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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 2026, 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 3 out of 5 stars in 2026.
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 $257.00. 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 $615.00 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 $2000.00 (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 $2000.00 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) prescription drug plan features an annual drug deductible of $615. Under this plan, you will pay no copay for Tier 1 preferred generic drugs when using a preferred pharmacy or standard mail order. Tier 2 generic medications are also highly affordable, starting at a low $3 copay for a one-month supply at preferred pharmacies and standard mail order. For Tier 3 preferred brand drugs, the plan requires a $47 copay for a one-month supply at both preferred and standard pharmacies. Higher-tier medications require coinsurance, with Tier 4 non-preferred drugs carrying a 50% coinsurance and Tier 5 specialty drugs requiring a 25% coinsurance. Standard pharmacies generally carry higher copays for lower-tier drugs, making preferred pharmacies and standard mail order the most cost-effective choices for your prescriptions.
Additional Benefits
The Essence Advantage Premier Plus (PPO) plan offers many of its covered medical services with no copays, no deductibles, and no coinsurance. This includes no-cost coverage for primary care and specialist visits, preventive services, outpatient hospital care, home health, and skilled nursing facility stays. Additionally, emergency care, urgent care, and dialysis services are covered with no copays or coinsurance. For inpatient hospital stays, members will pay a $500 copay per admission with no coinsurance. While Medicare Part B drugs carry a coinsurance ranging up to 20% with insulin capped at $35, many routine extras like dental cleanings, eyeglasses, and over-the-counter items are not covered. Hearing care is partially covered with no copay or deductible, offering up to a $1,000 benefit for prescription hearing aids every two years.
Inpatient Hospital See details
Essence Advantage Premier Plus (PPO) covers inpatient acute and psychiatric hospital stays with a $500 copay per admission and no coinsurance, subject to prior authorization. This benefit is partially covered, as upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Essence Advantage Premier Plus (PPO) provides outpatient services with no copay and no coinsurance for outpatient hospital, ambulatory surgical center, and blood services. Under the outpatient substance abuse benefit, some services are covered, but individual and group sessions are not covered.
Partial Hospitalization See details
Essence Advantage Premier Plus (PPO) covers partial hospitalization services with no copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered under the Essence Advantage Premier Plus (PPO) with no copay and no coinsurance, though prior authorization is required. While some services are covered, ground ambulance, air ambulance, and transportation to health-related locations are not covered.
Emergency Services See details
Emergency services are covered by Essence Advantage Premier Plus (PPO) with no copay and no coinsurance for both emergency and urgently needed care. Worldwide emergency and urgent care are also covered with no copay or coinsurance, but this benefit is only partially covered as worldwide emergency transportation is not covered.
Primary Care See details
Primary Care benefits under the Essence Advantage Premier Plus (PPO) are partially covered, featuring no copay and no coinsurance for primary care physician, specialist, occupational therapy, physical therapy, speech-language pathology, telehealth, and opioid treatment services. However, podiatry, routine and other chiropractic care, and individual or group sessions for mental health and psychiatric services are not covered.
Preventive Services See details
Essence Advantage Premier Plus (PPO) covers preventive services, including annual physical exams, kidney disease education, and various screenings, with no copay and no coinsurance. Additional preventive services are partially covered, featuring a memory fitness benefit, while sub-services like health education, in-home safety assessments, and weight management programs are not covered.
Hearing Services See details
Essence Advantage Premier Plus (PPO) partially covers hearing services with no copay, no coinsurance, and no deductible for routine exams and covered prescription hearing aids, which have a $1,000 maximum benefit every two years. However, OTC hearing aids as well as inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Vision services are covered by Essence Advantage Premier Plus (PPO) with no copay, no coinsurance, and no deductible. While some services are covered, routine eye exams, other eye exam services, contact lenses, eyeglasses, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Essence Advantage Premier Plus (PPO) partially covers dental services, providing Medicare-covered dental services with no copay and no coinsurance, subject to prior authorization. Other dental services, such as oral exams, cleanings, x-rays, preventive care, and orthodontics, are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Essence Advantage Premier Plus (PPO) with no copay and no coinsurance, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and insulin, have a coinsurance ranging from no coinsurance up to 20%, with insulin copays capped at $35.
Dialysis Services See details
Dialysis services are fully covered under the Essence Advantage Premier Plus (PPO) plan with no copay and no coinsurance.
Medical Equipment See details
Essence Advantage Premier Plus (PPO) covers Medical Equipment with no copay and no coinsurance, although prior authorization is required. While Durable Medical Equipment is covered, other services under this benefit—including prosthetic devices, medical supplies, diabetic supplies, and diabetic therapeutic shoes or inserts—are not covered.
Diagnostic and Radiological Services See details
Essence Advantage Premier Plus (PPO) covers some diagnostic and radiological services with no copay and no coinsurance, though prior authorization is required. However, diagnostic procedures or tests, lab services, diagnostic radiological services, therapeutic radiological services, and outpatient x-ray services are not covered.
Home Health Services See details
Essence Advantage Premier Plus (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Essence Advantage Premier Plus (PPO) technically offers Cardiac Rehabilitation Services with no copay and no coinsurance, subject to prior authorization, but in practice only some services are covered while cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Essence Advantage Premier Plus (PPO) covers Skilled Nursing Facility (SNF) services with no copay and no coinsurance, although prior authorization is required. This benefit is partially covered, as additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other Services are not covered under the Essence Advantage Premier Plus (PPO) plan, meaning there is no coverage for acupuncture, over-the-counter (OTC) items, or meal benefits. Consequently, there are no copays or coinsurance for these services as they are not offered by the plan.
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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.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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