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Medical benefits overview
| CareFirst BlueChoice Advantage | Kaiser Permanente | ||
|---|---|---|---|
| In-network | Out-of-network | HMO | |
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*The amount that BCBS will pay for a given covered service is determined by the Plan Allowance for that service. The Plan Allowance for covered services is determined by the contracted rate or fee schedule that participating providers have agreed to accept for that service or the rate or fee that is established by law. |
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Choice of physician |
May use any provider in BlueChoice, BluePreferred PPO, or BlueCard PPO. No referrals required. |
Choose any physician. No network limitations. No referrals required. |
Must select a primary care physician from the list of physicians at one of Kaiser Permanente's medical centers. |
|
Annual deductible |
$400 individual $800 individual +1 $800 family The in-network annual deductible applies to non-preventive care services. Preventive care such as annual physicals and mammograms are not subject to the deductible, however, copayments still apply. |
$1,000 individual $2,000 individual + 1 $2,000 family |
None |
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Copayments |
$20 primary care $40 specialty care No copayment for preventive care office visits. No copayment for women's preventive health services. |
None |
$20 primary care $40 specialty care Does not apply to outpatient mental health and prescription benefits. No copayment for preventive care office visits for adult and children over age 5. No copayment for primary care physician office visits for children under age 5 (specialist copayments apply for children under age 5). No copayment for women's preventive health services. |
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Coinsurance |
90% paid by health plan* 10% paid by participant |
65% paid by health plan* 35% paid by participant |
None |
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Maximum out-of-pocket expense |
$2,750 individual $5,500 individual +1 $5,500 family The BlueChoice plan does not cover any portion of your medical bills until you first meet your annual deductible; copayments still apply and do not count toward the deductible. After the deductible is met for the year, you pay the copayment for certain covered services. Most covered services are reimbursed by BCBS at 90% of plan allowance and you pay 10%. If you reach the maximum out-of-pocket expense for the year, BCBS pays 100% of the plan allowance(s) for covered expenses for the remainder of the year. |
$4,000 individual $8,000 individual +1 $8,000 family The out-of-network plan does not cover any portion of your medical bills until you first meet your annual deductible. After the deductible is met for the year, most covered services are reimbursed by BCBS at 65% of plan allowance and you pay 35%. Once you reach the maximum out-of-pocket expense for the year, BCBS pays 100% of the plan allowance(s) for covered expenses for the remainder of the year. |
$3,500 individual $9,400 family |
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Lifetime maximum |
Unlimited |
Unlimited |
Unlimited |
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Claim forms |
No claim forms to file. |
You may need to file your own claims. If your provider participates with BCBS through another plan, they are required to submit your claims on your behalf and BCBS will reimburse them directly. |
No claim forms to file. |
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Pre-certification |
Hospital certifications arranged by physicians. |
You are responsible for arranging your own hospital certifications. There is a financial penalty if pre-certification is not arranged. |
Hospital certification arranged by the member through the plan. |
Alcohol and drug abuse treatment
| CareFirst BlueChoice Advantage | Kaiser Permanente | ||
|---|---|---|---|
| In-network | Out-of-network | HMO | |
|
Outpatient/alcohol substance abuse |
100% coverage for physician expenses after $20 per visit copayment, subject to annual deductible. |
65% of plan allowance for physician expenses, subject to annual deductible. Limited to 30 visits per calendar year. 65% of plan allowance for covered services at an outpatient facility, subject to annual deductible. |
100% coverage for first 20 visits. $20 per visit copayment for individual or $10 per visit copayment for group for each additional visit. |
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Inpatient alcohol/substance abuse treatment |
Detoxification: 90% coverage after $250 copayment, subject to annual deductible. Rehabilitation: 90% coverage after $250 copayment, subject to annual deductible. Coverage for up to 30 days. All detoxification and rehabilitation benefits count against the mental health day/visit maximums. |
Detoxification: 65% of plan allowance, subject to annual deductible. Rehabilitation: 65% of plan allowance, subject to annual deductible. |
$250 copayment. Unlimited inpatient days. |
Diagnostic and screening services
| CareFirst BlueChoice Advantage | Kaiser Permanente | ||
