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Capital Blue Cross | WellSpan Health Value (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Blue Cross | WellSpan Health Value (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 Value (PPO) in 2025, please refer to our full plan details page.
Capital Blue Cross | WellSpan Health Value (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 Value (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 Value (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 Value (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. Additionally, this plan comes with a Part B Premium reduction of $28.00. You must continue to pay paying your reduced 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 $9000.00 (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 $9000.00 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 | WellSpan Health Value (PPO)
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Drug Coverage
The Capital Blue Cross | WellSpan Health Value (PPO) plan has a $200 deductible for prescription drugs. After you meet the deductible, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, you'll pay a $5 copay for preferred generic drugs at a preferred pharmacy, or 20% coinsurance for standard generic drugs. After your total drug costs reach $2000, you will enter the catastrophic coverage phase and pay nothing for your Part D covered drugs.
Additional Benefits
The Capital Blue Cross | WellSpan Health Value (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $200 copay for the first four days, while outpatient services range from no copay to a $450 copay. Primary care, preventive, and many dental services are available with no copay, while specialist visits have a $40 copay. This plan covers ambulance services with a $305 copay, and emergency services with a $110 copay. Hearing exams have a $40 copay, and prescription hearing aids have a copay between $499 and $999. Vision services include eye exams with no copay to $40, and eyewear with no copay.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you pay a $200 copay for days 1-4, and no copay for days 5-90; Additional Days for Inpatient Hospital-Acute is covered with no copay. Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered. For Inpatient Hospital Psychiatric, you pay a $200 copay for days 1-4, and no copay for days 5-90; Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $450, Observation Services with a $375 copay, Ambulatory Surgical Center (ASC) Services with no copay, Outpatient Substance Abuse Services with a $40 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 Value (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, with a $305 copay for both ground and air ambulance services, and no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered, with a $110 copay and no coinsurance. Urgently Needed Services are covered with a $45 copay and no coinsurance, and Worldwide Emergency Coverage has a $110 copay and no coinsurance. Worldwide Urgent Coverage has a $45 copay and no coinsurance, while Worldwide Emergency Transportation is not covered.
Primary Care See details
The Capital Blue Cross | WellSpan Health Value (PPO) plan offers primary care services with no copay, chiropractic services with a $15 copay, and occupational therapy with a $35 copay. Specialist visits have a $40 copay, while mental health and psychiatric individual and group sessions have a $40 copay. Physical therapy and speech-language pathology services have a $35 copay, and additional telehealth benefits range from no copay to a $40 copay. Opioid Treatment Program Services have a $40 copay.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, annual physical exams with no copay, and additional services like Medical Nutrition Therapy, Glaucoma Screenings, and Diabetes Self-Management Training, all with no copay. Some services, like In-Home Safety Assessments, are not covered.
Hearing Services See details
Hearing Services include coverage for hearing exams with a $40 copay, and prescription hearing aids, with a copay between $499 and $999 for all types. OTC hearing aids have a $499 copay, while prescription hearing aids - inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$40, and eyewear with no copay. Eyeglasses (lenses and frames) and contact lenses are covered, with a combined maximum plan benefit of $150 every year, while eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services include Medicare Dental Services with a $40 copay, and Other Dental Services with no copay. Additional services include Oral Exams with no copay, Dental X-Rays, Other Diagnostic Dental Services with 50% coinsurance, Prophylaxis (Cleaning), Fluoride Treatment, Restorative Services with 50% coinsurance, Adjunctive General Services with 50% coinsurance, Endodontics with 50% coinsurance, Periodontics with 50% coinsurance, Prosthodontics (removable) with 50% coinsurance, Prosthodontics (fixed) with 50% coinsurance, and Oral and Maxillofacial Surgery with 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. Other Medicare Part B Drugs and Medicare Part B Chemotherapy/Radiation Drugs are covered with coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Capital Blue Cross | WellSpan Health Value (PPO) plan. The coinsurance for Dialysis Services is 20%.
Medical Equipment See details
Medical Equipment, including durable medical equipment (DME), prosthetics, medical supplies, and diabetic equipment, is covered. DME has a 20% coinsurance, and prosthetics/medical supplies have a 20% coinsurance. 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 by this plan, with a copay for some services. Diagnostic Procedures/Tests have no copay, while Lab Services have no copay. Diagnostic Radiological Services have a copay of up to $285, while Therapeutic Radiological Services have a coinsurance of at least 20%. Outpatient X-Ray Services have a $35 copay.
Home Health Services See details
Home Health Services are covered 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 technically covered, but the plan does not cover any of the sub-services, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. There is a copay for some services, but more information is needed to determine the cost.
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.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items, with a maximum benefit coverage amount of $75.00 every three months, but acupuncture, meal benefits, and many other services are not covered.
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