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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 $18.50. 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) prescription drug plan has an annual drug deductible of $550. You can save on coverage with no copay for Tier 1 preferred generics and Tier 2 generics when using a preferred pharmacy or preferred mail-order service. If you use standard pharmacies or mail-order services, Tier 1 copays start at $10 and Tier 2 copays start at $15 for a one-month supply. For brand-name and specialty medications, your costs are determined by coinsurance. Tier 3 preferred brand drugs require a 16% coinsurance, and Tier 4 non-preferred drugs require a 39% coinsurance at both preferred and standard pharmacies. Specialty drugs under Tier 5 carry a 26% coinsurance for a one-month supply.
Additional Benefits
The Capital Blue Cross Value (PPO) plan offers affordable coverage for core medical services, featuring no copays and no coinsurance for primary care visits, preventive care, and home health services. Specialist visits, urgent care, and outpatient therapies require low copayments with no coinsurance, while inpatient hospital stays charge a daily copay for only the first four days. Emergency room visits and ambulance services are also covered with flat copayments and no coinsurance. For supplemental care, the plan provides routine eye exams and preventive dental services with no copays, alongside allowances for eyewear and up to a two thousand dollar annual limit for dental care. Hearing aids and routine hearing exams are available with fixed copayments and no coinsurance. Diagnostic lab tests have no copays, while medical equipment and dialysis services are covered with a twenty percent coinsurance.
Inpatient Hospital See details
Capital Blue Cross Value (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $245 daily copay for days 1 through 4 and no copay for days 5 through 90. Unlimited additional days are covered for acute care, but additional psychiatric days, room upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Capital Blue Cross Value (PPO) covers outpatient services with no coinsurance, featuring a $0 to $500 copay for outpatient hospital services and a $375 copay per stay for observation services. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, while outpatient substance abuse sessions require a $30 copay and no coinsurance.
Partial Hospitalization See details
Capital Blue Cross Value (PPO) covers partial hospitalization services with a $55.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Capital Blue Cross Value (PPO), offering ground and air ambulance services for a $275 copay and no coinsurance, subject to prior authorization. Although some transportation services are covered, transportation to plan-approved health-related locations and any health-related locations is not covered in practice.
Emergency Services See details
Capital Blue Cross Value (PPO) covers emergency services with a $115 copay (waived if admitted to the hospital within 24 hours) and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency and urgent services are partially covered with a $20,000 maximum limit and no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Capital Blue Cross Value (PPO) primary care benefits feature no copay and no coinsurance for primary care visits and opioid treatment, while specialist, mental health, and psychiatric services require a $30 copay with no coinsurance. Physical and occupational therapies have a $25 copay with no coinsurance, telehealth ranges from no copay to a $30 copay with no coinsurance, and chiropractic and podiatry services are not covered.
Preventive Services See details
Capital Blue Cross Value (PPO) preventive services are covered with no copayments and no coinsurance for annual physical exams, kidney disease education, glaucoma screenings, diabetes self-management training, digital rectal exams, and EKGs. Additional preventive benefits are partially covered with no coinsurance, featuring memory fitness, remote access technologies, and medical nutrition therapy, while sub-services like health education, weight management, and in-home safety assessments are not covered.
Hearing Services See details
Hearing services covered by Capital Blue Cross Value (PPO) include annual routine hearing exams for a $30 copay and no coinsurance, with no deductible. Prescription hearing aids are partially covered with no coinsurance and a copay between $499 and $999 for up to two aids yearly, but inner ear, outer ear, and over the ear types are not covered. Over-the-counter hearing aids are covered with a $499 copay and no coinsurance for up to two aids per year.
Vision Services See details
Vision Services are partially covered by Capital Blue Cross Value (PPO) with no deductibles and no coinsurance. Routine eye exams are covered with no copay (limited to one per year), while eyewear is covered with no copay up to a $150 annual limit for one pair of contact lenses or eyeglasses, excluding separate lenses, frames, and upgrades.
Dental Services See details
Capital Blue Cross Value (PPO) provides partially covered dental services up to a $2,000 annual maximum, featuring a $30 copay and no coinsurance for Medicare-covered dental. Preventive services like exams, cleanings, fluoride, and x-rays have no copay and no coinsurance, while restorative care and oral surgery have no copay and 50% coinsurance. Other diagnostic, other preventive, adjunctive general, endodontic, periodontic, prosthodontic, implant, maxillofacial prosthetic, and orthodontic services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Capital Blue Cross Value (PPO) with no copay, though prior authorization and step therapy are required. Under this benefit, Medicare Part B insulin has a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and a 0% to 20% 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 medical supplies, with no copay and 20% coinsurance. Diabetic supplies are also covered with no copay and coinsurance ranging from no coinsurance to 20%, though prior authorization is required and manufacturer limitations apply.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the Capital Blue Cross Value (PPO) plan, with prior authorization required for all services. Diagnostic tests, lab services, and diagnostic radiological services have no copay and no coinsurance, while outpatient X-rays require a $25 copay and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Home health services are covered by Capital Blue Cross Value (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by Capital Blue Cross Value (PPO) with no coinsurance, but copayments do apply. There is a $20 copay for cardiac and intensive cardiac rehabilitation, a $15 copay for pulmonary rehabilitation, and a $10 copay for supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD).
Skilled Nursing Facility (SNF) See details
Capital Blue Cross Value (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20, followed by a $130 copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Capital Blue Cross Value (PPO) partially covers other services, which includes over-the-counter (OTC) items with no copay and no coinsurance up to $30 every three months. Acupuncture and meal benefits are not covered.
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