|---|---|---|---|
| In-network | Out-of-network | HMO | |
|
Diagnostic services |
90% coverage only at approved locations, subject to annual deductible. |
65% of plan allowance, subject to annual deductible. |
100% coverage. |
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Non-emergency CT scans and MRIs |
$40 copayment, subject to annual deductible. |
65% of plan allowance, subject to annual deductible. |
$50 copayment. |
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Family planning/fertility |
100% coverage for primary care provider, after $20 per visit copayment, subject to annual deductible then 100% of allowed benefit to $100,000 lifetime maximum. 100% coverage for specialist, after $40 per visit copayment, subject to annual deductible then 100% of allowed benefit to $100,000 lifetime maximum. Prior authorization is required. Documented 1 year period of trying to become pregnant. Diagnosis and treatment of infertility, including medically necessary, non-experimental artificial insemination and in vitro fertilization (IVF). |
Testing provided to determine that a diagnosis for infertility exists. The testing is covered at 65% of plan allowance, subject to the annual deductible. No further benefits available if diagnosis is confirmed. |
50% coverage, after $40 per visit copayment for family planning and counseling services and physician services for the diagnosis and treatment of involuntary infertility such as artificial insemination, lab and x-rays. In vitro fertilization (IVF): 50% coverage to $100,000 benefit maximum up to 3 procedures per live birth. Documented 1 year of trying to become pregnant. |
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Preventive care mammography |
100% coverage. |
65% of plan allowance, subject to annual deductible. Limited to: Ages 35-39: one preventive mammogram of both breasts in the 5 years. Ages 40-49: one preventive mammogram of both breasts every 2 years. Ages 50 and above: one preventive mammogram of both breasts every year. |
100% coverage. |
Durable medical equipment
| CareFirst BlueChoice Advantage | Kaiser Permanente | ||
|---|---|---|---|
| In-network | Out-of-network | HMO | |
|
Durable medical equipment |
90% of plan allowance, subject to annual deductible. |
65% of plan allowance, subject to annual deductible. |
100% coverage with certification by primary care physician. |
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Hearing aids |
90% of plan allowance per 36-month period, subject to annual deductible. Amount above the allowed amount is billed to the member. |
65% of plan allowance per 36-month period, subject to annual deductible. Amount above the allowed amount is billed to the member. |
$0 copayment, 1 hearing aid per ear every 36 months up to a $1,000 maximum. |
Emergency and urgent care
| CareFirst BlueChoice Advantage | Kaiser Permanente | ||
|---|---|---|---|
| In-network | Out-of-network | HMO | |
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Emergency room |
$100 copayment waived when admitted. |
$100 copayment waived when admitted. |
100% coverage after $75 copayment when life-threatening situation or when authorized by plan. $75 copayment waived when admitted but $250 inpatient copayment applies. |
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Emergency transportation |
100% coverage, subject to annual deductible. |
100% coverage, subject to annual deductible. | 100% coverage after $50 copayment when life-threatening situation or when authorized by plan. |
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Urgent care |
$40 copayment. |
$40 copayment. |
Urgent care centers are available at Kaiser facilities for urgent and non-life threatening emergencies. |
Hospital admissions
| CareFirst BlueChoice Advantage | Kaiser Permanente | ||
|---|---|---|---|
| In-network | Out-of-network | HMO | |
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In-patient admissions |
90% coverage after $250 copayment when admitted by a BCBS physician to an approved hospital only at approved locations. Subject to annual deductible. |
65% of plan allowance, subject to annual deductible. Pre-certification is required. |
100% coverage after $250 copayment. |
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Preadmission testing |
90% coverage, subject to annual deductible. If testing requires hospital stay, $250 copayment applies. |
65% of plan allowance, subject to annual deductible for diagnostic testing, x-rays and lab work when rendered in the outpatient department of a hospital. |
100% coverage. If testing requires hospital stay, $250 copayment applies. |
Inpatient physician visits
| CareFirst BlueChoice Advantage | Kaiser Permanente | ||
|---|---|---|---|
| In-network | Out-of-network | HMO | |
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Medical/surgical physician services |
90% coverage for an approved admission, subject to annual deductible. |
65% of plan allowance, subject to annual deductible. |
100% coverage. |
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Specialist care |
90% coverage for an approved admission, subject to annual deductible. |
