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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 2026, 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 2026 to people living in Central Pennsylvania. This plan received an overall rating of 4.5 out of 5 stars in 2026.
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 $31.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $300.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $550.00 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) prescription drug plan features an annual drug deductible of $550. For generic medications, you will pay no copay for Tier 1 preferred generics and Tier 2 generics when using a preferred pharmacy or preferred mail order service. If you choose a standard pharmacy or standard mail order, Tier 1 copays range from $10 to $30, and Tier 2 copays range from $15 to $45. Higher-tier medications are covered under coinsurance at both preferred and standard pharmacies. You will pay a 16% coinsurance for Tier 3 preferred brands and a 39% coinsurance for Tier 4 non-preferred drugs. Tier 5 specialty drugs require a 26% coinsurance for a one-month supply.
Additional Benefits
The Capital Blue Cross Value (PPO) plan provides comprehensive healthcare coverage featuring no coinsurance and no copay for primary care visits, preventive care, and home health services. Specialist visits and therapy sessions require a $25 copay, while emergency room visits carry a $115 copay. For inpatient hospital stays, members pay a $200 daily copay for days one through four and no copay for days five through 90. This plan also includes valuable supplemental benefits, such as routine eye exams and preventive dental care with no copay. Dental services are covered up to a $2,000 annual limit, while eyewear is covered up to $150 annually. Additionally, members receive a $30 quarterly over-the-counter allowance with no copay, while durable medical equipment and dialysis services are covered with a 20% coinsurance.
Inpatient Hospital See details
Capital Blue Cross Value (PPO) covers inpatient acute and psychiatric hospital services with no coinsurance, featuring a $200 daily copay for days 1 through 4 and no copay for days 5 through 90. While unlimited additional acute care days are covered at no copay, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Capital Blue Cross Value (PPO) covers outpatient services with no coinsurance, offering ambulatory surgical center and outpatient blood services with no copay, though prior authorization is required for surgical services. Outpatient hospital services require a copay of $0 to $450 with prior authorization, while observation services carry a $375 copay per stay and outpatient substance abuse sessions require a $25 copay.
Partial Hospitalization See details
Capital Blue Cross Value (PPO) covers partial hospitalization services with a $55 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Capital Blue Cross Value (PPO) covers Medicare-covered ground and air ambulance services with a $275 copay and no coinsurance, though prior authorization is required. Transportation services to plan-approved or any other health-related locations are not covered under this plan.
Emergency Services See details
Capital Blue Cross Value (PPO) covers emergency services with a $115 copay (waived if admitted within 24 hours) and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency and urgent services are partially covered up to a $20,000 maximum with no coinsurance and matching copays of $115 and $40 respectively, though worldwide emergency transportation is not covered.
Primary Care See details
Capital Blue Cross Value (PPO) covers primary care visits and opioid treatment with no copay and no coinsurance, while specialist visits, therapy services, and mental health sessions require a $25 copay and no coinsurance. Telehealth benefits are available with a $0 to $25 copay and no coinsurance, podiatry is not covered, and while some chiropractic services are covered, routine and other chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered under the Capital Blue Cross Value (PPO) plan with no copay and no coinsurance for covered care like annual physicals, diabetes self-management training, and kidney disease education. While some supplemental benefits like memory fitness and medical nutrition therapy are included, other services such as health education, weight management, counseling, and in-home safety assessments are not covered.
Hearing Services See details
Capital Blue Cross Value (PPO) covers hearing services, including one routine hearing exam annually for a $25 copay and no coinsurance with no deductible. Hearing aids are partially covered, offering up to two prescription aids per year with no coinsurance and a $499 to $999 copay (inner ear, outer ear, and over the ear types are not covered), or up to two OTC hearing aids per year for a $499 copay and no coinsurance.
Vision Services See details
Capital Blue Cross Value (PPO) covers vision services with no deductible, offering one routine eye exam per year with no copay and no coinsurance. Eyewear is partially covered with no copay and no coinsurance up to a $150 annual limit for contact lenses and complete eyeglasses, though other eye exams, individual lenses, individual frames, and upgrades are not covered.
Dental Services See details
Capital Blue Cross Value (PPO) dental services are partially covered up to a $2,000 annual limit, with Medicare-covered dental requiring a $25 copay and no coinsurance, and preventive services like exams, cleanings, x-rays, and fluoride requiring no copay and no coinsurance. Restorative services and oral surgery are covered with no copay and 50% coinsurance, while other diagnostic, other preventive, endodontics, periodontics, prosthodontics, implants, maxillofacial prosthetics, adjunctive general services, and orthodontics are not covered.
Home Infusion bundled Services See details
Capital Blue Cross Value (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Under this plan, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs require a 0% to 20% coinsurance.
Dialysis Services See details
Capital Blue Cross Value (PPO) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Capital Blue Cross Value (PPO) covers medical equipment, including durable medical equipment, prosthetics, and medical supplies, with no copay and 20% coinsurance. Diabetic equipment and supplies are also covered with no copay and coinsurance ranging from no coinsurance to 20%, though prior authorization is required and some items are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Capital Blue Cross Value (PPO) covers diagnostic and radiological services, with prior authorization required. Diagnostic procedures, lab services, and diagnostic radiological services are provided with no copay and no coinsurance, while outpatient X-rays require a $30 copay and therapeutic radiological services carry a minimum 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the Capital Blue Cross Value (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Capital Blue Cross Value (PPO) does not cover Cardiac Rehabilitation Services, as none of the specific sub-services, including intensive cardiac, pulmonary, and SET for PAD rehabilitation, are covered under this plan.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Capital Blue Cross Value (PPO) with no coinsurance, featuring no copay for days 1 through 20 and a $145 daily copay for days 21 through 100. Prior authorization is required, and additional days beyond the standard 100-day Medicare limit are not covered.
Other Services See details
Other services are partially covered by Capital Blue Cross Value (PPO), which provides an over-the-counter (OTC) benefit with no copay and no coinsurance up to a maximum of $30 every three months. Acupuncture, meal benefits, and nicotine replacement therapy are not covered under these services.
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