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Essence Advantage Choice Plus (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Essence Advantage Choice 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 Choice Plus (PPO) in 2025, please refer to our full plan details page.
Essence Advantage Choice Plus (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 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 Choice 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 Choice Plus (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $47.00. 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 $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 Plus (PPO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay a copay for your prescriptions. For example, preferred generic drugs have a $3 copay at preferred pharmacies, while standard generic drugs have a $47 copay at both preferred and standard pharmacies. For non-preferred drugs, you pay 33% coinsurance. After your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Essence Advantage Choice Plus (PPO) plan offers comprehensive coverage for inpatient and outpatient services, including hospital stays with varying copays depending on the length of stay. The plan also covers primary care, preventive services, and specialized services like hearing, vision, and dental, each with its own copay structure and annual benefit limits. This plan includes coverage for emergency services, ambulance, and home health services, often with copays or coinsurance. Additionally, you'll find coverage for home infusion, dialysis, medical equipment, and diagnostic services, as well as skilled nursing facility care. However, some services like cardiac rehabilitation and certain "other services" are not covered.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Acute and Psychiatric care. For Acute care, you will pay a $275 copay for days 1-5, and no copay for days 6-90; there is no coinsurance. For days 91-999, you will pay 50% coinsurance. For Psychiatric care, you will pay a $275 copay for days 1-6, and no copay for days 7-90; there is no coinsurance. For days 91-999, you will pay 50% coinsurance. 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 are covered, including outpatient hospital services with a $275 copay, observation services with a $275 copay, and ambulatory surgical center services with a $225 copay. Individual sessions for outpatient substance abuse have a copay of $15, and group sessions have a copay of $10. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Essence Advantage Choice Plus (PPO) plan, with a $55 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services, offered by Essence Advantage Choice Plus (PPO), covers both ground and air ambulance services, each with a copay of $275. Transportation Services to any health-related location are not covered by this plan.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Essence Advantage Choice Plus (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a copay of $135, while Urgently Needed Services have a copay of $45; all three services have no coinsurance. Worldwide Urgent Coverage has a copay of $135 and no coinsurance, while Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Chiropractic services have a $20 copay, occupational therapy has a $40 copay, physician specialist services have a $25 copay, individual mental health sessions have a $15 copay, group mental health sessions have a $10 copay, other health care professional services have a $25 copay, individual psychiatric sessions have a $15 copay, group psychiatric sessions have a $10 copay, physical therapy and speech-language pathology services have a $40 copay, and opioid treatment program services have a $15 copay. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
The Essence Advantage Choice Plus (PPO) plan covers preventive services, including Medicare-covered services with no copay, annual physical exams, and other preventive services with a copay for certain services, such as remote access technologies. The plan does not cover health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and several other services.
Hearing Services See details
Hearing services include hearing exams, with a $20 copay, as well as fitting/evaluation for hearing aids with a copay of $20. Prescription hearing aids are covered up to $1,000 every two years, but inner ear, outer ear, and over the ear hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $25 copay, as well as coverage for eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames, all of which are unlimited. Eyewear has a combined maximum benefit of $200 every year. Upgrades are not covered.
Dental Services See details
Dental services are covered, including Medicare dental services with a $25 copay and other dental services. This plan has a maximum benefit of $2,500 per year for both in-network and out-of-network services.
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 and coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Essence Advantage Choice Plus (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits are covered by the Essence Advantage Choice Plus (PPO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, with no copay, and requires authorization, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a 20% coinsurance, with no copay. Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance, with no copay, and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for diagnostic procedures and outpatient x-ray services. Diagnostic procedures have a copay of $0-$50, while outpatient X-ray services have a $30 copay. Therapeutic Radiological Services have a 20% coinsurance, and Medicare-covered X-Ray services have a coinsurance. Lab Services are not covered.
Home Health Services See details
Home Health Services are covered by the Essence Advantage Choice Plus (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Essence Advantage Choice Plus (PPO) plan. Prior authorization is required for these services.
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 SNF stays and non-Medicare-covered SNF stays are not covered.
Other Services See details
Other Services are not covered, including acupuncture, over-the-counter items, meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, private duty nursing services, and more. No authorization or referrals are required for these services.
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