2027 Medicare Advantage plan

Essence Advantage Premier Plus (PPO): 2027 benefits and costs

Essence Healthcare PPO

CMS plan ID: H6200-008-0 · Plan year: 2027

Essence Advantage Premier Plus (PPO) is a 2027 Medicare Advantage plan offered by Essence Healthcare. It is listed in Illinois, Missouri.

2027 plan costs at a glance

Monthly plan premium$264.00

Drug deductible$700.00

In-network medical out-of-pocket maximum$2,900.00

Organization: Essence Healthcare
Plan organization: ESSENCE HEALTHCARE PPO, INC.
Parent company: Lumeris Group Holdings Corporation
Plan type: PPO
Part C premium: $183.30
Part D premium: $80.70
Prescription drug coverage: Yes
2027 CMS Star Rating

Standard monthly Medicare Part B premium: $209.50 (estimated)

You must continue to pay your Medicare Part B premium.

Annual medical deductible: None
In-network medical maximum: $2,900.00
Applies to certain in-network supplemental services.
Combined in/out-of-network medical maximum: $2,900.00
Applies to certain out-of-network supplemental services and certain in-network supplemental services.
Out-of-network medical maximum: Not applicable

2027 benefit summary

Doctor visits and medical care

Common medical services and member costs
Service	In-network	Out-of-network	What to know
Primary care doctor	$0 Service-specific deductible No	$0 Deductible applies No
Specialist visit	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No
Telehealth	$0 Service-specific deductible No	Not summarized. Check coverage with the plan.	Approval required Yes Referral required No
Emergency care	$0	Not summarized. Check coverage with the plan.
Urgent care	$0	Not summarized. Check coverage with the plan.
Home health	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Dialysis	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Part B chemotherapy and radiation drugs	0% to 20% coinsurance Deductible applies No	20% coinsurance Deductible applies No	Approval required Yes
Other Part B drugs	0% to 20% coinsurance Deductible applies No	20% coinsurance Deductible applies No	Approval required Yes
Kidney disease education services	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Medicare-covered chiropractic	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Medicare-covered foot care	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Other health professionals	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No

Hospital, outpatient surgery and observation care

Inpatient stays and skilled nursing care

In-network stays. Charges can depend on the number of days and the benefit period.
Care	Your share of the cost	What to know
Inpatient hospital stay	$0.00 copay per stay Days 1–7: $300.00 copay per day Days 8–90: $0.00 copay per day	Approval required Yes Referral required No Benefit period Per Admission or Per Stay
Inpatient mental health care	$0.00 copay per stay Days 1–7: $300.00 copay per day Days 8–90: $0.00 copay per day	Approval required Yes Referral required No Benefit period Per Admission or Per Stay

See plan documents for out-of-network hospital and skilled nursing costs.

Hospital, outpatient surgery and observation care and member costs
Service	In-network	Out-of-network	What to know
Outpatient hospital care	$0 Service-specific deductible No	$0 Deductible applies No
Hospital observation services	$0 Service-specific deductible No	$0 Deductible applies No
Ambulatory surgical center	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No
Outpatient blood	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No

Tests, imaging and laboratory services

Tests, imaging and laboratory services and member costs
Service	In-network	Out-of-network	What to know
Diagnostic procedures and tests	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No
Laboratory services	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No
Diagnostic radiology (CT, MRI)	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No
Therapeutic radiology	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No
X-rays	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No

Mental health and substance use treatment

Mental health and substance use treatment and member costs
Service	In-network	Out-of-network	What to know
Partial hospitalization	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No
Intensive outpatient program	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No
Substance use treatment, individual sessions	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No
Substance use treatment, group sessions	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No
Opioid treatment program	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Mental health, individual sessions	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Mental health, group sessions	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Psychiatry, individual sessions	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No
Psychiatry, group sessions	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No

Therapy and rehabilitation

Therapy and rehabilitation and member costs
Service	In-network	Out-of-network	What to know
Occupational therapy	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Physical and speech therapy	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Cardiac rehabilitation	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Intensive cardiac rehabilitation	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Pulmonary rehabilitation	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Supervised exercise for peripheral artery disease	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
Service	In-network	Out-of-network	What to know
Ground ambulance	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes
Air ambulance	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes
Durable medical equipment	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes
Prosthetic devices	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes
Medical supplies	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes
Diabetic supplies	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes
Diabetic shoes and inserts	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes
Diabetic monitors	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes

Dental benefits

Dental benefits and member costs
Service	In-network	Out-of-network	What to know
Medicare-covered dental	$0	$0 Deductible applies No

Vision benefits

Vision benefits and member costs
Service	In-network	Out-of-network	What to know
Medicare-covered eye exams	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Medicare-covered eyewear	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No

Hearing benefits

Hearing benefits and member costs
Service	In-network	Out-of-network	What to know
Medicare-covered hearing exams	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Routine hearing examsAdditional plan benefit	$0	$0 Deductible applies No	Approval required No Referral required No
Hearing aid fitting and evaluationAdditional plan benefit	$0	$0 Deductible applies No	Approval required No Referral required No
Prescription hearing aids (all types)Additional plan benefit	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No

Additional network details

These costs apply to the listed service categories and networks.

