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Capital Blue Cross | WellSpan Health Complete (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Blue Cross | WellSpan Health 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 | WellSpan Health Complete (PPO) in 2025, please refer to our full plan details page.
Capital Blue Cross | WellSpan Health Complete (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 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 | WellSpan Health 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 | WellSpan Health 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 | WellSpan Health Complete (PPO)
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Drug Coverage
The Capital Blue Cross | WellSpan Health Complete (PPO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay different amounts depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have no copay, while standard generic drugs have 20% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for Medicare Part D covered drugs. The plan's premium may be reduced if you qualify for the low-income subsidy, with a monthly premium of $14.60.
Additional Benefits
The Capital Blue Cross | WellSpan Health Complete (PPO) plan offers a wide range of benefits, including inpatient and outpatient hospital services, with varying copays. The plan also covers primary care, preventive services, hearing, vision, and dental services, with some services having no copay. You will also have access to ambulance and emergency services, with copays ranging from $125 to $300. Additional benefits include coverage for partial hospitalization, home infusion, dialysis, and durable medical equipment, with different cost-sharing arrangements. The plan also covers diagnostic and radiological services, home health, cardiac rehabilitation, and skilled nursing facility services. The plan also covers over-the-counter items with a quarterly maximum benefit of $125.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you pay a $100 copay for days 1-3, and no copay for days 4-90. For Inpatient Hospital Psychiatric, you pay a $100 copay for days 1-3, and no copay for days 4-90. Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and 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 $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 the Capital Blue Cross | WellSpan Health Complete (PPO) plan, but requires prior authorization. You will have a $55 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with a $300 copay for both ground and air ambulance services; there is no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered, with a $125 copay and no coinsurance. Urgently Needed Services have a $45 copay and no coinsurance, and Worldwide Emergency Coverage has a $125 copay and no coinsurance. Worldwide Urgent Coverage has a $45 copay and no coinsurance, but Worldwide Emergency Transportation is not covered.
Primary Care See details
The Primary Care benefit includes coverage for Primary Care Physician Services with no copay, Chiropractic Services with a $15 copay, Occupational Therapy Services with a $15 copay, Physician Specialist Services with a $15 copay, and Mental Health Specialty Services with a $15 copay for both individual and group sessions. This benefit also covers 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-$25, and Opioid Treatment Program Services with a $15 copay.
Preventive Services See details
Preventive Services include an annual physical exam with no copay, and additional preventive services with a copay. In-home safety assessment, personal emergency response system, 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, 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 have no copay.
Hearing Services See details
Hearing exams are covered with a $15 copay, while prescription hearing aids are partially covered, with a copay between $499 and $999, and OTC hearing aids are covered with a $499 copay. Fitting/evaluation for hearing aids is covered, and the plan does not cover prescription hearing aids - inner ear, outer ear, or over the ear.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a copay between $0 and $15, and routine eye exams have no copay. Eyewear has a combined maximum plan benefit coverage of $300 every year for both in-network and out-of-network services, and contact lenses have no copay. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services include a $15 copay for Medicare Dental Services and no copay for Other Dental Services. Other Diagnostic Dental Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), and Oral and Maxillofacial Surgery have 50%, 50%, 50%, 50%, 50%, and 30% coinsurance, respectively. Orthodontic Services are covered under Diagnostic and Preventive Dental, with a maximum of $5,000 every year. However, Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and prior authorization is required. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered with a 20% coinsurance.
Medical Equipment See details
Medical equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment with varying copays and coinsurance depending on the service. Diabetic Supplies have no copay, and Diabetic Therapeutic Shoes/Inserts have 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services and lab services with no copay, while outpatient X-ray services have a $15 copay, diagnostic radiological services have a copay of at most $230, and therapeutic radiological services have at least 20% coinsurance. All radiological services require prior authorization.
Home Health Services See details
Home Health Services are covered with no copay and no coinsurance, but Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the specific sub-services including Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services are not covered. 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 by the Capital Blue Cross | WellSpan Health Complete (PPO) plan. You will pay a $10 copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered for Skilled Nursing Facility (SNF) and Non-Medicare-covered stays for Skilled Nursing Facility (SNF) are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items, with a maximum benefit of $125 every three months, but acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, and other services are not covered. Additionally, the plan does not cover 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.
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