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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 2025, 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 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 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 $247.00. 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 $590.00 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 $1000.00 (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 $1000.00 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) plan has a $590 deductible for prescription drugs. After meeting the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs have a $3 copay at preferred pharmacies. The plan offers an "Enhanced Alternative" drug benefit. During the initial coverage phase, you'll pay a percentage of the cost for brand-name drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Essence Advantage Premier Plus (PPO) plan offers a range of additional benefits beyond standard Medicare coverage. This plan covers inpatient hospital stays with a $500 copay, outpatient services, and partial hospitalization with prior authorization. Emergency services, including worldwide coverage, have no copay. The plan also includes coverage for primary care, preventive services, hearing exams, and hearing aids with a maximum benefit, but vision services are not covered. Additional benefits include home infusion, dialysis, durable medical equipment, and home health services with no copay, but some services require prior authorization.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric care, are covered with a $500 copay per admission or stay. Additional days for both Acute and Psychiatric inpatient hospital stays are also covered. 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, observation services, ambulatory surgical center (ASC) services, and outpatient blood services. Outpatient substance abuse services are partially covered, but individual and group sessions are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Essence Advantage Premier Plus (PPO) plan, but requires prior authorization.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Essence Advantage Premier Plus (PPO) plan, but ground and air ambulance services are not covered. All ambulance services have no copay and no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Services, Worldwide Emergency Coverage, and Worldwide Urgent Coverage are covered with no copay and no coinsurance, but Worldwide Emergency Transportation is not covered.
Primary Care See details
The Essence Advantage Premier Plus (PPO) plan covers Primary Care Physician 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. Chiropractic Services, Routine Chiropractic Care, Individual Sessions for Mental Health Specialty Services, Group Sessions for Mental Health Specialty Services, Individual Sessions for Psychiatric Services, and Group Sessions for Psychiatric Services are not covered. Occupational Therapy Services and Physical Therapy and Speech-Language Pathology Services have no copay or coinsurance.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, annual physical exams, and additional preventive services. Other services, such as health education, in-home safety assessments, and several others, are not covered.
Hearing Services See details
Hearing services include routine hearing exams and fitting/evaluation for hearing aids with no copay or coinsurance. Prescription hearing aids are covered up to a maximum of $1,000 every two years for both in and out-of-network services, but inner ear, outer ear, and over-the-ear hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services are partially covered by the Essence Advantage Premier Plus (PPO) plan. Eye exams are not covered, and none of the eyewear services are covered.
Dental Services See details
Dental Services are covered, but most sub-services such as Orthodontic Services, Restorative Services, and others are not covered. Medicare Dental Services require prior authorization.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Essence Advantage Premier Plus (PPO) plan. There is no copay or coinsurance for this benefit.
Medical Equipment See details
The Essence Advantage Premier Plus (PPO) plan covers Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, but does not cover Durable Medical Equipment for use outside the home, Prosthetic Devices, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts. There is no copay or coinsurance for DME and Prosthetics/Medical Supplies.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are not covered by the Essence Advantage Premier Plus (PPO) plan. Diagnostic procedures/tests, lab services, diagnostic radiological services, therapeutic radiological services, and outpatient X-ray services are all not covered.
Home Health Services See details
Home Health Services are covered by the Essence Advantage Premier Plus (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are covered. Prior authorization is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but additional days beyond Medicare-covered for Skilled Nursing Facility (SNF) and Non-Medicare-covered stays for Skilled Nursing Facility (SNF) are not covered. Prior authorization is required.
Other Services See details
Other Services are not covered by this plan. Acupuncture, Over-the-Counter (OTC) Items, Meal Benefit, 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, and Self-Directed Personal Assistance Services are not covered.
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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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