Essence Advantage Plus (HMO)
Available to residents of Macoupin County, IL for 2026. Contract H2610, plan 006, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Macoupin County
- Plan website
- Browse the Essence Advantage Plus (HMO) formulary
Renewed for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $59.00 |
|---|---|
| — medical (Part C) part | $5.00 |
| — drug (Part D) part | $54.00? |
| Monthly premium with full Extra Help (LIS) | $24.60?drug (Part D) part $19.60; Extra Help does not cover the medical (Part C) premium |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $2,900.00? |
| Drug deductible | $0.00 |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO? |
| Contract / plan | H2610-006-0 |
| Offered by | Essence Healthcare |
| Parent organization | Lumeris Group Holdings Corporation |
| Formulary drugs | 3,508 |
| Formulary exception tier | 4? |
| Pharmacy search | www.essencehealthcare.com/ |
| Member services | (866)509-5399TTY 711 |
CMS star ratings
- Overall
- 4.5 out of 5 stars for Overall
- Health plan (Part C)
- 4.5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 3.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H2610 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $30 copay(authorization and referral required) |
| Other health care professional | $30 copay(authorization and referral required) |
| Additional telehealth services | $0–$30 copay(authorization and referral required) |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $0–$30 copay(authorization required) |
| Lab services | $0 copay(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | $0–$200 copay(authorization required) |
| Therapeutic radiology | 20% coinsurance(authorization required) |
| Outpatient x-rays | $20 copay(authorization required) |
| Emergency and urgent care | |
| Emergency room | $125 copay |
| Urgent care | $30 copay |
| Worldwide emergency coverage | $125 copay |
| Worldwide urgent care | $125 copay |
| Worldwide emergency transportation | Not covered |
| Hospital care | |
| Inpatient hospital stay | $250 per day for days 1–7; $0 per day for days 8–90(authorization required) |
| Outpatient hospital services | $250 copay(authorization required) |
| Outpatient observation | $250 copay |
| Ambulatory surgical center | $125 copay(authorization required) |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $125 per day for days 21–100(authorization required) |
| Home health care | $0 copay(referral required) |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | $20 copay(referral required) |
| Physical therapy and speech-language therapy | $20 copay(referral required) |
| Cardiac rehabilitation | $20 copay(referral required) |
| Pulmonary rehabilitation | $20 copay(referral required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $250 per day for days 1–7; $0 per day for days 8–90(authorization required) |
| Outpatient mental health, individual session | $15 copay |
| Outpatient mental health, group session | $10 copay |
| Psychiatrist, individual session | $15 copay(authorization required) |
| Psychiatrist, group session | $10 copay(authorization required) |
| Partial hospitalization | $0 copay(authorization required) |
| Intensive outpatient program | $0 copay(authorization required) |
| Outpatient substance use, individual session | $15 copay(authorization required) |
| Outpatient substance use, group session | $10 copay(authorization required) |
| Opioid treatment program | $15 copay |
| Ambulance and transportation | |
| Ground ambulance | $160 copay(authorization required) |
| Air ambulance | $160 copay(authorization required) |
| Transportation to plan-approved locations | $0 copay(limits apply) |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | $0 copay(authorization required) |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $20 copay(referral required) |
| Routine chiropractic care | Not covered |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | $30 copay(referral required) |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $30 copay(authorization and referral required) |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | $0 copay(limits apply) |
| Dental x-rays | $0 copay(limits apply) |
| Other diagnostic dental services | Not covered |
| Other preventive dental services | Not covered |
| Comprehensive dental plan limit | $2,000 plan limit every year |
| Restorative services (fillings, crowns) | $0 copay |
| Endodontics (root canals) | $0 copay |
| Periodontics (gum disease) | $0 copay |
| Dentures and other removable prosthodontics | $0 copay |
| Maxillofacial prosthetics | $0 copay |
| Implants | $0 copay |
| Bridges and other fixed prosthodontics | $0 copay |
| Oral and maxillofacial surgery | $0 copay |
| Orthodontics | $0 copay |
| Adjunctive general services | $0 copay |
| Vision? | |
| Eye exam (Medicare-covered) | $30 copay(referral required) |
| Routine eye exam | $0 copay(referral required, limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) |
| Eyewear plan limit | $300 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | $0 copay(limits apply) |
| Eyeglass frames | $0 copay(limits apply) |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | $20 copay(referral required) |
| Routine hearing exam | $20 copay(referral required) |
| Hearing aid fitting and evaluation | $0 copay(referral required, limits apply) |
| Hearing aid plan limit | $1,000 plan limit every two years |
| Hearing aids (all types) | $0 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | 0%–20% coinsurance(authorization required) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required) |
| Other Part B drugs | 0%–20% coinsurance(authorization required) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | $40 allowance every three months |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | $0 copay |
| Health education | Not covered |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | Not covered |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $3.00 |
| Tier 3 | $45.00 |
| Tier 4 | $95.00 |
| Tier 5 | 33% |
| Tier 6 | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $4.00 | $0.00 | $0.00 | $12.00 | $0.00 |
| Tier 2: Generic | $3.00 | $12.00 | $3.00 | $9.00 | $36.00 | $6.00 |
| Tier 3: Preferred Brand | $45.00 | $47.00 | $45.00 | $135.00 | $141.00 | $90.00 |
| Tier 4: Non-Preferred Drug | $95.00 | $100.00 | $95.00 | $285.00 | $300.00 | $190.00 |
| Tier 5: Specialty Tier | 33% | 33% | 33% | n/a | n/a | n/a |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 6 other IL counties
Benefits in plain text
Essence Advantage Plus (HMO) (H2610-006-0) is a 2026 HMO Medicare Advantage plan offered by Essence Healthcare, available to residents of Macoupin County, IL.
The monthly premium is $59.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $24.60.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $2,900.00.
The drug deductible is $0.00.
The plan's formulary lists 3,508 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $3.00; tier 3: $45.00; tier 4: $95.00; tier 5: 33%; tier 6: $0.00.
CMS gives the plan's contract (H2610) an overall rating of 4.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.