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Capital Blue Cross Complete (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Blue Cross Complete (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 Complete (PPO) in 2025, please refer to our full plan details page.
Capital Blue Cross Complete (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 Complete (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 Complete (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 Complete (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $43.00. 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $6000.00 (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 $6000.00 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 Complete (PPO)
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Drug Coverage
The Capital Blue Cross Complete (PPO) plan has an Enhanced Alternative drug benefit. There is no deductible for prescription drugs. During the initial coverage phase, you will pay either a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you will have no copay at preferred pharmacies and mail order, and a $15 copay at standard pharmacies. After your total drug costs reach $2,000, you enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The Capital Blue Cross Complete (PPO) plan offers a range of benefits with varying cost-sharing. You can expect to pay a copay for inpatient hospital stays, outpatient services, primary care, specialist visits, and emergency services. Many preventive services, hearing exams, vision exams, and dental services have no copay. This plan also covers ambulance services, diagnostic tests, home health, and medical equipment, though some services may involve coinsurance. The plan includes coverage for prescription hearing aids and eyewear, with set limits. Additionally, the plan offers over-the-counter (OTC) items with a quarterly allowance.
Inpatient Hospital See details
Inpatient Hospital services, including acute and psychiatric care, are covered by Capital Blue Cross Complete (PPO). For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, you pay a $100 copay for days 1-3, and no copay for days 4-90.
Outpatient Services See details
Outpatient Services are covered, including outpatient hospital services with a copay between $0 and $375, observation services with a $200 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a $15 copay for both individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by Capital Blue Cross Complete (PPO) with a $55 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Capital Blue Cross Complete (PPO). Ground and Air Ambulance Services have a $285 copay and 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 by the Capital Blue Cross Complete (PPO) plan. For Emergency Services, there is a $125 copay, and no coinsurance. Urgently Needed Services have a $45 copay, and no coinsurance. Worldwide Emergency Coverage has a $125 copay, and no coinsurance. Worldwide Urgent Coverage has a $45 copay, and no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care Physician Services have no copay, Chiropractic Services have a $15 copay, Occupational Therapy, Physician Specialist Services, Physical Therapy and Speech-Language Pathology Services have a $15 copay, Additional Telehealth Benefits have a copay between $0 and $25, and Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, Psychiatric Services, and Opioid Treatment Program Services have a $15 copay. Routine Chiropractic Care is limited to 6 visits per year.
Preventive Services See details
Preventive Services, including Medicare-covered services and annual physical exams, are covered with no copay. Additional preventive services, including Health Education, Medical Nutrition Therapy, Remote Access Technologies, and Fitness Benefit (Memory Fitness) are covered, while In-Home Safety Assessment, Personal Emergency Response System, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss, 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 are not covered. Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are covered with no copay.
Hearing Services See details
Hearing Services includes routine hearing exams with a $15 copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are partially covered, but inner ear, outer ear, and over the ear hearing aids are not covered. OTC hearing aids are covered with a $499 copay.
Vision Services See details
Vision services include coverage for routine eye exams with a copay of $0-$15, and eyewear. Eyewear includes coverage for contact lenses and eyeglasses (lenses and frames), with a combined maximum plan benefit of $300 per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $15 copay, and Other Dental Services with no copay. Other covered services include Oral Exams with no copay, Dental X-Rays, Other Diagnostic Dental Services with 50% coinsurance, Prophylaxis (Cleaning), Fluoride Treatment, Restorative Services with 30-50% 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 30% 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 Complete (PPO) plan. For Medicare Part B Insulin Drugs, there is a $35 copay; for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by the Capital Blue Cross Complete (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, while Prosthetic Devices and Medical Supplies also have a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance. Diabetic Supplies have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by Capital Blue Cross Complete (PPO). Diagnostic Procedures/Tests and Lab Services have no copay, while Diagnostic Radiological Services have a copay of at most $200, 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 Capital Blue Cross Complete (PPO) 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 Capital Blue Cross Complete (PPO), but the plan does not cover the sub-services of Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD. The copay is dependent on the specific service.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under Capital Blue Cross Complete (PPO), with a copay of $10 for days 1-20, and $214 for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) items with a maximum benefit coverage amount of $120.00 every three months, but 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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