Essence Advantage Gold (HMO)

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We’ve got you covered from head to toe

NO Deductibles

With Essence Advantage Gold, 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 Advantage Gold 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

Essence Healthcare members can get generic prescriptions for low copays and reduced copays on brand-name medications.

Important Financial Protection

Essence Healthcare 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)

Monthly Premium

Monthly Premium — $30

Maximum Out-of-Pocket Limit

Maximum Out-of-Pocket Limit — $5,500 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 — $110 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 — $275 Per Day for Days 1-7, $0 Per Day for Days 8 and Beyond

Outpatient Surgery at Hospital

Outpatient Surgery at Hospital — $250 Copay

Outpatient Surgery at Ambulatory Surgery Center

Outpatient Surgery at Ambulatory Surgery Center — $250 Copay

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 an in-network pharmacy.

Essence Advantage Gold (HMO)

Annual Deductible

Annual Deductible — $0

Tier 1 – Preferred Generics

Tier 1 – Preferred Generics — $5 Copay*

Tier 2 – Generics

Select Insulins†

Tier 2 – Generics — $15 Copay*

Select Insulins — $15 Copay*

Tier 3 – Preferred Brands

Select Insulins†

Tier 3 – Preferred Brands — $47 Copay*

Select Insulins — $35 Copay*

Tier 4 – Non-Preferred Brands

Tier 4 – Non-Preferred Brands — $100 Copay*

Tier 5 – Specialty Drugs

Tier 5 – Specialty Drugs — 33% Coinsurance*

Tier 6 – Select Care**

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 — $4,660 Per Year

*30-Day supply.

**Select care drugs are all Tier 6 drugs and are used for the treatment of diabetes, high cholesterol and high blood pressure.

Drug Price Search Tool

Pharmacy Search Tool

Insulin Coverage

You won’t pay more than $35 for a one-month supply of each Part D insulin product covered by our plan, no matter the cost-sharing tier of the insulin product, the prescription drug coverage stage you are in (initial coverage, coverage gap or catastrophic coverage), your Extra Help status or whether the insulin product is considered a Select Insulin under the plan’s Prescription Drug Formulary.^†

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 incur low, consistent copays through the coverage gap. Insulins administered via a durable medical equipment insulin pump are not included in the program. 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. The program doesn’t apply during the catastrophic coverage stage or if you receive Extra Help.

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.

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