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||$3,200 Per Year|
|Preventative care/screening||$0 Copay|
|Primary care physician visits||$0 Copay|
|Specialist doctor visits||$35 Copay|
|Urgent care||$45 Copay|
|Emergency care||$125 Copay|
|Lab services||$5 Copay|
|Home health visit||$0 Copay|
|Chiropractic care||$20 Copay|
|Inpatient hospital care||$295 Copay Per Day, Per Stay for Days 1-6
$0 Per Day, Per Stay for Days 7 and Beyond
|Outpatient surgery at hospital||$220 Copay|
|Outpatient surgery at ambulatory surgery center||$220 Copay|
|Preferred Pharmacies*||Other Network Pharmacies*|
|Tier 1 – Preferred Generic||$0 Copay*||$5 Copay*|
|Tier 2 – Generics||$5 Copay*||$10 Copay*|
|Tier 3 – Preferred Brands||$42 Copay*||$47 Copay*|
|Tier 4 – Non-Preferred Brands||$95 Copay*||$100 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|
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No pharmacies have been selected.
|Flexible Benefits Card / Over-the-Counter (OTC) Items||$110 credit per quarter, supplied in the form of a debit card, to use on health-related over-the-counter items, no quarter-to-quarter rollover.
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||Routine Eye Exam $0 Copay when using an EyeQuest Provider, Eyeglasses $0 Copay, $200 allowance every 2 calendar years|
|Preventive Dental Care||$0 Copay|
|Comprehensive Dental Care||A max benefit of $1,250 for preventative and comprehensive combined|
|Hearing||$1,000 Allowance for up to 2 hearing aids every 2 years (both ears combined)
$20 Copay for hearing exam
$0 Copay for hearing aid fitting/evaluation (covered once every 2 calendar years)
|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 $0
- Specialist Copay $35
- Annual Deductible $0
- Generic Rx Drug Copay $0
- Max. Out-of-Pocket Cost $3,200
- Vision Care
- Dental Coverage
- Hearing Benefits
- Fitness Club Membership
- Worldwide Coverage while Traveling
- Generous Over-the-Counter Allowance
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