Benefits at a Glance:
We Have Got You Covered From Head to Toe
The following table highlights just some of the many benefits available to you as a valued Essence Advantage Select member. For more details and a complete list of benefits, please review our Summary of Benefits or Evidence of Coverage which can be downloaded by clicking the links below.
Medical & Hospital Coverage
Your Essence Healthcare plan provides comprehensive medical and hospital coverage with no annual deductible and low copayments.
|
Essence Advantage Select (HMO) |
| Monthly Premium |
$0 |
| Maximum Out-of-Pocket Limit What’s This? |
$2,900 Per Year |
| Annual Medical Deductible |
$0 Per Year |
| Preventive Care/Screenings |
$0 Copay |
| Primary Care Doctor Visits |
$0 Copay |
| Specialty Care Doctor Visits |
$45 Copay |
| Urgent Care |
$35 Copay |
| Emergency Care |
$120 Copay |
| Lab Services |
0% Co-insurance |
| Home Health Care |
100% Coverage |
| Chiropractic Services |
$20 Copay |
| Inpatient Hospital Care |
$350 Copay Per Day for Days 1-7,
$0 Per Day for Day 8 and beyond |
| Outpatient Surgery at Hospital |
$250 Copay |
| Outpatient Surgery at Ambulatory Surgical Center |
$175 Copay |
Part D Drug Coverage
This table shows the drug tiers associated with your plan, and the copayments or co-insurance that you will pay in each tier. A drug formulary provides a list of drugs that are covered by our plan.
|
Essence Advantage Select (HMO) |
|
Preferred
Pharmacies* |
Other Network
Pharmacies |
| Annual Part D Deductible |
$0 Per Year |
$0 Per Year |
| Tier 1 – Preferred Generics |
$0 Copay |
$4 Copay |
| Tier 2 – Generics |
$0 Copay |
$12 Copay |
| Tier 3 – Preferred Brand |
$39 Copay |
$47 Copay |
| Tier 4 – Non-Preferred Brands |
$75 Copay |
$100 Copay |
| Tier 5 – Specialty Drugs |
33% Co-insurance |
33% Co-insurance |
| Initial Coverage Limit |
$4,020 Per Year |
$4,020 Per Year |
*Schnucks, CVS, Target and Pharmax are Essence preferred pharmacies. Other pharmacies are available in our network.
Extra Benefits
Your Essence Healthcare plan offers many valuable extras not offered by Original Medicare or Medicare supplement plans-at no additional cost to you.
|
Essence Advantage Select (HMO) |
| Routine Eye Exam |
$35 Copay |
| Eyeglass Frames ** |
$0 Copay |
| Preventive Dental Visits |
$0 Copay |
| Comprehensive Dental Visits |
$100 Deductible,
$1,000 Maximum Benefit Per Year |
| Over-the-Counter (OTC) Items |
$100 Per Quarter |
| Transportation Assistance |
$0 Copay for 24 one-way trips to approved locations per year |
| SilverSneakers® Fitness Benefits What’s this? |
Included at No Additional Cost |
| Travel Coverage |
Urgent and emergent care is available worldwide |
Important Plan Documents
