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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 $23.50. 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 has an annual drug deductible of $550. You can enjoy no copay for Tier 1 preferred generic and Tier 2 generic drugs when using a preferred pharmacy or preferred mail-order service. For standard pharmacies and standard mail order, copays start at $10 for Tier 1 drugs and $15 for Tier 2 drugs for a one-month supply. Brand-name and specialty medications are subject to coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 16% coinsurance, while Tier 4 non-preferred drugs have a 39% coinsurance. Tier 5 specialty drugs carry a 26% coinsurance for a one-month supply, regardless of whether you use a preferred or standard pharmacy.
Additional Benefits
The Capital Blue Cross Value (PPO) plan offers comprehensive healthcare coverage with no copay or coinsurance for primary care visits, home health services, and routine preventive care. For specialist visits and routine hearing exams, you will pay a $30 copay with no coinsurance. Inpatient hospital stays require a $275 daily copay for the first four days and no copay for days five through ninety, while emergency room visits carry a $115 copay that is waived if you are admitted. This plan also includes valuable dental, vision, and hearing benefits, featuring no copay for annual routine eye exams and preventive dental cleanings, alongside a $150 annual eyewear allowance and a $2,000 yearly dental limit. Diagnostic lab tests and screenings are available with no copay, while dialysis and durable medical equipment require a 20% coinsurance. Additionally, members receive a quarterly $30 over-the-counter allowance with no copay to help cover everyday health essentials.
Inpatient Hospital See details
Capital Blue Cross Value (PPO) covers inpatient hospital services with no coinsurance, requiring a $275 daily copay for days 1 through 4 and no copay for days 5 through 90 for acute and psychiatric stays. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional days for psychiatric stays are not covered.
Outpatient Services See details
Capital Blue Cross Value (PPO) outpatient services are covered with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Outpatient hospital services require a copay of $0 to $500, observation services have a $375 copay per stay, and outpatient substance abuse sessions have a $30 copay, all with no coinsurance.
Partial Hospitalization See details
Capital Blue Cross Value (PPO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization is required to access this covered benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered under the Capital Blue Cross Value (PPO) plan, with Medicare-covered ground and air ambulance services requiring prior authorization and a $335 copay with no coinsurance. The ambulance copay is not waived upon hospital admission, and transportation services to plan-approved or any other health-related locations are not covered.
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 services are partially covered up to a $20,000 maximum benefit with no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Capital Blue Cross Value (PPO) provides primary care physician services with no copay and no coinsurance, while specialist visits and mental health sessions require a $30 copay and no coinsurance. Physical, occupational, and speech therapies are covered with a $35 copay and no coinsurance, but podiatry is not covered, and chiropractic benefits are only partially covered with routine care excluded.
Preventive Services See details
Capital Blue Cross Value (PPO) provides partially covered preventive services with no copay and no coinsurance for covered benefits, including annual physical exams, kidney disease education, glaucoma screenings, and diabetes self-management training. While supplemental benefits like medical nutrition therapy, memory fitness, and remote access technologies are covered, other services such as health education, weight management, and in-home safety assessments are not covered.
Hearing Services See details
Capital Blue Cross Value (PPO) covers routine hearing exams with a $30 copay and no coinsurance, while fitting and evaluation services have no copay and no coinsurance. Hearing aids are limited to two per year with no coinsurance, featuring a $499 copay for OTC devices and a $499 to $999 copay for prescription hearing aids, though inner ear, outer ear, and over the ear types are not covered.
Vision Services See details
Capital Blue Cross Value (PPO) provides partially covered vision services with no deductibles and no coinsurance. Routine eye exams are covered once per year with no copay, while eyewear is covered with no copay up to a $150 annual combined limit for eyeglasses or contact lenses. Other eye exams, separate lenses or 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 for both in-network and out-of-network care. Medicare-covered dental services require a $30 copay and no coinsurance, while covered preventive services like exams, cleanings, x-rays, and fluoride have no copay and no coinsurance. Covered restorative services and simple extractions have no copay and 50% coinsurance, but other diagnostic, other preventive, adjunctive general, endodontic, periodontic, prosthodontic, implant, and orthodontic services 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 and step therapy are required. Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs feature no copay and a coinsurance ranging from 0% to 20%.
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 equipment, with no copay and a 20% coinsurance for most items. Diabetic supplies feature a coinsurance ranging from no coinsurance up to 20%, and prior authorization is required for these covered benefits.
Diagnostic and Radiological Services See details
Capital Blue Cross Value (PPO) covers diagnostic and radiological services, 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 $30 copay and no coinsurance, and therapeutic radiological services require 20% coinsurance and no copay.
Home Health Services See details
Capital Blue Cross Value (PPO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered by Capital Blue Cross Value (PPO) with no coinsurance and no copay, but only some services are covered in practice. Standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
Capital Blue Cross Value (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no copay for days 1 through 20 and a $160 daily copay for days 21 through 100. Prior authorization is required, a prior three-day inpatient hospital stay is not required, and additional days beyond the standard Medicare-covered period are not covered.
Other Services See details
Capital Blue Cross Value (PPO) partially covers other services, featuring over-the-counter (OTC) items with no copay and no coinsurance up to $30 every three months. Acupuncture, meal benefits, and nicotine replacement therapies are not covered under this benefit.
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