Hospital & Medical Coverage
|Maximum out of pocket|
|Primary care physician visits|
|Specialist doctor visits|
|Home health visit|
|Inpatient hospital care|
|Outpatient surgery at hospital|
|Outpatient surgery at ambulatory surgery center|
Other network pharmacies*
|Tier 1 – Preferred Generic||
|Tier 2 – Generics||
|Tier 3 – Preferred Brands||
|Tier 4 – Non-Preferred Brands||
|Tier 5 – Specialty Drugs||
|Initial Coverage Limits||
Essence Advantage (HMO) Plan Details
Hospital & Medical Coverage
|Maximum out of pocket||$3,000 Per Year|
|Preventative care/screening||$0 Copay|
|Primary care physician visits||$10 Copay|
|Specialist doctor visits||$40 Copay|
|Urgent care||$30 Copay|
|Emergency care||$125 Copay|
|Lab services||$20 Copay|
|Home health visit||$0 Copay|
|Chiropractic care||$20 Copay per visit|
|Inpatient hospital care||$310 Per Day for Days 1-7, $0 Per Day for Days 8 and Beyond|
|Outpatient surgery at hospital||$250 Copay|
|Outpatient surgery at ambulatory surgery center||$175 Copay|
|Preferred Pharmacies*||Other Network Pharmacies*|
|Tier 1 – Preferred Generic||$0 Copay*||$7 Copay*|
|Tier 2 – Generics||$0 Copay*||$12 Copay*|
|Tier 3 – Preferred Brands||$42 Copay*||$47 Copay*|
|Tier 4 – Non-Preferred Brands||$85 Copay*||$95 Copay*|
|Tier 5 – Specialty Drugs||33% Coinsurance*||33% Coinsurance*|
|Tier 6 – Insulins||$0 Copay*||$0 Copay*|
|Initial Coverage Limits||$4,660 Per Year||$4,660 Per Year|
No prescriptions have been selected.
No pharmacies have been selected.
|Flexible Benefits Card / Over-the-Counter (OTC) Items||$55 quarterly allowance for over-the-counter items
The Flexible Benefits Card is not a credit card, cannot be converted to cash, cannot be used to pay plan premiums, and cannot be used to pay for non-covered Flexible Benefit card services.
|Vision Care||$0 Copay for routine eye exam, $0 Copay for eyewear (eyeglass frames and lenses or contact lenses), $200 allowance every 2 calendar years|
|Preventive Dental Care||$0 Copay|
|Comprehensive Dental Care||$40 Copay for Medicare-covered services|
|Hearing||$20 Copay for hearing exam|
|SilverSneakers||Included at no additional cost|
|Travel Benefits||Emergency or urgent care coverage if you are making a trip out of state or country|
This is a summary of the plan benefits. Limitations, copayments, and exclusions may apply. See Evidence of Coverage or contact the plan for more details.
For the 2023 plan year, there is 1 plan available in your area
- Primary Doctor Copay $10
- Specialist Copay $40
- Annual Deductible $0
- Generic Rx Drug Copay $0
- Max. Out-of-Pocket Cost $3,000
- Vision Care
- Dental Coverage
- Hearing Benefits
- Transportation Assistance
- Fitness Club Membership
- Worldwide Coverage while Traveling
- Generous Over-the-Counter Allowance
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