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Capital Blue Cross Enhanced (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Blue Cross Enhanced (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 Enhanced (PPO) in 2026, please refer to our full plan details page.
Capital Blue Cross Enhanced (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 Enhanced (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 Enhanced (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 Enhanced (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $26.00. 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 a $275.00 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 $6500.00 (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 $6500.00 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 Enhanced (PPO) prescription drug plan features an annual drug deductible of $275. For Tier 1 preferred generics and Tier 2 generics, there is no copay when using a preferred pharmacy or preferred mail-order service for up to a three-month supply. If you use a standard pharmacy or standard mail-order service, Tier 1 drugs carry a copay of $10 to $30, while Tier 2 drugs require a copay of $15 to $45 depending on the supply duration. Higher-tier medications are subject to coinsurance across all pharmacy and mail-order channels. Tier 3 preferred brand drugs require a 20% coinsurance, while Tier 4 non-preferred drugs have a 42% coinsurance. Specialty drugs in Tier 5 are covered with a 29% coinsurance for a one-month supply.
Additional Benefits
The Capital Blue Cross Enhanced (PPO) plan offers robust coverage for core medical needs with predictable out-of-pocket costs and no coinsurance for many services. Members benefit from no copay for primary care visits and preventive care, while specialist visits require affordable copays between $15 and $20. For hospital stays, inpatient care features a $140 daily copay for the first four days followed by no copay, and emergency care is available with a $115 copay. In addition to medical care, this plan provides strong supplemental benefits including dental coverage up to a $4,000 annual limit with no copay for preventive services. Vision and hearing benefits feature no copay for annual routine exams, alongside allowances for eyewear and coverage for hearing aids. Additional conveniences include home health services with no copay and a $60 over-the-counter allowance every three months.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Capital Blue Cross Enhanced (PPO) with no coinsurance and a copay of $140 per day for days 1 through 4, followed by no copay for days 5 and beyond. Prior authorization is required, and certain sub-services such as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by Capital Blue Cross Enhanced (PPO) with no coinsurance, including ambulatory surgical center and blood services with no copay. Outpatient hospital service copays range from no copay to $425, observation services require a $250 copay per stay, and outpatient substance abuse sessions have a $20 copay, all with no coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered by Capital Blue Cross Enhanced (PPO) with a $55.00 copay and no coinsurance. Prior authorization is required before you can receive these services.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by Capital Blue Cross Enhanced (PPO), with ground and air ambulance services requiring a $150 copay and no coinsurance. Transportation services to plan-approved or any other health-related locations are not covered under this plan.
Emergency Services See details
Capital Blue Cross Enhanced (PPO) covers emergency services with a $115 copay and no coinsurance, which is waived if hospitalized within 24 hours, and urgent care with a $40 copay and no coinsurance. Worldwide emergency services are partially covered up to a $20,000 maximum with no coinsurance and copays of $115 for emergency and $40 for urgent care, though worldwide emergency transportation is not covered.
Primary Care See details
Capital Blue Cross Enhanced (PPO) offers primary care physician services and opioid treatment with no copay and no coinsurance, while specialist, therapy, and mental health services carry copays between $15 and $20 with no coinsurance. Chiropractic benefits are partially covered, offering up to 6 routine visits per year for a $15 copay and no coinsurance, while other chiropractic services are not covered.
Preventive Services See details
Capital Blue Cross Enhanced (PPO) provides partially covered preventive services with no copay and no coinsurance for covered care, including annual physical exams, glaucoma screenings, and kidney disease education. However, several supplemental options are not covered, such as health education, weight management programs, personal emergency response systems, and therapeutic massage.
Hearing Services See details
Capital Blue Cross Enhanced (PPO) covers hearing services, offering routine hearing exams for a $20 copay and no coinsurance, alongside fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $499 to $999 for up to two aids per year, though inner ear, outer ear, and over the ear models are not covered. Over-the-counter hearing aids are also covered with a $499 copay and no coinsurance for up to two devices annually.
Vision Services See details
Vision services are partially covered by Capital Blue Cross Enhanced (PPO) with no deductibles or coinsurance, featuring no copay for one annual routine eye exam and no copay for eyewear up to a $225 yearly limit. While contact lenses and complete eyeglasses are covered, other eye exam services, separate eyeglass lenses, separate eyeglass frames, and upgrades are not covered.
Dental Services See details
Capital Blue Cross Enhanced (PPO) covers dental services up to a $4,000 annual maximum, featuring a $20 copay and no coinsurance for Medicare-covered dental, no copay or coinsurance for preventive care, and no copay with 50% coinsurance for comprehensive services. Dental coverage is partial, as other preventive dental services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Capital Blue Cross Enhanced (PPO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy and other Part B drugs have a 0% to 20% coinsurance and no copay.
Dialysis Services See details
Dialysis Services are covered by Capital Blue Cross Enhanced (PPO) with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by Capital Blue Cross Enhanced (PPO) with no copays and coinsurance ranging from no coinsurance up to 20%, depending on the item. This benefit includes durable medical equipment, prosthetics, medical supplies, and diabetic services, all of which require prior authorization and may be subject to manufacturer or vendor limitations.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under Capital Blue Cross Enhanced (PPO), with prior authorization required for all services. Diagnostic procedures, lab services, and diagnostic radiological services are available with no copay and no coinsurance, while outpatient X-rays require a $15 copay and therapeutic radiological services require a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Capital Blue Cross Enhanced (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 Enhanced (PPO) with no coinsurance, though only some services are covered in practice. Standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) rehabilitation services are not covered and require a $10 copay.
Skilled Nursing Facility (SNF) See details
Capital Blue Cross Enhanced (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no copay for days 1 through 20 and a $200 daily copay for days 21 through 100. Prior authorization is required, and while a prior three-day inpatient hospital stay is not needed, additional days beyond the standard 100 days are not covered.
Other Services See details
Other services under the Capital Blue Cross Enhanced (PPO) are partially covered, featuring an over-the-counter (OTC) benefit with no copay and no coinsurance up to $60 every three months. Acupuncture, meal benefits, and nicotine replacement therapy are not covered under this plan.
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