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Capital Blue Cross Prime (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Blue Cross Prime (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 Prime (PPO) in 2026, please refer to our full plan details page.
Capital Blue Cross Prime (PPO) is a PPO plan offered by CAPITAL BLUE CROSS available for enrollment in 2025 to people living in Central Pennsylvania. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Capital Blue Cross Prime (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 Prime (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 Prime (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $177.00. 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 $100.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
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 Prime (PPO)
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Drug Coverage
The Capital Blue Cross Prime (PPO) plan features a budget-friendly $100 drug deductible and offers substantial savings on generic prescriptions. Under this plan, you will pay no copay for Tier 1 preferred generic and Tier 2 generic drugs when filled through preferred pharmacies or preferred mail order. For standard pharmacies or mail order, one-month copays are $10 for Tier 1 and $15 for Tier 2. For higher-tier medications, the plan maintains consistent pricing across both preferred and standard networks. Tier 3 preferred brand drugs require a $47 copay for a one-month supply, while Tier 4 non-preferred drugs have a $100 copay. Specialty medications in Tier 5 carry a 31% coinsurance for a one-month supply.
Additional Benefits
The Capital Blue Cross Prime (PPO) plan offers robust medical coverage with predictable copays and no coinsurance for many core services. For inpatient hospital stays, members pay a $225 daily copay for days one through six, followed by no copay for days seven through 90. Routine doctor visits are highly affordable, featuring no copay for primary care physicians and a $25 copay for specialists. Supplemental benefits include dental coverage up to a $2,000 annual limit and vision services with no copays up to a $125 yearly limit. Hearing services feature routine exams for a $25 copay, alongside covered prescription and over-the-counter hearing aids. Members also benefit from a $45 quarterly over-the-counter allowance with no copay and no coinsurance.
Inpatient Hospital See details
Capital Blue Cross Prime (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $225 daily copay for days 1 through 6 and no copay for days 7 through 90. While unlimited additional days are covered with no copay for acute care, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Capital Blue Cross Prime (PPO) covers outpatient services with no coinsurance, featuring no copays for ambulatory surgical center and outpatient blood services. Outpatient hospital services require copays ranging from no copay to $375 (with a $225 copay per stay for observation services), and outpatient substance abuse sessions have a $25 copay.
Partial Hospitalization See details
Partial hospitalization is covered by Capital Blue Cross Prime (PPO) with a $55.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Capital Blue Cross Prime (PPO), requiring a $230 copay and no coinsurance for Medicare-covered ground and air ambulance services, which require prior authorization. While some transportation services are covered, transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Capital Blue Cross Prime (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if hospitalized within 24 hours, and urgently needed services with a $35 copay and no coinsurance. Worldwide emergency and urgent services are partially covered up to a $20,000 limit with no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Capital Blue Cross Prime (PPO) covers primary care physician services and opioid treatment with no copay and no coinsurance, while specialist visits, physical therapy, and mental health services require a $25 copay and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance—excluding routine chiropractic care—while podiatry services are not covered.
Preventive Services See details
Preventive Services under Capital Blue Cross Prime (PPO) are partially covered with no copay and no coinsurance for covered benefits like annual physical exams, kidney disease education, and medical nutrition therapy. However, several supplemental benefits are not covered, including health education, in-home safety assessments, personal emergency response systems, and weight management programs.
Hearing Services See details
Hearing services are partially covered by Capital Blue Cross Prime (PPO), featuring routine exams for a $25 copay and no coinsurance, and up to two OTC hearing aids per year for a $499 copay and no coinsurance. Up to two prescription hearing aids are covered annually with copays ranging from $499 to $999 and no coinsurance, though inner ear, outer ear, and over the ear models are not covered.
Vision Services See details
Capital Blue Cross Prime (PPO) vision services are partially covered, offering routine eye exams and eyewear with no copays, no coinsurance, and a $125 annual benefit limit. While one routine exam and one pair of contact lenses or eyeglasses are covered each year, other eye exams, upgrades, and separate lenses or frames are not covered.
Dental Services See details
Capital Blue Cross Prime (PPO) partially covers dental services up to a $2,000 annual maximum for both in-network and out-of-network care. Medicare-covered dental services require a $25 copay and no coinsurance, while other covered services have no copay and either no coinsurance or 50% coinsurance, though implants, orthodontics, maxillofacial prosthetics, and other preventive dental services are not covered.
Home Infusion bundled Services See details
Capital Blue Cross Prime (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Under this plan, Medicare Part B insulin drugs are covered with a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs carry a 0% to 20% coinsurance and no copay.
Dialysis Services See details
Capital Blue Cross Prime (PPO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Capital Blue Cross Prime (PPO) covers medical equipment, including durable medical equipment (DME), prosthetics, medical supplies, and diabetic equipment, with no copays. A 20% coinsurance applies to DME, prosthetics, medical supplies, and diabetic shoes, while diabetic supplies carry between no coinsurance and 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Capital Blue Cross Prime (PPO) with prior authorization required for these benefits. Diagnostic tests, procedures, and lab services have no copay and no coinsurance, while outpatient X-rays require a $25 copay, diagnostic radiological services have no copay, and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Capital Blue Cross Prime (PPO) covers home health services with no copay and no coinsurance. Prior authorization is required to access these benefits.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services under Capital Blue Cross Prime (PPO) are offered with no coinsurance, and while some services are covered, cardiac rehabilitation ($25 copay), intensive cardiac rehabilitation ($25 copay), pulmonary rehabilitation ($15 copay), and SET for PAD services ($10 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are partially covered by Capital Blue Cross Prime (PPO) with no coinsurance, requiring a daily copay of $10 for days 1 to 20 and $218 for days 21 to 100. Prior authorization is required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other Services for Capital Blue Cross Prime (PPO) are partially covered, featuring an over-the-counter (OTC) benefit of $45 every three months with no copay and no coinsurance. Acupuncture, meal benefits, and nicotine replacement therapy are not covered.
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