $35 copay and 0% 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) covers durable medical equipment, prosthetics, and medical supplies with no copay and 20% coinsurance. Diabetic equipment is covered with no copay and no coinsurance, though diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Essence Advantage Choice (PPO) partially covers diagnostic and radiological services with prior authorization required, though lab services are not covered. Covered diagnostic tests feature no coinsurance and copays ranging from no copay to $95, while radiological services require a $25 copay for X-rays and a minimum 20% coinsurance for therapeutic services.
Home Health Services See details
Home Health Services are covered under 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 with no copay and no coinsurance under the Essence Advantage Choice (PPO) plan, although only some services are covered in practice. Specific sub-services, including cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) rehabilitation, are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Essence Advantage Choice (PPO) with no coinsurance, requiring a $20 daily copay for days 1 through 20 and a $203 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not required for admission, and additional days beyond the standard 100 days are not covered.
Other Services See details
Other Services are not covered under the Essence Advantage Choice (PPO), as acupuncture, over-the-counter (OTC) items, and meal benefits are all excluded from coverage.
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