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Capital Blue Cross Classic (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Blue Cross Classic (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Capital Blue Cross Classic (PPO) in 2025, please refer to our full plan details page.
Capital Blue Cross Classic (PPO) is a PPO plan offered by CAPITAL BLUE CROSS available for enrollment in 2025 to people living in 21 Counties in Central PA. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Capital Blue Cross Classic (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 Capital Blue Cross Classic (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 Capital Blue Cross Classic (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $66.00. 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 $6700.00 (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 $6700.00 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 Capital Blue Cross Classic (PPO)
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Drug Coverage
The Capital Blue Cross Classic (PPO) plan has no deductible for prescription drugs. During the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have a $5 copay at preferred pharmacies, while preferred brand drugs have a 38% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase and pay nothing for Part D covered drugs. This plan also offers a Part D premium reduction for those who qualify for the low-income subsidy.
Additional Benefits
The Capital Blue Cross Classic (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services have copays that vary depending on the service. Primary care visits, preventive services, and many diagnostic tests have no copay, while other services like specialist visits and hearing exams have copays. The plan also includes coverage for ambulance services, emergency services, and home health services, each with associated copays or coinsurance. Dental, vision, and hearing services are included, with different costs for exams, eyewear, and hearing aids. The plan also provides coverage for home infusion, dialysis, and medical equipment with some cost-sharing.
Inpatient Hospital See details
Inpatient Hospital services, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered under the Capital Blue Cross Classic (PPO) plan. For Inpatient Hospital-Acute, you will pay a $215 copay for days 1-5, and no copay for days 6-90; the Additional Days benefit is unlimited with no copay. Inpatient Hospital Psychiatric has the same cost-sharing as Inpatient Hospital-Acute, with a $215 copay for days 1-5, and no copay for days 6-90. Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with copays ranging from $0 to $300, and observation services with a $240 copay. Ambulatory Surgical Center (ASC) Services have no copay, Outpatient Substance Abuse Services have a $25 copay for both individual and group sessions, and Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Capital Blue Cross Classic (PPO) plan, with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Capital Blue Cross Classic (PPO) plan. Ground and air ambulance services each have a $250 copay, and there is no coinsurance. Transportation Services to a plan-approved health-related location are covered for up to 12 one-way trips per year, but transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered under the Capital Blue Cross Classic (PPO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $45 copay, and Worldwide Emergency Coverage has a $125 copay. Worldwide Urgent Coverage has a $45 copay, while Worldwide Emergency Transportation is not covered.
Primary Care See details
The Capital Blue Cross Classic (PPO) plan offers primary care with no copay for Primary Care Physician Services. Chiropractic Services have a $15 copay, while Occupational Therapy Services have a $25 copay. Physician Specialist Services have a $25 copay, and Mental Health Specialty Services have a $25 copay for both individual and group sessions. Physical Therapy and Speech-Language Pathology Services have a $25 copay, and Additional Telehealth Benefits have a copay between $0 and $30. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
Preventive Services are covered, including annual physical exams with no copay, and additional preventive services, such as Health Education and Medical Nutrition Therapy (MNT), with no copay. Other services such as In-Home Safety Assessment, Personal Emergency Response System (PERS), 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, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered. Kidney Disease Education Services are covered with no copay, as are other preventive services like Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, all with no copay.
Hearing Services See details
Hearing Services include hearing exams, prescription hearing aids, and OTC hearing aids. Hearing exams have a $25 copay, while prescription hearing aids (all types) have a copay between $499 and $999, and OTC hearing aids have a $499 copay.
Vision Services See details
Vision Services include eye exams with a copay between $0 and $25, and eyewear with a combined maximum benefit of $150 per year. Routine eye exams have no copay, and contact lenses are covered. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Capital Blue Cross Classic (PPO) plan covers dental services, with a $25 copay for Medicare dental services and no copay for other dental services. Other Diagnostic Dental Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), and Oral and Maxillofacial Surgery are covered with a 50% coinsurance. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with coinsurance between 0% and 20%. Prior authorization is required.
Dialysis Services See details
Dialysis services are covered under the Capital Blue Cross Classic (PPO) plan. You will pay 20% coinsurance for dialysis services.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with a coinsurance for Medicare-covered items, and Diabetic Equipment. Diabetic Supplies have no copay, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with copays and coinsurance depending on the specific service. Diagnostic Procedures/Tests and Lab Services have no copay, while Diagnostic Radiological Services have a copay of up to $200, and Therapeutic Radiological Services have a coinsurance of up to 20%. Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by the Capital Blue Cross Classic (PPO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Capital Blue Cross Classic (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Capital Blue Cross Classic (PPO) plan, but require prior authorization. For days 1-20, there is a $10 copay, and for days 21-100, there is a $214 copay. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Capital Blue Cross Classic (PPO) plan does not cover acupuncture, meal benefits, or Dual Eligible SNPs with Highly Integrated Services. Over-the-counter items are covered up to $75 every three months, and the plan does not cover nicotine replacement therapy. The plan also does not cover Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services.
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