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Blue Advantage Capital (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Advantage Capital (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Blue Advantage Capital (PPO) in 2026, please refer to our full plan details page.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
Blue Advantage Capital (PPO) is a PPO plan offered by Patrius Health, Inc. available for the 2026 plan year to people living in Capital Area. This plan received an overall rating of 3 out of 5 stars in 2026.
It's important to know that Blue Advantage Capital (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 Blue Advantage Capital (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 Blue Advantage Capital (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 a $300.00 drug deductible that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6400.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $6400.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
This plan has a Maximum Out-Of-Pocket cost of $9500.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $9500.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
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 Blue Advantage Capital (PPO)
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Drug Coverage
The Blue Advantage Capital (PPO) plan features a $300 drug deductible for prescription drug coverage. For Tier 1 preferred generic drugs, you will pay no copay for either a 1-month or 3-month supply at standard pharmacies and mail-order services. Tier 2 generic drugs require a $13 copay for a 1-month supply or a $26 copay for a 3-month supply through standard channels. For higher-tier medications, costs shift to a coinsurance model at standard pharmacies and mail-order services. Tier 3 preferred brand drugs carry a 20% coinsurance, while Tier 4 non-preferred drugs require a 30% coinsurance for both 1-month and 3-month supplies. Specialty Tier 5 drugs are covered with a 29% coinsurance for 1-month and 3-month fills.
Additional Benefits
The Blue Advantage Capital (PPO) plan offers comprehensive coverage for your core medical needs, featuring no copay for primary care doctor visits and a $25 copay for specialist appointments. If you require hospital services, inpatient stays have a $300 daily copay for days 1 through 7 and no copay for days 8 through 90, while outpatient hospital services range from no copay to a $225 copay. Emergency room visits require a $130 copay, which is waived if you are admitted to the hospital. For extra benefits, the plan features preventive dental care with no copay up to a $375 annual limit and routine hearing exams for a $10 copay, though vision services and transportation are not covered. Durable medical equipment carries a 25% coinsurance, while home health services are provided with no copay. Skilled nursing facility stays are also covered, requiring a $10 daily copay for the first 20 days and a $218 daily copay for days 21 through 100.
Inpatient Hospital See details
Blue Advantage Capital (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $300 daily copay for days 1 through 7 and no copay for days 8 through 90. While unlimited additional acute care days are covered at no copay, hospital upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Blue Advantage Capital (PPO) covers outpatient services with no coinsurance, including outpatient hospital and observation services with a copay of $0 to $225, and outpatient substance abuse sessions with a $25 copay. Ambulatory surgical center and outpatient blood services are also covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by the Blue Advantage Capital (PPO) plan with a $55.00 copay and no coinsurance.
Ambulance and Transportation Services See details
Blue Advantage Capital (PPO) covers Medicare-covered ground and air ambulance services with a $395 copay and no coinsurance, which is not waived if you are admitted to the hospital. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Blue Advantage Capital (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require no copay to a $25 copay with no coinsurance, while worldwide emergency services are covered up to $50,000 with no coinsurance and copays ranging from no copay to $395 depending on the service.
Primary Care See details
Blue Advantage Capital (PPO) primary care benefits are partially covered, offering primary care doctor visits and opioid treatment programs with no copay and no coinsurance, while podiatry services are not covered. Specialist visits, mental health, and psychiatric services require a $25 copay and no coinsurance, while occupational, physical, and speech therapies require a $40 copay and no coinsurance. For chiropractic services, some services are covered with a $15 copay and no coinsurance, but routine chiropractic care and other chiropractic services are not covered.
Preventive Services See details
Blue Advantage Capital (PPO) partially covers preventive services, offering covered care with no copay and no coinsurance for Medicare-covered zero-dollar services, kidney disease education, and select screenings. However, annual physical exams and additional preventive benefits—such as fitness programs, health education, weight management, and in-home safety assessments—are not covered.
Hearing Services See details
Blue Advantage Capital (PPO) hearing services include one annual routine exam for a $10 copay and no coinsurance, and unlimited fitting evaluations with no copay or coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay of $499 to $999 for up to two devices per year, though inner ear, outer ear, over the ear, and OTC hearing aids are not covered.
Vision Services See details
Blue Advantage Capital (PPO) does not cover vision services in practice because all sub-services, including routine eye exams, contact lenses, and eyeglasses, are not covered. Although eye exams technically have a $25 copay with no coinsurance and eyewear has no copay with 20% coinsurance, no actual benefits are provided.
Dental Services See details
Blue Advantage Capital (PPO) provides partially covered dental services, featuring Medicare-covered dental with a $30 copay and no coinsurance, and preventive care like exams and cleanings with no copay and no coinsurance up to a $375 annual limit. Restorative services, endodontics, periodontics, prosthodontics, implants, oral surgery, and orthodontics are not covered.
Home Infusion bundled Services See details
Blue Advantage Capital (PPO) covers home infusion bundled services with no copay, though associated Medicare Part B chemotherapy, radiation, and other drugs require a coinsurance ranging from no coinsurance to 20%. Covered Part B insulin drugs carry a $35 copay and a coinsurance ranging from no coinsurance to 20%, and step therapy may apply.
Dialysis Services See details
Dialysis services are covered under the Blue Advantage Capital (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Blue Advantage Capital (PPO) covers durable medical equipment, prosthetics, and medical supplies with no copay and 25% coinsurance. Diabetic equipment is partially covered with no copay and no coinsurance, but diabetic supplies and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Blue Advantage Capital (PPO) diagnostic services are partially covered with no copay or coinsurance, though diagnostic procedures, tests, and lab services are not covered. Radiological services require prior authorization and have no coinsurance, with copays of $10 for outpatient X-rays, a minimum of $30 for therapeutic radiology, and a minimum of $75 for diagnostic radiology.
Home Health Services See details
Home health services are covered by Blue Advantage Capital (PPO) with no copay and no coinsurance.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are not covered under the Blue Advantage Capital (PPO) plan, as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all not covered.
Skilled Nursing Facility (SNF) See details
Blue Advantage Capital (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copayment for days 1 through 20 and a $218 daily copayment for days 21 through 100. Prior authorization is required, and while a prior three-day inpatient hospital stay is not necessary, additional days beyond the 100 Medicare-covered days are not covered.
Other Services See details
Other Services are not covered under the Blue Advantage Capital (PPO) plan, which does not provide coverage for acupuncture, over-the-counter (OTC) items, or meal benefits.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
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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.
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