Hearing benefits: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Hearing exams (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No
Prescription hearing aids (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No

Extra benefits

Extra benefits and member costs
Service	In-network	Out-of-network	What to know
Annual physical examAdditional plan benefit	$0 Service-specific deductible No	$0 Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Fitness benefitAdditional plan benefit	$0 Service-specific deductible No	50% coinsurance Deductible applies No Dollar benefit limit applies Yes Benefit allowance $100.00 How often this limit applies Every year	Approval required No Referral required No

Additional services and network costs

Additional network details

These costs apply to the listed service categories and networks.

Additional medical services: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost
Medicare-covered preventive servicesMedicare-covered care	Out-of-network	$0 Deductible applies No
Glaucoma ScreeningMedicare-covered care	Out-of-network	$0 Deductible applies No
Diabetes Self-Management TrainingMedicare-covered care	Out-of-network	$0 Deductible applies No
Digital Rectal ExamsMedicare-covered care	Out-of-network	$0 Deductible applies No
EKG after a Welcome to Medicare visitMedicare-covered care	Out-of-network	$0 Deductible applies No
Medicare Part B insulinMedicare-covered care	Out-of-network	0% to 20% coinsurance Deductible applies No

Prescription drug coverage

Costs shown are for initial coverage.

Drug deductible exceptions: Tier 1; Tier 2 are exempt from the deductible.

Preferred retail costs

On a small screen, scroll the table sideways to compare all fill lengths.

Preferred retail: initial-coverage cost per prescription fill
Drug tier	30 days	60 days	90 days
Tier 1Preferred Generic	$0.00	$0.00	$0.00
Tier 2Generic	$5.00	$10.00	$15.00
Tier 3Preferred Brand	25%	25%	25%
Tier 4Non-Preferred Drug	27%	27%	27%
Tier 5Specialty Tier	25%	Not listed	Not listed

Standard retail costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard retail: initial-coverage cost per prescription fill
Drug tier	30 days	60 days	90 days
Tier 1Preferred Generic	$10.00	$20.00	$30.00
Tier 2Generic	$15.00	$30.00	$45.00
Tier 3Preferred Brand	25%	25%	25%
Tier 4Non-Preferred Drug	27%	27%	27%
Tier 5Specialty Tier	25%	Not listed	Not listed

Mail-order and other pharmacies

Out-of-network pricing: The standard retail copay or coinsurance applies, without an added difference between the billed charge and the plan’s allowed amount. The plan’s out-of-network coverage rules still apply.

Standard mail order costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard mail order: initial-coverage cost per prescription fill
Drug tier	30 days	60 days	90 days
Tier 1Preferred Generic	$0.00	$0.00	$0.00
Tier 2Generic	$5.00	$10.00	$10.00
Tier 3Preferred Brand	25%	25%	25%
Tier 4Non-Preferred Drug	27%	27%	27%
Tier 5Specialty Tier	25%	Not listed	Not listed

Long-term care pharmacy costs

Long-term care pharmacy: initial-coverage cost per prescription fill
Drug tier	31 days
Tier 1Preferred Generic	$10.00
Tier 2Generic	$15.00
Tier 3Preferred Brand	25%
Tier 4Non-Preferred Drug	27%
Tier 5Specialty Tier	25%

Out-of-network pharmacy costs

Out-of-network pharmacy: initial-coverage cost per prescription fill
Drug tier	30 days
Tier 1Preferred Generic	$10.00
Tier 2Generic	$15.00
Tier 3Preferred Brand	25%
Tier 4Non-Preferred Drug	27%
Tier 5Specialty Tier	25%

Drug coverage rules and exceptions

Tier 1: Preferred Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 2: Generic

Drugs included in this tier: Both Part D and Excluded Drugs
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 3: Preferred Brand

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 4: Non-Preferred Drug

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 5: Specialty Tier

Drugs included in this tier: Part D Drugs Only

Initial-coverage prices also apply to drugs exempt from the deductible: Yes

Special cost protections apply to covered insulin and recommended adult vaccines.

Where this plan is offered

CMS lists this plan in 2 states or territories. Availability can vary by county and ZIP code.

View all locations 18 county listings across 2 states or territories