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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 Chicago Metropolitan Area. 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 a $295.00 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 has a $295 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy type. For example, for preferred generic drugs, you'll pay a $3 copay at a preferred pharmacy and $12 at a standard pharmacy. For non-preferred drugs, you pay 29% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for Part D covered drugs.
Additional Benefits
The Essence Advantage Choice (PPO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have copays depending on the length of stay, while outpatient services have a $325 copay. The plan also covers primary care, preventive, vision, and dental services, with copays for exams and specific treatments. Additional benefits include hearing services with a hearing exam copay and hearing aid coverage, and home health services with no copay. There is also coverage for ambulance, emergency, and diagnostic services. However, some services, like certain dental and vision upgrades, and services like acupuncture, over-the-counter items, and private duty nursing services, are not covered.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you will pay a $310 copay for days 1-5, and no copay for days 6-90, with no coinsurance, while Additional Days for Inpatient Hospital-Acute has 50% coinsurance for days 91-999. For Inpatient Hospital Psychiatric, you will pay a $325 copay for days 1-7, and no copay for days 8-90, with no coinsurance, while Additional Days for Inpatient Hospital Psychiatric has 50% coinsurance for days 91-999. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services and observation services, have a $325 copay. Ambulatory Surgical Center (ASC) Services have a $250 copay. Individual and Group Sessions for Outpatient Substance Abuse have copays ranging from $10 to $15. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Essence Advantage Choice (PPO) plan with a $65 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, with prior authorization required for all ambulance services. Ground and Air Ambulance Services have a copay of $280, while Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage all have a copay of $140, $65, and $140 respectively, with no coinsurance. Worldwide Urgent Coverage also has a copay of $140 with no coinsurance, while Worldwide Emergency Transportation is not covered.
Primary Care See details
The Essence Advantage Choice (PPO) plan covers primary care services, including a $20 copay for chiropractic services, a $40 copay for occupational therapy services, and a $30 copay for physician specialist services. The plan also covers mental health specialty services with a minimum copay of $15 for individual sessions and $10 for group sessions, and physical therapy and speech-language pathology services with a $40 copay.
Preventive Services See details
The Essence Advantage Choice (PPO) plan covers preventive services including Medicare-covered services, annual physical exams, and additional preventive services, though some services require prior authorization. Remote Access Technologies have a copay between $0 and $40. Other services such as Health Education, In-Home Safety Assessment, and Personal Emergency Response System (PERS) are not covered.
Hearing Services See details
Hearing services include hearing exams with a $20 copay, and prescription hearing aids with a maximum benefit of $1,000 every two years. Prescription hearing aids - inner ear, outer ear, and over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services include coverage for 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, and contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are also covered. Upgrades are not covered.
Dental Services See details
Dental services are covered, with a $30 copay for Medicare dental services, which require prior authorization, and a $1,000 maximum plan benefit per year that applies to both in-network and out-of-network services. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are also covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay, with a coinsurance between 0-20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance is between 0-20%.
Dialysis Services See details
Dialysis Services are covered by the Essence Advantage Choice (PPO) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment is covered by the Essence Advantage Choice (PPO) plan, including Durable Medical Equipment (DME) with 20% coinsurance and Prosthetics/Medical Supplies - Non-Medicare benefit with 20% coinsurance, but Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with some services requiring prior authorization. Diagnostic Procedures/Tests have a copay between $0 and $95, while Lab Services are not covered. Diagnostic Radiological Services have a copay of up to $325, Therapeutic Radiological Services have a 20% coinsurance, and Outpatient X-Ray Services have a $25 copay.
Home Health Services See details
Home Health Services are covered by the Essence Advantage Choice (PPO) plan with no copay and no coinsurance, however, additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered with prior authorization, but the plan does not cover any of the specific sub-services, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. The plan's cost sharing includes a copay, but the exact amount is not specified in the provided information.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, the copay is $20, and for days 21-100, the copay is $203. Additional days beyond Medicare-covered for SNF, and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Essence Advantage Choice (PPO) plan does not cover 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, or self-directed personal assistance services. No authorization or referral is required for these services.
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