65% of plan allowance, subject to annual deductible. |
100% coverage. |
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Inpatient consultation |
90% coverage for an approved admission, subject to annual deductible. | 65% of plan allowance, subject to annual deductible. | 100% coverage. |
Maternity care
| CareFirst BlueChoice Advantage | Kaiser Permanente | ||
|---|---|---|---|
| In-network | Out-of-network | HMO | |
|
Inpatient hospital |
90% coverage after $250 copayment at approved locations. Subject to annual deductible. |
65% of plan allowance, subject to annual deductible. |
100% coverage after $250 copayment. |
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Outpatient hospital |
90% coverage at approved locations, subject to annual deductible. |
65% of plan allowance, subject to annual deductible. |
Not covered. |
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Physician office visit (prenatal) |
100% coverage. |
65% of plan allowance, subject to annual deductible. |
100% coverage through first postnatal visit. |
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Nurse midwife |
100% coverage after $40 per visit copayment up to $400 copayment per pregnancy. Nurse midwife must be associated with an approved center. Subject to annual deductible. |
65% of plan allowance, subject to annual deductible. Benefits may not be available for nurse midwife services if already billed by physician. |
100% coverage through first postnatal visit. |
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Birthing center |
100% coverage after $40 per visit copayment, subject to annual deductible. Up to $400 copayment per pregnancy at approved locations. |
65% of plan allowance, subject to annual deductible. |
Not covered. |
Mental health care
| CareFirst BlueChoice Advantage | Kaiser Permanente | ||
|---|---|---|---|
| In-network | Out-of-network | HMO | |
|
Outpatient mental health care |
100% coverage after $20 per visit copayment, subject to annual deductible. Includes psychotherapy for gender identity disorders. |
65% of plan allowance, subject to annual deductible for therapy rendered by psychiatrist, licensed psychologist, or licensed clinical social worker. Includes psychotherapy for gender identity disorders. |
100% coverage after $20 per visit copayment for individuals or $10 per visit copayment for group. |
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Psychological testing |
100% coverage after $20 per visit copayment, subject to annual deductible. Coverage for psychological and neuropsychological testing is provided for outpatient services to treat mental illnesses, emotional disorders, drug abuse, or alcohol abuse including psychological and neuropsychological diagnostic purposes. Services include evaluation, diagnosis and treatment of acute and non-acute conditions. The benefits for neuropsychological testing are not counted toward any outpatient mental health and substance abuse visit benefit. |
65% of plan allowance, subject to annual deductible. Coverage for psychological and neuropsychological testing is provided for outpatient services to treat mental illnesses, emotional disorders, drug abuse, or alcohol abuse including psychological and neuropsychological diagnostic purposes. Services include evaluation, diagnosis and treatment of acute and non-acute conditions. The benefits for neuropsychological testing are not counted toward any outpatient mental health and substance abuse visit benefit. |
Covered. |
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Inpatient mental health care |
90% coverage after $250 copayment for short term, acute mental health conditions. Subject to annual deductible. | 65% of plan allowance, subject to annual deductible. | 100% coverage after $250 copayment. |
Non-hospital care
| CareFirst BlueChoice Advantage | Kaiser Permanente | ||
|---|---|---|---|
| In-network | Out-of-network | HMO | |
|
Hospice care |
90% coverage, subject to annual deductible. No limit. Available during last 6 months of life. |
65% of plan allowance, subject to annual deductible. Limit of 180 days per lifetime, 60 of which may be used for inpatient hospice care. 45 lifetime reserve days are also available for inpatient or home care. Available during last 6 months of life. |
100% coverage. Subject to evaluation and authorization by plan. Available during last 6 months of life. |
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Home health care |
90% coverage, subject to annual deductible. |
65% of plan allowance, subject to annual deductible. |
100% coverage, when medically necessary. Subject to evaluation and authorization by plan. |
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Extended care facility (ECF) |
90% coverage when authorized by plan. Subject to annual deductible. |
65% of plan allowance, subject to annual deductible. |
100% coverage for up to 100 days. Includes bed, board and general nursing care, when authorized by HMO physician. |
Nursing care
| CareFirst BlueChoice Advantage | Kaiser Permanente | ||
|---|---|---|---|
| In-network | Out-of-network | HMO | |
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Inpatient private duty nurse |
