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Capital Blue Cross Enhanced (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Blue Cross Enhanced (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 Enhanced (PPO) in 2025, please refer to our full plan details page.
Capital Blue Cross Enhanced (PPO) is a PPO plan offered by CAPITAL BLUE CROSS available for enrollment in 2025 to people living in Lehigh Valley 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 Enhanced (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 Enhanced (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 Enhanced (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $27.00. 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 $150.00 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 $6200.00 (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 $6200.00 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 Enhanced (PPO) plan has a $150 deductible for prescription drugs. After meeting the deductible, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have no copay at preferred pharmacies and mail order, while standard pharmacies have a $15 copay. You will pay 20% coinsurance for standard generic drugs, 50% coinsurance for preferred brand drugs, and 31% coinsurance for non-preferred drugs. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, and you will pay nothing for your Part D covered drugs.
Additional Benefits
The Capital Blue Cross Enhanced (PPO) plan offers comprehensive coverage with a variety of benefits. It includes inpatient hospital stays with a $300 copay, outpatient services with copays ranging from $0 to $375, and emergency services with a $125 copay. This plan provides coverage for primary care, preventive services, hearing, vision, and dental services. There is no copay for primary care physician visits, and other services like hearing exams, eye exams, and dental services have copays ranging from $0 to $20. Additionally, the plan offers coverage for medical equipment, home health services, and skilled nursing facilities with varying copays or coinsurance amounts.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. Both services have a $300 copay per admission or stay for Medicare-covered stays, and additional days for Inpatient Hospital-Acute have no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, and additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a copay between $0 and $375, and for observation services with a $250 copay. Ambulatory Surgical Center (ASC) Services and Outpatient Blood Services have no copay, while Outpatient Substance Abuse Services have a $20 copay for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered by the Capital Blue Cross Enhanced (PPO) plan, with a $55 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Capital Blue Cross Enhanced (PPO) plan. Ground and Air Ambulance Services have a $190 copay, with no coinsurance. Transportation Services to a plan-approved health-related location are covered for up to 12 one-way trips per year, and any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Coverage, and Worldwide Urgent Coverage are covered by the Capital Blue Cross Enhanced (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, while Urgently Needed Services and Worldwide Urgent Coverage have a $50 copay; all of these services have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care, under the Capital Blue Cross Enhanced (PPO) plan, includes no copay for Primary Care Physician services, a $20 copay for Chiropractic Services, and a $15 copay for Occupational Therapy Services. Also covered are Physician Specialist Services with a $20 copay, Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services with a $15 copay, Additional Telehealth Benefits with a copay between $0-$20, and Opioid Treatment Program Services.
Preventive Services See details
Preventive Services include coverage for Medicare-covered zero-dollar preventive services, annual physical exams with no copay, and additional services with no copay for glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit. This plan does not cover in-home safety assessments, personal emergency response systems (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 benefits, 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 routine hearing exams with a $20 copay, fitting/evaluation for hearing aids with no copay, and OTC hearing aids with a $499 copay. Prescription hearing aids (all types) have a copay between $499 and $999, while prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
The Capital Blue Cross Enhanced (PPO) plan covers vision services, including eye exams with a copay of $0-$20, and eyewear. Eyewear benefits include contact lenses with no copay, and a $250 combined maximum plan benefit for eyewear every year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Capital Blue Cross Enhanced (PPO) plan covers Medicare dental services with a $20 copay and other dental services with no copay. Other covered dental services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery, all with 50% coinsurance. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Capital Blue Cross Enhanced (PPO) plan, with a $35 copay for Medicare Part B Insulin Drugs. Other Medicare Part B drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Capital Blue Cross Enhanced (PPO) plan. You will pay a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment. Diabetic Supplies have no copay, while Diabetic Therapeutic Shoes/Inserts have 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures, lab services, and all radiological services. Diagnostic Procedures/Tests and Lab Services have no copay, while Diagnostic Radiological Services have a copay of at most $150, and Outpatient X-Ray Services have a $15 copay. Therapeutic Radiological Services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the Capital Blue Cross Enhanced (PPO) plan with no copay and no coinsurance. However, Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Capital Blue Cross Enhanced (PPO) plan, but the plan does not cover any of the sub-services. There is a copay for the covered services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, the copay is $10, and for days 21-100, the copay is $214; additional days beyond Medicare-covered SNF and non-Medicare covered stays are not covered.
Other Services See details
Other Services under the Capital Blue Cross Enhanced (PPO) plan include Over-the-Counter (OTC) Items with a maximum benefit coverage of $110.00 every three months, but acupuncture, meal benefits, and other services are not covered. Additional services do not require authorization or a referral.
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