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CareFirst BlueCross BlueShield Advantage Essential (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for CareFirst BlueCross BlueShield Advantage Essential (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on CareFirst BlueCross BlueShield Advantage Essential (PPO) in 2025, please refer to our full plan details page.
CareFirst BlueCross BlueShield Advantage Essential (PPO) is a PPO plan offered by CareFirst, Inc. available for enrollment in 2025 to people living in Maryland. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that CareFirst BlueCross BlueShield Advantage Essential (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about CareFirst BlueCross BlueShield Advantage Essential (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For CareFirst BlueCross BlueShield Advantage Essential (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $13300.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $13300.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The CareFirst BlueCross BlueShield Advantage Essential (PPO) plan has no deductible for prescription drugs. During the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, you'll pay a $10 copay for preferred generic drugs at a standard pharmacy. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered Part D drugs. However, you may still pay for excluded drugs covered under any enhanced benefit.
Additional Benefits
The CareFirst BlueCross BlueShield Advantage Essential (PPO) plan offers a wide range of benefits, including coverage for inpatient and outpatient services. Inpatient hospital stays have a copay, while many outpatient services have a $0 copay. The plan also covers preventive, hearing, vision, and dental services. It includes coverage for emergency services, ambulance, and transportation, and offers additional benefits like home health services, and home infusion.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered under the CareFirst BlueCross BlueShield Advantage Essential (PPO) plan. For acute care, you will pay a $350 copay for days 1-5, and no copay for days 6-90; for psychiatric care, you will pay a $250 copay for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient services are covered by the CareFirst BlueCross BlueShield Advantage Essential (PPO) plan, including outpatient hospital services with a copay of $0-$295, observation services with a copay of $295, ambulatory surgical center (ASC) services with a $200 copay, outpatient substance abuse services with a $10 copay for both individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the CareFirst BlueCross BlueShield Advantage Essential (PPO) plan, but requires prior authorization. You will have a $40 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the CareFirst BlueCross BlueShield Advantage Essential (PPO) plan. Both ground and air ambulance services have a $300 copay, with no coinsurance. Transportation Services to any health-related location are covered for 10 one-way trips per year, with the mode of transportation including bus/subway, medical transport, and other. Transportation Services to a plan-approved health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the CareFirst BlueCross BlueShield Advantage Essential (PPO) plan, with a $110 copay and no coinsurance. Urgently Needed Services have a copay between $0 and $30 and no coinsurance, and Worldwide Emergency Services are covered with a maximum benefit of $25,000.
Primary Care See details
CareFirst BlueCross BlueShield Advantage Essential (PPO) covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy services with a $15 copay, physician specialist services with a $45 copay, mental health specialty services with a copay of $10, podiatry services with a copay of $10, other health care professional services with a copay between $0 and $45, psychiatric services with a copay of $10, physical therapy and speech-language pathology services with a $15 copay, additional telehealth benefits with no copay, and opioid treatment program services with no copay. Routine Chiropractic Care is limited to 12 visits per year.
Preventive Services See details
Preventive services include no copay for annual physical exams and additional preventive services such as In-Home Safety Assessment, Fitness Benefit (Memory Fitness), Remote Access Technologies, and Kidney Disease Education Services. Other preventive services such as Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit also have no copay. However, Health Education, Personal Emergency Response System, Medical Nutrition Therapy, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
The CareFirst BlueCross BlueShield Advantage Essential (PPO) plan covers hearing exams with a $20 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are partially covered, with a copay between $475 and $1950, but inner ear, outer ear, and over the ear prescription hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
CareFirst BlueCross BlueShield Advantage Essential (PPO) covers vision services, including eye exams with a $20 copay. Eyewear is covered with no copay, and contact lenses are covered. Eyeglasses (lenses and frames) have a $10 copay, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services include coverage for Medicare dental services with a $40 copay, oral exams with no copay, dental x-rays with no copay, prophylaxis (cleaning) with no copay, and fluoride treatment with no copay. Orthodontic services are covered with a $1,000 maximum plan benefit coverage per year. Restorative services have a copay of $15-$400, Adjunctive General Services have a copay of $15-$30, Endodontics have a copay of $100-$200, Periodontics have a copay of $50-$300, Prosthodontics, removable have a copay of $30-$700, Implant Services have a copay of $70-$500, Prosthodontics, fixed have a copay of $40-$400, and Oral and Maxillofacial Surgery have a copay of $40-$100. Maxillofacial Prosthetics and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the CareFirst BlueCross BlueShield Advantage Essential (PPO) plan. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and Prosthetics/Medical Supplies with no copay and coinsurance for Medicare-covered items. Diabetic Equipment is covered with coinsurance for Medicare-covered diabetic supplies and a copay for therapeutic shoes or inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by CareFirst BlueCross BlueShield Advantage Essential (PPO). Diagnostic Procedures/Tests have a $15 copay, and Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $200, Therapeutic Radiological Services have a copay of at most $80, and Outpatient X-Ray Services have a $25 copay.
Home Health Services See details
Home Health Services are covered by the CareFirst BlueCross BlueShield Advantage Essential (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover any of the listed sub-services, which include Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by CareFirst BlueCross BlueShield Advantage Essential (PPO) with prior authorization required. There is no copay for days 1-20, and a $200 copay for days 21-100; additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes acupuncture and over-the-counter (OTC) items. Acupuncture has a $20 copay and is limited to 12 treatments per year, and requires prior authorization. Over-the-counter items are covered up to $50 every three months.
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