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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) Medicare plan features a $275 annual prescription drug deductible. For Tier 1 preferred generic and Tier 2 generic drugs, members pay no copay when using a preferred pharmacy or preferred mail-order service. If you use a standard pharmacy or standard mail-order service, Tier 1 copays range from $10 to $30, while Tier 2 copays range from $15 to $45 depending on the supply fill. For higher-tier medications, costs transition to a percentage-based coinsurance across all pharmacy and mail-order options. Tier 3 preferred brand drugs require a 20% coinsurance, and Tier 4 non-preferred drugs carry a 42% coinsurance. Tier 5 specialty drugs require a 29% coinsurance and are limited to a one-month supply.
Additional Benefits
The Capital Blue Cross Enhanced (PPO) plan offers comprehensive medical coverage with predictable out-of-pocket costs, featuring no coinsurance for most standard services. Primary care visits, preventive care, and home health services are available with no copay, while specialist visits require a small copay of $15 to $20. For hospital care, inpatient stays require a $140 daily copay for days one through four and no copay for days five through 90, while emergency room visits carry a $115 copay. This plan also includes robust supplemental benefits, including a $4,000 annual dental limit with no copay for preventive cleanings and a 50% coinsurance for diagnostic services. Vision and hearing benefits feature low copays, offering a $225 annual allowance for eyewear and routine hearing exams for a $20 copay. Additionally, members can access a quarterly over-the-counter item allowance of $60 with no copay, and standard diagnostic lab work is covered with no copay or coinsurance.
Inpatient Hospital See details
Capital Blue Cross Enhanced (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $140 copay per day for days 1 through 4 and no copay for days 5 through 90. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered, though unlimited additional acute care days are provided at no copay.
Outpatient Services See details
Capital Blue Cross Enhanced (PPO) covers outpatient services with no coinsurance, featuring copays ranging from $0 to $425 for outpatient hospital services and $250 per stay for observation services. Outpatient substance abuse sessions require a $20 copay, while ambulatory surgical center and blood services are covered with no copay.
Partial Hospitalization See details
Partial hospitalization is covered under the Capital Blue Cross Enhanced (PPO) plan with a $55.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Capital Blue Cross Enhanced (PPO) covers ground and air ambulance services with a $150 copay and no coinsurance, subject to prior authorization. Routine transportation services to 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 admitted to the hospital within 24 hours, and urgently needed services with a $40 copay and no coinsurance. Worldwide emergency and urgent care are partially covered up to a $20,000 lifetime maximum with no coinsurance and copays of $115 and $40 respectively, though worldwide emergency transportation is not covered.
Primary Care See details
Capital Blue Cross Enhanced (PPO) covers primary care visits and opioid treatment with no copay and no coinsurance, while therapy and specialist visits require copays of $15 to $20 with no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance, as other chiropractic services are not covered. Telehealth, mental health, psychiatric, and podiatry services are also covered with copays up to $20 and no coinsurance.
Preventive Services See details
Preventive services are partially covered by Capital Blue Cross Enhanced (PPO), with covered options like annual physical exams, kidney disease education, and diabetes self-management training featuring no copay and no coinsurance. While medical nutrition therapy and memory fitness are also covered, several supplemental benefits such as health education, weight management programs, and in-home safety assessments are not covered.
Hearing Services See details
Hearing services covered by Capital Blue Cross Enhanced (PPO) include annual routine exams for a $20 copay and no coinsurance, alongside OTC hearing aids for a $499 copay and no coinsurance. Prescription hearing aids are partially covered with copays between $499 and $999 and no coinsurance, though inner ear, outer ear, and over the ear models are not covered.
Vision Services See details
Vision services are partially covered by Capital Blue Cross Enhanced (PPO), offering eye exams with no deductibles, no coinsurance, and copays ranging from no copay to $20. Eyewear is covered with no copay, no coinsurance, and a $225 annual limit for one pair of glasses or contacts, though other eye exams, separate lenses or frames, and upgrades are not covered.
Dental Services See details
Capital Blue Cross Enhanced (PPO) offers partially covered dental services with a $4,000 annual maximum, requiring a $20 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for preventive cleanings, exams, and x-rays. Diagnostic and comprehensive services require no copay and a 50% coinsurance, while other preventive services, maxillofacial prosthetics, implants, 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 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
Capital Blue Cross Enhanced (PPO) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Capital Blue Cross Enhanced (PPO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay and coinsurance ranging from no coinsurance up to 20%. Prior authorization is required for these benefits, and coverage for some equipment may be limited to preferred vendors or manufacturers.
Diagnostic and Radiological Services See details
Capital Blue Cross Enhanced (PPO) covers diagnostic and radiological services, offering diagnostic tests, lab work, and diagnostic radiology with no copay and no coinsurance. Outpatient x-rays require a $15 copay plus coinsurance, while therapeutic radiological services require a copay and a minimum 20% coinsurance, with prior authorization required.
Home Health Services See details
Home health services are covered by Capital Blue Cross Enhanced (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Capital Blue Cross Enhanced (PPO) offers Cardiac Rehabilitation Services with no coinsurance. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for 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 to 20 and a $205 daily copay for days 21 to 100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the standard 100 days are not covered.
Other Services See details
Capital Blue Cross Enhanced (PPO) partially covers other services, offering over-the-counter (OTC) items with no copay and no coinsurance up to a maximum of $60 every three months. Acupuncture and meal benefits are not covered under this plan.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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