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Capital Blue Cross | WellSpan Health Advantage (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Blue Cross | WellSpan Health Advantage (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 | WellSpan Health Advantage (PPO) in 2025, please refer to our full plan details page.
Capital Blue Cross | WellSpan Health Advantage (PPO) is a PPO plan offered by CAPITAL BLUE CROSS available for enrollment in 2025 to people living in 7 County South 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 | WellSpan Health Advantage (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 | WellSpan Health Advantage (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 | WellSpan Health Advantage (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 $200.00 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 $6800.00 (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 $6800.00 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:
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Drug Coverage
The Capital Blue Cross | WellSpan Health Advantage (PPO) plan has a $200 deductible for prescription drugs. After you meet your deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you'll pay a $5 copay at preferred pharmacies and a $20 copay at standard pharmacies. For standard generic drugs, you'll pay 20% coinsurance, and for preferred brand drugs, you'll pay 50% coinsurance.
Additional Benefits
The Capital Blue Cross | WellSpan Health Advantage (PPO) plan offers a range of benefits with varying costs. For inpatient hospital stays, you'll pay a $150 copay for the first four days, with no copay for the remainder of the stay. Outpatient services have a range of copays, and many primary care and preventive services have no copay. This plan includes coverage for hearing and vision services, with copays for exams and some services. Dental services have a copay for Medicare dental services, and no copay for other dental services. Additional benefits include home health services with no copay, and coverage for ambulance, emergency, and home infusion services with associated copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for acute and psychiatric care. For inpatient hospital acute care, you will pay a $150 copay for days 1-4, and no copay for days 5-90. For inpatient hospital psychiatric care, you will pay a $150 copay for days 1-4, and no copay for days 5-90. Additional days and upgrades for inpatient hospital acute and psychiatric care are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $375, Observation Services with a $250 copay, Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse Services with a $30 copay for both individual and group sessions, and Outpatient Blood Services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Capital Blue Cross | WellSpan Health Advantage (PPO) plan, with a $55 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground and Air Ambulance Services each have a $315 copay, and there is no coinsurance, while 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 this plan. Emergency Services have a $110 copay, Urgently Needed Services have a $45 copay, and Worldwide Emergency Coverage has a $110 copay. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care includes coverage for a variety of services. Primary Care Physician Services have no copay, while Chiropractic Services have a $15 copay. Occupational Therapy Services, Physician Specialist Services, Physical Therapy and Speech-Language Pathology Services have a $25 copay, with Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, Psychiatric Services, and Opioid Treatment Program Services having a $30 copay. Additional Telehealth Benefits have a copay between $0 and $30.
Preventive Services See details
Preventive services include an annual physical exam with no copay, along with additional preventive services, kidney disease education services, and other preventive services, with some services having a copay. Additional services include Health Education, Fitness Benefit, Remote Access Technologies, and Glaucoma Screening, all with no copay. The plan does not cover In-Home Safety Assessment, Personal Emergency Response System, 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, or Counseling Services.
Hearing Services See details
Hearing Services include hearing exams with a $30 copay, fitting/evaluation for hearing aids, and OTC hearing aids with a $499 copay. Prescription hearing aids are partially covered, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
The Capital Blue Cross | WellSpan Health Advantage (PPO) plan covers vision services, including eye exams with a copay of $0-$30, and eyewear with a $0 copay for contact lenses. Eyeglasses (lenses and frames) are also covered. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services has a $30 copay for Medicare dental services, and no copay for other dental services. This plan covers other dental services including oral exams with a limit of 2 visits per year, dental x-rays with a limit of 2 sets per year, Other Diagnostic Dental Services with a 50% coinsurance and a limit of 1 visit per year, Prophylaxis (Cleaning) with a limit of 2 visits per year, and Fluoride Treatment with a limit of 2 visits per year. Additionally, 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 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered by the Capital Blue Cross | WellSpan Health Advantage (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics, Medical Supplies, and Diabetic Equipment, is covered. DME has a 20% coinsurance, while Prosthetic Devices and Medical Supplies have a 20% coinsurance. Diabetic Supplies have no copay, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures and lab services with no copay, and outpatient X-ray services with a $15 copay. Therapeutic Radiological Services have a coinsurance of at most 20%, while Diagnostic Radiological Services have a copay of at most $175.
Home Health Services See details
Home Health Services are covered by the Capital Blue Cross | WellSpan Health Advantage (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 | WellSpan Health Advantage (PPO) plan. The plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items with a maximum plan benefit coverage amount of $90 every three months, but does not cover acupuncture, meal benefits, or dual eligible SNPs with highly integrated services. This plan 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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