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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 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 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 $26.00. 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:
Sign up for Capital Blue Cross Enhanced (PPO)
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Drug Coverage
The Capital Blue Cross Enhanced (PPO) plan has a $150 deductible for prescription drugs. After the deductible, you will pay either a copay or coinsurance depending on the drug tier and the pharmacy you use. For preferred generic drugs, there is no copay at preferred pharmacies or mail order, while standard pharmacies have a $15 copay. For other tiers, you will pay coinsurance, ranging from 20% to 50% depending on the drug. 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 Enhanced (PPO) plan offers comprehensive coverage for a variety of healthcare services. This plan includes no copay for primary care physician services, preventive services, home health services, and eyewear. The plan does have copays for inpatient hospital stays, outpatient services, specialist visits, and hearing exams. This plan also covers a range of other services, including ambulance and transportation services, emergency services, and dental services. The plan covers skilled nursing facility stays, with a copay that varies by the length of stay. Additionally, this plan offers coverage for home infusion bundled services, dialysis services, medical equipment, and diagnostic and radiological services.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric, are covered with a $300 copay per admission or stay, and no coinsurance. Additional days for Inpatient Hospital-Acute are covered with no copay, while 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, observation services with a $250 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services include individual and group sessions with a copay of $20, and outpatient blood services are covered with no copay.
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, with prior authorization required. Ground and Air Ambulance Services have a $235 copay, and Transportation Services to a plan-approved health-related location are covered for up to 12 one-way trips per year, 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 by the Capital Blue Cross Enhanced (PPO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $50 copay, and Worldwide Emergency Coverage has a $125 copay. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Capital Blue Cross Enhanced (PPO) plan covers primary care physician services with no copay. Chiropractic services have a $20 copay, and routine chiropractic care is limited to 6 visits per year with a $20 copay. Occupational therapy services have a $15 copay, while physician specialist services have a $20 copay. Mental health specialty services, including individual and group sessions, and podiatry services have a $20 copay. Other health care professional services have a $20 copay, as do psychiatric services in both individual and group sessions. Physical therapy and speech-language pathology services have a $15 copay, and additional telehealth benefits have a copay between $0 and $20. Opioid treatment program services have a $20 copay.
Preventive Services See details
The Capital Blue Cross Enhanced (PPO) plan covers preventive services, including an annual physical exam with no copay. Additional preventive services, Health Education, Kidney Disease Education Services, and Other Preventive Services are covered. Some services under Additional Preventive Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit have no copay. The plan does not cover In-Home Safety Assessment, Personal Emergency Response System (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 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, and Counseling Services.
Hearing Services See details
Hearing Services include routine hearing exams with a $20 copay, fitting/evaluation for hearing aids, and OTC hearing aids with a $499 copay; prescription hearing aids (all types) are covered with a copay between $499 and $999, while prescription hearing aids - inner ear, outer ear, and over the ear are not covered. Routine hearing exams are limited to 1 per year, while prescription hearing aids are limited to 2 per year.
Vision Services See details
Vision Services include eye exams and eyewear. Eye exams have a copay of $0 to $20, while routine eye exams have no copay. Eyewear is covered with no copay, but contact lenses are subject to copay. Eyeglasses (lenses and frames) are also covered. 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 services include oral exams, dental x-rays, other diagnostic dental services with 50% coinsurance, and fluoride treatments. Restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered 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, 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 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 and Diabetic Therapeutic Shoes/Inserts have 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with all diagnostic services requiring prior authorization. Diagnostic Procedures/Tests and Lab Services have no copay, while Diagnostic Radiological Services have a copay of at most $200, Therapeutic Radiological Services have a coinsurance of at most 20%, and Outpatient X-Ray Services have a $15 copay.
Home Health Services See details
Home Health Services are covered by the Capital Blue Cross Enhanced (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 covered by the Capital Blue Cross Enhanced (PPO) plan, but the specific cardiac and pulmonary rehabilitation services are not covered. The plan has a copay for covered services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Capital Blue Cross Enhanced (PPO) plan, but require prior authorization. For days 1-20, the copay is $10, and for days 21-100, the copay is $214; there is no coinsurance.
Other Services See details
The Capital Blue Cross Enhanced (PPO) plan's "Other Services" benefit covers over-the-counter items with a maximum benefit coverage of $110 every three months; however, 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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