90% coverage when authorized by plan for an approved admission due to medical necessity. Subject to annual deductible. |
Not covered. |
100% coverage when authorized by plan. |
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Outpatient private duty nurse |
Not covered. |
65% of plan allowance, subject to annual deductible. Limited to a maximum of two hours a day (1 visit) up to 50 visits per calendar year. |
100% coverage when authorized by plan. |
Outpatient physician visits
| CareFirst BlueChoice Advantage | Kaiser Permanente | ||
|---|---|---|---|
| In-network | Out-of-network | HMO | |
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Medical services and physician office visits |
100% coverage for primary care provider after $20 per visit copayment. 100% coverage for specialist after $40 per visit copayment. Subject to annual deductible for non-preventive care services. |
65% of plan allowance, subject to annual deductible. |
100% coverage for primary care provider after $20 per visit copayment. 100% coverage for specialist after $40 per visit copayment. No copayment for primary care physician for children under age 5; specialist copayments apply for children under age 5. |
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Well baby care |
100% coverage for primary care provider. |
65% of plan allowance, not subject to annual deductible. Unlimited visits to age 18. |
100% coverage for preventive services for children. |
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Routine physicals |
100% coverage for primary care provider. |
Not covered. |
100% coverage for preventive services. |
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Home physician visits |
100% coverage for primary care provider after $20 per visit copayment. 100% coverage for specialist after $40 per visit copayment. Subject to annual deductible for non-preventive care services. |
65% of plan allowance, subject to annual deductible. |
100% coverage when medically necessary. Subject to evaluation and authorization by plan. |
Prescription drug coverage
| Express Scripts | Kaiser Permanente | ||
|---|---|---|---|
| In-network | Kaiser Center Pharmacy | Outside Pharmacy | |
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*After the first three retail prescription fills for maintenance drugs, CareFirst participants pay an additional $10 for each retail fill. Use CVS Smart90 program or switch to home delivery to avoid the surcharge. **Excluded drugs do not apply towards out-of-pocket maximums. |
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Generic drugs, retail |
$10 |
$10 |
$20 |
| Brand name formulary drugs, retail* (30-day supply) |
30% coinsurance to $30 maximum |
$20 |
$40 |
| Brand name non-formulary drugs, retail* (30-day supply) |
50% coinsurance to $50 maximum |
$35 |
$55 |
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Excluded drugs**, retail |
100% participant responsibility |
Not applicable |
Not applicable |
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Generic drugs, home delivery |
$25 |
$20 |
$20 |
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Brand name formulary drugs, home delivery |
30% coinsurance to $75 maximum |
$40 |
$40 |
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Brand name non-formulary drugs, home delivery |
50% coinsurance to $125 maximum |
$70 |
$70 |
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Excluded drugs** |
100% participant responsibility |
Not applicable |
Not applicable |
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Out-of-pocket maximum**, individual |
$3,850 |
Included with medical |
Included with medical |
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Out-of-pocket maximum**, individual + 1 or family |
$7,700 |
Included with medical |
Included with medical |
Special care services
| CareFirst BlueChoice Advantage | Kaiser Permanente | ||
|---|---|---|---|
| In-network | Out-of-network | HMO | |
|
Acupuncture |
$40 copayment, subject to annual deductible, up to 20 visits. Covers acupuncture for pain management and anesthesia. Coverage will be provided when such treatment is rendered by a trained practitioner who is licensed or certified as such by the duly constituted authority in the area in which service is rendered and when acting within the scope of such license or certification; and if the practitioner rendering the acupuncture treatment is not an M.D., such treatment must be under the direct supervision of an M.D. |
65% of plan allowance, subject to annual deductible. No visit limit. Covers acupuncture for pain management and anesthesia. Coverage will be provided when such treatment is rendered by a trained practitioner who is licensed or certified as such by the duly constituted authority in the area in which service is rendered and when acting within the scope of such license or certification; and if the practitioner rendering the acupuncture treatment is not an M.D., such treatment must be under the direct supervision of an M.D. |
$40 copayment, up to 20 visits. |
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Chiropractic |
$40 copayment, subject to annual deductible, up to 20 visits. |
65% of plan allowance, subject to annual deductible. No visit limit. |
