Plan Details: Essence Advantage Gold (HMO)

We’ve got you covered from head to toe.

NO Deductibles

With Essence Advantage, there are no annoying deductibles to meet. Your coverage begins right away.

Complete Coverage With One Plan From One Company

Unlike Original Medicare plans, Essence bundles your medical, hospital and prescription drug coverage together in one comprehensive plan.

The plan comes with valuable extra benefits that save you even more.

Low Copays on Generic Prescriptions

Save even more money on your prescription drugs when you fill your prescription at preferred pharmacies. Essence members can get generic prescriptions for $5 copays and reduced copays on brand-name medications at any participating preferred pharmacy.

Important Financial Protection

Essence protects your savings and retirement by putting an annual limit on what you have to pay out of your own pocket for your covered medical expenses—important protection not offered by Original Medicare plans.

Important Travel Coverage

Whether you are making a trip out of the state or out of the country, we have you covered. If you ever get sick or injured when away from home, you can rest easy knowing you have emergency or urgent-care coverage.

Benefits at a Glance

Hospital and Medical Coverage

Essence Advantage Gold (HMO) – Alameda / San Mateo
Monthly Premium
Monthly Premium — $59
Maximum Out-of-Pocket Limit
Maximum Out-of-Pocket Limit — $5,900 Per Year
Annual Deductible
Annual Deductible — $0
Preventive Care/Screenings
Preventive Care/Screenings — $0 Copay
Primary Care Physician Visits
Primary Care Physician Visits — $5 Copay
Specialist Doctor Visits
Specialist Doctor Visits — $35 Copay
Urgent Care
Urgent Care — $35 Copay
Emergency Care
Emergency Care — $90 Copay
Lab Services
Lab Services — $10 Copay
Home Health Care
Home Health Care — 100% Coverage
Chiropractic Care
Chiropractic Care — $20 Copay
Inpatient Hospital Care
Inpatient Hospital Care — $315 Per Day for Days 1-7, $0 Per Day for Days 8 and Beyond
Outpatient Surgery at Hospital
Outpatient Surgery at Hospital — 20% Coinsurance
Outpatient Surgery at Ambulatory Surgery Center
Outpatient Surgery at Ambulatory Surgery Center — 20% Coinsurance

Part D Drug Coverage

Each Essence plan also includes generous prescription drug coverage. While we offer low copays
at all participating pharmacies, you also have the option of saving even more if you get your
prescriptions filled at a preferred pharmacy.

Essence Advantage Gold (HMO) – Alameda / San Mateo

In-Network Pharmacies
Out of Network Pharmacies
Annual Deductible
Annual Deductible — $0
Annual Deductible — $0
Tier 1 – Preferred Generic
Tier 1 – Preferred Generic — $5 Copay*
Tier 1 – Preferred Generic — $5 Copay*
Tier 2 – Generics
Tier 2 – Generics — $15 Copay*
Tier 2 – Generics — $15 Copay*
Tier 3 – Preferred Brands
Tier 3 – Preferred Brands — $47 Copay*
Tier 3 – Preferred Brands — $47 Copay*
Tier 4 – Non-Preferred Brands
Tier 4 – Non-Preferred Brands — $100 Copay*
Tier 4 – Non-Preferred Brands — $100 Copay*
Tier 5 – Specialty Drugs
Tier 5 – Specialty Drugs — 33% Co-insurance*
Tier 5 – Specialty Drugs — 33% Co-insurance*
Tier 6 – Select Care**
Tier 6 – Insulins — $0 Copay*
Tier 6 – Insulins — $0 Copay*
Mail Order – 90-Day Supply
Mail Order – 90-Day Supply — $10, $30, $94, $200, N/A, $0
Mail Order – 90-Day Supply — N/A
Initial Coverage Limits
Initial Coverage Limits — $4,430
Initial Coverage Limits — $4,430

*30-Day Supply

**Select Care drugs are generic drugs on Tier 6

Insulin Savings Program

As an Essence member, you’ll have low, predictable copays on Select Insulins through the Insulin Savings Program.† Costs for Select Insulins will remain the same during the Initial Coverage and Coverage Gap phases of your prescription drug benefit. The program doesn’t apply during the Catastrophic Coverage stage. Note that this program isn’t available if you receive Extra Help from the government.

Standard Retail Cost Sharing
Tier 2 Select Insulins†

30-Day Supply: $15 copay
60-Day Supply: $30 copay
90-Day Supply: $45 copay

Tier 3 Select Insulins†

30-Day Supply: $35 copay
60-Day Supply: $70 copay
90-Day Supply: $105 copay

Standard Mail-Order Cost Sharing
Tier 2 Select Insulins†

30-Day Supply: Not Offered
60-Day Supply: Not Offered
90-Day Supply: $30 copay

Tier 3 Select Insulins†

30-Day Supply: Not Offered
60-Day Supply: Not Offered
90-Day Supply: $94 copay

†Select Insulins are those that are part of the Insulin Savings Program and therefore will incur low, consistent copays through the coverage gap. For information regarding which insulins are Select Insulins under the plan’s benefit, refer to the plan’s Prescription Drug Formulary. See the Evidence of Coverage for more information regarding Select Insulins, including full cost-sharing information.

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Extra Benefits

In addition to comprehensive medical, hospital and Part D prescription drug coverage, Essence plans also include many valuable extras not offered by Original Medicare or Medicare supplements at no additional cost to you—just another way of helping you stay healthy while saving you money.

Learn More

Important Plan Documents

Ready to get the all-in-one coverage of an Essence Healthcare plan?

We make it easy for you to get the information you need, when and how you need it.

Request your FREE Information Kit

Download your FREE Medicare Advantage info kit or request a copy by mail.

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Schedule a one-on-one consultation

Get all your questions answered in a one-on-one appointment with a licensed Medicare advisor.

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Attend a Medicare Seminar

Learn more about Essence Healthcare plans at one of our FREE local or online Medicare seminars.

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Talk with a licensed Medicare advisor

Call anytime to discuss your options with a local, licensed Essence Healthcare advisor.

1-866-509-5398 (TTY: 711)