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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 2026, 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 3 out of 5 stars in 2026.
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 $49.00. 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) prescription drug plan features no drug deductible, meaning your coverage starts immediately. For Tier 1 preferred generic drugs, you will pay no copay at preferred pharmacies or through standard mail order, while standard pharmacies charge a $4 copay for a one-month supply. Tier 2 generic medications cost a $5 copay for a one-month supply at preferred pharmacies and standard mail order, or a $12 copay at standard pharmacies. Tier 3 preferred brand drugs require a $47 copay for a one-month supply across preferred pharmacies, standard pharmacies, and standard mail order. For higher-tier medications, Tier 4 non-preferred drugs carry a 50% coinsurance, while Tier 5 specialty drugs require a 33% coinsurance for a one-month supply. These clear copayments and coinsurance rates allow you to easily estimate your out-of-pocket prescription drug costs.
Additional Benefits
The Essence Advantage Choice Plus (PPO) plan offers robust healthcare coverage with no copay for primary care visits, home health services, and preventive care like annual physicals. Members enjoy extensive dental benefits featuring no copay for preventive and comprehensive care up to a $2,500 annual maximum, as well as affordable $25 copays for specialist visits and routine eye exams. Additionally, prescription hearing aids and eyewear are covered with no copay up to generous plan limits. For acute care, the plan requires a $150 copay for emergency services and a $295 daily copay for the first seven days of inpatient hospital stays, with no copay for days 8 through 90. Outpatient hospital procedures carry a $345 copay, while medical equipment and dialysis services generally require a 20% coinsurance. Skilled nursing facility care is also covered, requiring a low daily copay of $20 for the first 20 days of your stay.
Inpatient Hospital See details
Essence Advantage Choice Plus (PPO) partially covers inpatient acute and psychiatric hospital stays, excluding upgrades and non-Medicare-covered stays. Covered stays require prior authorization and incur a $295 daily copay for days 1 through 7, no copay and no coinsurance for days 8 through 90, and a 50% coinsurance with no copay for days 91 and beyond.
Outpatient Services See details
Outpatient services are covered by Essence Advantage Choice Plus (PPO) with no coinsurance, featuring a $345 copay for outpatient hospital and observation services and a $245 copay for ambulatory surgical center services. Outpatient substance abuse services require a $10 to $15 copay with no coinsurance, while outpatient blood services are covered with no copay or coinsurance.
Partial Hospitalization See details
Essence Advantage Choice Plus (PPO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization is required to receive coverage for this benefit.
Ambulance and Transportation Services See details
Essence Advantage Choice Plus (PPO) covers ground and air ambulance services with a $275 copay and no coinsurance, subject to prior authorization. While transportation services are technically covered, some services are covered but transportation to plan-approved health-related locations and any health-related locations is not covered.
Emergency Services See details
Essence Advantage Choice Plus (PPO) covers emergency services with a $150 copay (waived if admitted within 24 hours) and urgent care with a $45 copay, both with no coinsurance. Worldwide emergency and urgent services are partially covered with a $150 copay and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Essence Advantage Choice Plus (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $25 copay and therapy services require a $40 copay, both with no coinsurance. The plan's primary care benefits are partially covered as routine chiropractic and podiatry services are not covered, though mental health individual sessions are covered with a $15 copay and no coinsurance.
Preventive Services See details
Essence Advantage Choice Plus (PPO) covers preventive services, including annual physical exams, kidney disease education, and a fitness benefit, with no copay and no coinsurance. However, additional preventive services are only partially covered, with options like health education, in-home safety assessments, medical nutrition therapy, and weight management programs not covered under the plan.
Hearing Services See details
Essence Advantage Choice Plus (PPO) covers hearing exams with a $20 copay and no coinsurance. Prescription hearing aids are partially covered with no copay and no coinsurance up to a $1,000 maximum benefit every two years, but inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Essence Advantage Choice Plus (PPO) provides partially covered vision services, which include one annual routine eye exam for a $25 copay and no coinsurance, though other eye exam services are not covered. Eyewear is also covered with no copay and no coinsurance up to a $200 combined annual limit, but upgrades are not covered.
Dental Services See details
Dental services are covered by Essence Advantage Choice Plus (PPO) with no copay and no coinsurance for preventive and comprehensive care, up to a $2,500 annual maximum for both in-network and out-of-network services. Medicare-covered dental services are available with a $25 copay and no coinsurance, though prior authorization is required.
Home Infusion bundled Services See details
Home infusion bundled services are partially covered by Essence Advantage Choice Plus (PPO) with no copay, though Part D home infusion drugs are not covered under this bundle. Covered Medicare Part B drugs, including chemotherapy and radiation, require 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 Plus (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Essence Advantage Choice Plus (PPO) partially covers medical equipment with no copays and a 20% coinsurance, though prior authorization is required. Covered items include durable medical equipment, prosthetics, and diabetic therapeutic shoes, while diabetic supplies are not covered.
Diagnostic and Radiological Services See details
Essence Advantage Choice Plus (PPO) partially covers diagnostic services, excluding lab services, with diagnostic tests requiring no coinsurance and a copay ranging from $0 to $50. Covered radiological services require prior authorization and feature no copay for diagnostic radiology, a $30 copay for outpatient X-rays, and a 20% coinsurance for therapeutic radiological services.
Home Health Services See details
Home health services are covered under the Essence Advantage Choice Plus (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Essence Advantage Choice Plus (PPO) covers cardiac rehabilitation services with no coinsurance, though prior authorization is required. While some services are covered, specific programs including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered in practice and carry a $20 copayment.
Skilled Nursing Facility (SNF) See details
Essence Advantage Choice Plus (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a daily copay of $20 for days 1 through 20 and $203 for days 21 through 100. Prior authorization is required, and while a prior three-day inpatient hospital stay is not required, additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by Essence Advantage Choice Plus (PPO), which offers over-the-counter (OTC) items with no copay and no coinsurance up to a maximum benefit of $40 every three months via reimbursement. Acupuncture, meal benefits, and nicotine replacement therapy are not covered under this benefit.
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