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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 $32.50. 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) Medicare plan features a $550 annual drug deductible. For Tier 1 preferred generics and Tier 2 generics, there is no copay for any supply duration when using preferred pharmacies or preferred mail order. Standard pharmacies and standard mail order options require copays ranging from $10 to $30 for Tier 1 and $15 to $45 for Tier 2. For brand-name and specialty prescriptions, costs are calculated as coinsurance. Tier 3 preferred brand drugs require a 16% coinsurance, and Tier 4 non-preferred drugs carry a 39% coinsurance at all pharmacy locations. Tier 5 specialty drugs are covered with a 26% coinsurance for a 1-month supply at both standard and preferred pharmacies.
Additional Benefits
The Capital Blue Cross Value (PPO) plan offers affordable medical coverage with no copay and no coinsurance for primary care visits, preventive services, and home health care. Specialists, therapists, and routine hearing exams require a low $25 copay with no coinsurance, while emergency room visits carry a $115 copay. For inpatient hospital stays, members pay a $190 daily copay for the first four days, followed by no copay for the remainder of a 90-day stay. Supplemental benefits include routine vision exams and preventive dental cleanings with no copay or coinsurance, supported by a $150 annual eyewear allowance and a $2,000 annual dental limit. Medical equipment, prosthetics, and dialysis services generally require a 20% coinsurance with no copay, while diagnostic lab tests are covered with no copay and no coinsurance. Members also receive an over-the-counter item allowance of $30 every three months with no copay or coinsurance.
Inpatient Hospital See details
Capital Blue Cross Value (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance and a copay of $190 per day for days 1 through 4, followed by no copay for days 5 through 90. Unlimited additional days for acute care are covered with no copay, but 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. Outpatient hospital services require a $0 to $450 copay (including a $375 copay per stay for observation services) with no coinsurance, while outpatient substance abuse sessions have a $25 copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered by Capital Blue Cross Value (PPO) with a $55.00 copay and no coinsurance, although prior authorization is required.
Ambulance and Transportation Services See details
Capital Blue Cross Value (PPO) covers ground and air ambulance services with a $260 copay and no coinsurance, with prior authorization required. Transportation services to 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 and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $40 copay and no coinsurance. Worldwide emergency and urgent services are partially covered up to a $20,000 maximum plan benefit with a $115 and $40 copay respectively and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Primary care benefits under Capital Blue Cross Value (PPO) feature no copay and no coinsurance for primary care provider visits, while specialists, therapists, and psychiatric services require a $25 copay and no coinsurance. Some chiropractic services are covered with a $15 copay and no coinsurance, but routine and other chiropractic services are not covered, and podiatry services are not covered.
Preventive Services See details
Preventive services are covered by Capital Blue Cross Value (PPO) with no copay and no coinsurance for key services like annual physical exams, kidney disease education, and diabetes self-management training. Additional preventive benefits are partially covered, with exclusions on certain sub-services including health education, weight management programs, and in-home safety assessments.
Hearing Services See details
Capital Blue Cross Value (PPO) covers hearing services, including one annual routine hearing exam for a $25 copay and no coinsurance, alongside unlimited fitting evaluations. Hearing aids are partially covered for up to two devices per year with no coinsurance and copays of $499 for OTC aids and $499 to $999 for prescription aids, though inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Vision Services are partially covered by Capital Blue Cross Value (PPO) with no deductibles, featuring one routine eye exam annually with no copay and no coinsurance, though other eye exams are not covered. Eyewear is covered with no copay or coinsurance up to a $150 annual combined limit for one pair of contact lenses or eyeglasses (lenses and frames), but upgrades, individual eyeglass lenses, and individual eyeglass frames are not covered.
Dental Services See details
Capital Blue Cross Value (PPO) dental services are partially covered, featuring a $25 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for preventive care like exams, cleanings, fluoride, and x-rays up to a $2,000 annual limit. Restorative services and simple extractions are covered with no copay and 50% coinsurance, while other diagnostic and preventive services, endodontics, periodontics, prosthodontics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Capital Blue Cross Value (PPO) covers home infusion bundled services with no copay, subject to prior authorization. Under this plan, Medicare Part B chemotherapy and other drugs are covered with no copay and 0% to 20% coinsurance, while Part B insulin requires a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis services are covered under the Capital Blue Cross Value (PPO) plan 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 diabetic supplies, with no copays and required prior authorizations. While most of these covered items require a 20% coinsurance, diabetic supplies range from no coinsurance up to 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Capital Blue Cross Value (PPO) with no copay and no coinsurance for diagnostic tests, procedures, and lab services. Outpatient X-rays require a $20 copay, therapeutic radiological services require a 20% coinsurance, and diagnostic radiology copays start at $0, with prior authorization required.
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) provides Cardiac Rehabilitation Services with no coinsurance; while some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) are not covered and require copays of $20, $20, $15, and $10 respectively.
Skilled Nursing Facility (SNF) See details
Capital Blue Cross Value (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance and does not require a prior three-day inpatient hospital stay. There is no copay for days 1 through 20 and a $145 copay for days 21 through 100, though prior authorization is required and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Capital Blue Cross Value (PPO) partially covers other services, providing over-the-counter (OTC) items 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 this benefit.
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