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Capital Blue Cross Value (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Blue Cross 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 Value (PPO) in 2025, please refer to our full plan details page.
Capital Blue Cross Value (PPO) is a PPO plan offered by CAPITAL BLUE CROSS available for enrollment in 2025 to people living in Central Region. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Capital Blue Cross 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 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 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:
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Drug Coverage
The Capital Blue Cross Value (PPO) plan has a $200 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, in the initial coverage phase, preferred generic drugs have a $5 copay at preferred pharmacies, while standard generic drugs have 20% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Capital Blue Cross Value (PPO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services have copays that vary depending on the service. Emergency services and ambulance services have copays as well. The plan offers no copay for primary care, preventive services, and home health services. Vision benefits include no copay for eye exams and eyewear, but other services may have copays or coinsurance. Dental, hearing, and medical equipment services are covered with copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For the first 4 days of an inpatient stay, you will pay a $200 copay, and for days 5-90, you will have no copay. Additional days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient Hospital Services have a copay between $0 and $450, Observation Services have a $375 copay, Ambulatory Surgical Center Services have no copay, and Individual and Group Sessions for Outpatient Substance Abuse have a copay of $40. Outpatient Blood Services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Capital Blue Cross Value (PPO) plan, with a $55 copay, and requires prior authorization.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Capital Blue Cross Value (PPO) plan, 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, Urgently Needed Services, and Worldwide Emergency Coverage are covered under the Capital Blue Cross Value (PPO) plan, with copays of $110, $45, and $110 respectively, and no coinsurance. Worldwide Urgent Coverage is covered with a $45 copay and no coinsurance, while Worldwide Emergency Transportation is not covered.
Primary Care See details
Under the Capital Blue Cross Value (PPO) plan, primary care physician services have no copay, chiropractic services have a $15 copay, and occupational therapy services have a $35 copay. Physician specialist services have a $40 copay, and physical therapy and speech-language pathology services have a $35 copay. Mental health and psychiatric services, as well as other health care professional and opioid treatment program services, have a copay of $40.
Preventive Services See details
The Capital Blue Cross Value (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, health education, and kidney disease education services are also covered, but some services like in-home safety assessments and personal emergency response systems are not covered. Other covered services, such as Medical Nutrition Therapy, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, have no copay.
Hearing Services See details
Hearing Services include Routine Hearing Exams with a $40 copay, Fitting/Evaluation for Hearing Aid with no copay, Prescription Hearing Aids with a copay between $499 and $999, and OTC Hearing Aids with a $499 copay. Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a copay between $0 and $40, while routine eye exams have no copay. Eyewear, including contact lenses, is covered with no copay, and has a combined maximum plan benefit of $150 per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Capital Blue Cross Value (PPO) plan covers Medicare Dental Services with a $40 copay, and other dental services with no copay. Other diagnostic dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with 50% coinsurance, while 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.
Dialysis Services See details
Dialysis Services are covered by the Capital Blue Cross Value (PPO) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. Durable Medical Equipment has a 20% coinsurance, while Prosthetic Devices and Medical Supplies have a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including all diagnostic services and radiological services. Diagnostic Procedures/Tests and Lab Services have no copay, while Diagnostic Radiological Services have a copay of at most $285, Therapeutic Radiological Services have a coinsurance of at least 20%, and Outpatient X-Ray Services have a $35 copay.
Home Health Services See details
Home Health Services are covered by the Capital Blue Cross Value (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 technically covered, but none of the sub-services are covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Capital Blue Cross Value (PPO) plan, but require prior authorization. You will have no copay for days 1-20, and a $214 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Capital Blue Cross Value (PPO) plan's other services benefit covers over-the-counter (OTC) items, with a maximum benefit coverage amount of $75.00 every three months. Acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, 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 are not covered.
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