$40 copayment, up to 20 visits. |
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Dental service |
Discounted dental benefits provided for limited number of services. |
Not covered. |
Discounted dental benefits provided for limited number of services after $30 copayment. |
|
Eye exams (routine) |
100% coverage for participating vision centers after $10 per visit copayment. 100% coverage for ophthalmologist after $25 per visit copayment. Limited to one per calendar year. |
Not covered. |
100% coverage for routine eye exam after $20 per visit copayment. 100% coverage for ophthalmologist after $40 per visit copayment. Limited to one per calendar year. |
|
Eyeglasses and contact lenses |
Discounts available at participating vision centers. Additional cost for contact lens fittings. |
Not covered. |
Discounts available at Kaiser centers and participating optical centers. |
|
Hearing screening exams |
100% coverage after $40 per visit copayment, subject to annual deductible. |
65% of plan allowance if exam is required as a result of accidental injury. Subject to annual deductible. |
100% coverage, copayments may apply. |
|
Inoculations including travel inoculations |
100% coverage after $20 per visit copayment for primary care provider, subject to annual deductible. 100% coverage after $40 per visit copayment for specialist, subject to annual deductible. |
65% of plan allowance, subject to annual deductible. |
Not covered. |
Surgery care
| CareFirst BlueChoice Advantage | Kaiser Permanente | ||
|---|---|---|---|
| In-network | Out-of-network | HMO | |
|
Outpatient surgery |
100% coverage for primary care provider after $20 per visit copayment. 100% coverage for specialist after $40 per visit copayment. 90% coverage for facility, subject to annual deductible. Subject to annual deductible for non-preventive care services. |
65% of plan allowance, subject to annual deductible. Pre-certification is required. |
100% coverage after $50 copayment. |
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Inpatient surgery |
90% coverage for an approved admission after $250 copayment. Subject to annual deductible. |
65% of plan allowance, subject to annual deductible. | 100% coverage after $250 copayment. |
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Second or multiple surgical opinion consultation |
100% coverage for specialist after $40 per visit copayment, subject to annual deductible. Paid in full if requested by CareFirst. |
65% of plan allowance, subject to annual deductible. |
100% coverage after $40 per visit copayment. |
|
Anesthesia services |
90% coverage, subject to annual deductible. |
65% of plan allowance, subject to annual deductible. |
100% coverage. |
|
Organ transplant |
90% coverage for limited services, subject to annual deductible. | 65% of plan allowance for limited services, subject to annual deductible. |
100% coverage for limited services when authorized by plan. |
Therapeutic services
| CareFirst BlueChoice Advantage | Kaiser Permanente | ||
|---|---|---|---|
| In-network | Out-of-network | HMO | |
|
Radiation/chemotherapy dialysis (physician) |
100% coverage after $40 per visit copayment or $20 copayment for primary care provider. Subject to deductible. |
65% of plan allowance, subject to deductible. |
100% coverage, after $40 per visit copayment. |
|
Physical therapy physician-billed or physical therapist billed |
100% coverage after $40 per visit copayment for short term care up to 40 visits, subject to deductible. Short term care means significant improvement is expected within 90 days. |
65% of plan allowance, subject to deductible. 40 visit limit (combined with in-network). |
100% coverage after $40 copayment per visit for up to 40 visits or 90 days, whichever is greater. |
|
Speech therapy |
100% coverage after $40 per visit copayment, subject to deductible. |
65% of plan allowance, subject to deductible. |
100% coverage after $40 per visit copayment for up to 40 visits or 90 days, whichever is greater. |
|
Occupational therapy |
100% coverage after $40 per visit copayment, subject to deductible. |
65% of plan allowance, subject to deductible. |
100% coverage after $40 per visit copayment for up to 2 months per contract year. |
Transgender care
| CareFirst BlueChoice Advantage | Kaiser Permanente | ||
|---|---|---|---|
| In-network | Out-of-network | HMO | |
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Covers pre- and post-surgical hormone therapy, surgery, if performed by a qualified provider and in conformance with HBIGDA standards. Requires pre-authorization. Surgical, hospital, and laboratory benefits, subject to $400,000 lifetime maximum. |
Covers pre- and post-surgical hormone therapy, surgery, if performed by a qualified provider and in conformance with HBIGDA standards. Requires pre-authorization. Surgical, hospital, and laboratory benefits, subject to $400,000 lifetime maximum. |
Covers pre- and post-surgical hormone therapy, surgery, if performed by a qualified provider and in conformance with HBIGDA standards. Requires pre-authorization. Surgical, hospital, and laboratory benefits, subject to $400,000 lifetime maximum. |