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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 $22.00. 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 $6800.00 (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 $6800.00 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) plan features a $275 annual prescription drug deductible. For Tier 1 preferred generic and Tier 2 generic medications, you will pay no copay for 1-month, 2-month, or 3-month supplies filled at preferred pharmacies or through preferred mail order. If you use standard pharmacies or standard mail order, Tier 1 drugs carry a $10 to $30 copay, while Tier 2 drugs require a $15 to $45 copay depending on the supply duration. Brand-name and specialty medications are covered under a coinsurance structure across all pharmacy and mail-order options. Tier 3 preferred brand drugs require a 20% coinsurance, and Tier 4 non-preferred drugs require a 42% coinsurance for all supply lengths. Specialty tier drugs in Tier 5 carry a 29% coinsurance and are limited to a 1-month supply.
Additional Benefits
The Capital Blue Cross Enhanced (PPO) plan offers robust medical coverage with no copay for primary care visits, preventive services, and home health care. Specialist visits, routine hearing exams, and outpatient diagnostic tests are highly affordable, featuring low copays and no coinsurance. For hospital stays, inpatient care requires a $110 daily copay for the first four days followed by no copay, while emergency care is covered with a $115 copay. Additional benefits include comprehensive dental coverage up to a $4,000 annual limit and routine vision care with no copay up to a $225 annual limit. While many services carry no coinsurance, a 20% coinsurance applies to dialysis and durable medical equipment, and prescription hearing aids require copays between $499 and $999. Members also benefit from a $60 over-the-counter quarterly allowance with no copays.
Inpatient Hospital See details
Capital Blue Cross Enhanced (PPO) partially covers inpatient hospital services with no coinsurance, though prior authorization is required. For both acute and psychiatric stays, you pay a $110 copay per day for days 1 through 4 and no copay for days 5 through 90, but upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Capital Blue Cross Enhanced (PPO) covers outpatient services with no coinsurance, featuring a $0 to $425 copay for outpatient hospital services and a $250 copay per stay for observation services. Ambulatory surgical center and outpatient blood services are provided with no copay and no coinsurance, while individual and group outpatient substance abuse sessions require a $15 copay.
Partial Hospitalization See details
Capital Blue Cross Enhanced (PPO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization is required for this covered benefit.
Ambulance and Transportation Services See details
Capital Blue Cross Enhanced (PPO) covers Medicare-covered ground and air ambulance services with a $150 copay per service and no coinsurance, although prior authorization is required. Routine transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Emergency services are covered by Capital Blue Cross Enhanced (PPO) with a $115 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgently needed services are covered with a $30 copay and no coinsurance. Worldwide emergency and urgent services are also covered up to a $20,000 maximum limit with no coinsurance and matching copays, though worldwide emergency transportation is not covered.
Primary Care See details
Capital Blue Cross Enhanced (PPO) covers primary care physician services with no copay and no coinsurance, while physical, occupational, and speech therapy services require a $10 copay and no coinsurance. Specialist, mental health, and psychiatric visits have a $15 copay and no coinsurance, though chiropractic care is only partially covered because other chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered under Capital Blue Cross Enhanced (PPO) with no copay and no coinsurance for covered benefits like annual physical exams, kidney disease education, and diabetes self-management training. While memory fitness and medical nutrition therapy are covered, other supplemental benefits such as health education, weight management programs, and in-home safety assessments are not covered.
Hearing Services See details
Capital Blue Cross Enhanced (PPO) covers routine hearing exams with a $15 copay and no coinsurance, alongside OTC hearing aids for a $499 copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and copays between $499 and $999, though inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Capital Blue Cross Enhanced (PPO) features partially covered vision services with no coinsurance and eye exam copays ranging from $0 to $15. Routine eye exams and eyewear (one pair of contact lenses or eyeglasses per year) are covered with no copay and no coinsurance up to a $225 annual limit, while other eye exams, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Capital Blue Cross Enhanced (PPO) provides partially covered dental services up to a $4,000 annual maximum, with Medicare-covered dental requiring a $15 copay and no coinsurance. Preventive care is available with no copay and no coinsurance, while covered comprehensive services carry no copay and a 50% coinsurance; however, other preventive services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Capital Blue Cross Enhanced (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Medicare Part B insulin drugs have 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
Capital Blue Cross Enhanced (PPO) covers medical equipment with no copays, though a 20% coinsurance applies to durable medical equipment, prosthetics, medical supplies, and diabetic shoes, while diabetic supplies range from no coinsurance up to 20% coinsurance. Prior authorization is required for these benefits, and some equipment may be limited to preferred manufacturers or vendors.
Diagnostic and Radiological Services See details
Capital Blue Cross Enhanced (PPO) covers diagnostic and radiological services with prior authorization required. Diagnostic tests, lab work, and diagnostic radiology are offered with no copay and no coinsurance, while outpatient X-rays require a $15 copay and therapeutic radiological services carry a 20% coinsurance.
Home Health Services See details
Home health services are covered under the Capital Blue Cross Enhanced (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Capital Blue Cross Enhanced (PPO) offers Cardiac Rehabilitation Services with no coinsurance, but in practice only some services are covered. Specifically, 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
Skilled Nursing Facility (SNF) services are partially covered by Capital Blue Cross Enhanced (PPO) with no coinsurance, though additional days beyond the standard 100 days are not covered. There is no copay for days 1 through 20, a $215 daily copay for days 21 through 100, and prior authorization is required.
Other Services See details
Capital Blue Cross Enhanced (PPO) provides partial coverage for other services, 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.
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