A non-government entity
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 2026, 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 2026.
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:
Sign up for CareFirst BlueCross BlueShield Advantage Essential (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The CareFirst BlueCross BlueShield Advantage Essential (PPO) prescription drug plan features a $0 drug deductible, meaning your coverage begins immediately. For Tier 1 preferred generic drugs, you will pay no copay for up to a 3-month supply at standard pharmacies and through standard mail order. Tier 2 generic drugs require a $5 copay for a 1-month supply, though standard mail order offers a flat $5 copay for 2-month and 3-month supplies as well. For brand-name and specialty medications, this Medicare plan utilizes coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 20% coinsurance, while Tier 4 non-preferred drugs carry a 40% coinsurance for standard pharmacy and mail order fills. Specialty drugs in Tier 5 require a 33% coinsurance for a 1-month supply through standard pharmacy or standard mail order.
Additional Benefits
The CareFirst BlueCross BlueShield Advantage Essential (PPO) plan offers robust coverage with no copay for primary care visits, annual physicals, and routine preventive screenings. Specialist office visits require a $45 copay, emergency services have a $115 copay, and urgently needed care ranges from no copay to a $25 copay. For acute inpatient hospital stays, members pay a $385 copay for days 1 to 5, followed by no copay for days 6 through 90. In addition to medical care, the plan provides preventive dental, routine vision exams, and routine hearing exams with no copay, alongside a $1,000 allowance for comprehensive dental services. Members can also take advantage of home health services with no copay, up to 32 free one-way trips to health-related locations, and a $50 over-the-counter item allowance every three months. Diagnostic lab tests and diabetic supplies are also covered with no copay or coinsurance.
Inpatient Hospital See details
CareFirst BlueCross BlueShield Advantage Essential (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $385 copay for days 1 to 5 of an acute stay and a $250 copay for days 1 to 5 of a psychiatric stay, with no copay for days 6 to 90 for both. Prior authorization is required, and additional days, non-Medicare-covered stays, and acute upgrades are not covered.
Outpatient Services See details
Outpatient services are covered by CareFirst BlueCross BlueShield Advantage Essential (PPO) with no coinsurance, featuring outpatient hospital copays ranging from $0 to $350 and daily observation copays of $295. Ambulatory surgical center services require a $200 copay with no coinsurance, outpatient substance abuse sessions have a $10 copay, and outpatient blood services are fully covered with no copay, coinsurance, or deductible.
Partial Hospitalization See details
Partial hospitalization is covered by CareFirst BlueCross BlueShield Advantage Essential (PPO) with a $40.00 copay and no coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered under the CareFirst BlueCross BlueShield Advantage Essential (PPO) plan, featuring a $300 copay and no coinsurance for ground and air ambulance services, which require prior authorization. The plan also offers up to 32 one-way trips per year to any health-related location with no copay and no coinsurance, though transportation to plan-approved health-related locations is not covered.
Emergency Services See details
CareFirst BlueCross BlueShield Advantage Essential (PPO) covers emergency services with a $115 copay and no coinsurance, and urgently needed services with a $0 to $25 copay and no coinsurance. Worldwide emergency and urgent services are partially covered up to $25,000 with no copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
CareFirst BlueCross BlueShield Advantage Essential (PPO) covers primary care physician services and opioid treatment with no copay and no coinsurance. Other services require no coinsurance, with copays ranging from $10.00 for mental health and podiatry visits to $15.00 for physical, occupational, and speech therapies, and $45.00 for specialists. Chiropractic benefits are partially covered, offering routine care for a $15.00 copay and no coinsurance for up to 12 visits yearly, while other chiropractic services are not covered.
Preventive Services See details
Preventive Services are partially covered by CareFirst BlueCross BlueShield Advantage Essential (PPO) with no copay and no coinsurance for annual physicals, kidney disease education, memory fitness, and routine screenings. Excluded from coverage are health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, smoking cessation, enhanced disease management, telemonitoring, remote access technologies, home modifications, and counseling.
Hearing Services See details
Hearing services are partially covered by CareFirst BlueCross BlueShield Advantage Essential (PPO), offering Medicare-covered exams for a $20 copay and no coinsurance, alongside annual routine exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are covered with no coinsurance and copays between $475 and $1,950, but OTC hearing aids and inner ear, outer ear, and over-the-ear prescription models are not covered.
Vision Services See details
CareFirst BlueCross BlueShield Advantage Essential (PPO) provides partially covered vision services with no deductible and no coinsurance, featuring eye exams with a $20 copay (or no copay to a $60 copay for routine exams) and eyewear with no copay (or a $10 copay for eyeglasses). Other eye exam services, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
CareFirst BlueCross BlueShield Advantage Essential (PPO) partially covers dental services, providing preventive care with no copay and no coinsurance, and Medicare-covered dental services for a $40 copay and no coinsurance. Comprehensive dental benefits have a $1,000 annual limit with copays ranging from $15 to $700 and no coinsurance, though other diagnostic services, other preventive services, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by CareFirst BlueCross BlueShield Advantage Essential (PPO) with no copay and no coinsurance, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other Part B drugs carry no copay and a 0% to 20% coinsurance, while Part B insulin drugs require a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
CareFirst BlueCross BlueShield Advantage Essential (PPO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
CareFirst BlueCross BlueShield Advantage Essential (PPO) covers durable medical equipment, prosthetics, and medical supplies with no copay and 20% coinsurance. Diabetic supplies are covered with no copay and no coinsurance, while diabetic therapeutic shoes and inserts require 20% coinsurance and no copay.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by CareFirst BlueCross BlueShield Advantage Essential (PPO) with no coinsurance, though prior authorization is required. Under this plan, lab services have no copay, diagnostic tests require a $15 copay, outpatient X-rays require a $25 copay, and therapeutic radiological services start at an $80 copay, while diagnostic radiological services start with no copay.
Home Health Services See details
Home Health Services are covered under the CareFirst BlueCross BlueShield Advantage Essential (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered with no coinsurance under the CareFirst BlueCross BlueShield Advantage Essential (PPO) plan, though only some services are covered in practice. Standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and require a $10 copay.
Skilled Nursing Facility (SNF) See details
CareFirst BlueCross BlueShield Advantage Essential (PPO) covers Skilled Nursing Facility (SNF) care with no coinsurance, featuring no copay for days 1 through 20 and a $200 copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
CareFirst BlueCross BlueShield Advantage Essential (PPO) offers coverage for acupuncture with a $20 copay and no coinsurance for up to 12 treatments per year, as well as over-the-counter (OTC) items with no copay and no coinsurance up to a $50 limit every three months. Meal benefits and certain OTC items, such as nicotine replacement therapy and naloxone, are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved