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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 $29.00. 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 $7200.00 (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 $7200.00 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 an annual prescription drug deductible of $275. For Tier 1 preferred generics and Tier 2 generics, there is no copay for up to a three-month supply when using preferred retail pharmacies or preferred mail order services. If you choose standard pharmacies or standard mail order, Tier 1 copays start at $10 and Tier 2 copays start at $15 for a one-month supply. Higher-tier medications are subject to coinsurance rather than flat copays across all pharmacy and mail-order options. You will pay 20% coinsurance for Tier 3 preferred brand drugs, 42% coinsurance for Tier 4 non-preferred drugs, and 29% coinsurance for Tier 5 specialty drugs. Specialty tier medications are limited to a one-month supply under this plan.
Additional Benefits
The Capital Blue Cross Enhanced (PPO) plan offers comprehensive medical coverage featuring no copays for primary care visits, preventive services, home health care, and routine eye exams. For inpatient hospital stays, members pay a $225 daily copay for days 1 through 4 and no copay for days 5 through 90, with no coinsurance required. Emergency room visits carry a $115 copay, while specialist visits, outpatient mental health care, and physical therapies require low copays between $15 and $25. This plan also features robust dental, vision, and hearing benefits, including up to a $4,000 annual limit for dental care and a $225 yearly allowance for contacts or eyeglasses. Most preventive dental services, lab tests, and diagnostic screenings require no copay, while hearing aids are covered with copays starting at $499. Additionally, members can take advantage of a $60 quarterly over-the-counter benefit and pay no copay with a 20% coinsurance for most durable medical equipment.
Inpatient Hospital See details
Capital Blue Cross Enhanced (PPO) covers inpatient acute and psychiatric hospital services with no coinsurance, requiring a $225 daily copay for days 1 through 4 and no copay for days 5 through 90. Inpatient benefits are partially covered because upgrades and non-Medicare-covered stays are not covered, and unlimited additional days are only covered for acute stays. Prior authorization is required for both acute and psychiatric admissions.
Outpatient Services See details
Capital Blue Cross Enhanced (PPO) covers outpatient hospital services with no coinsurance and copays ranging from $0 to $425, while ambulatory surgical center and blood services are covered with no copays or coinsurance. Outpatient substance abuse services require a $25 copay with no coinsurance, and observation services incur a $250 copay per stay with no coinsurance.
Partial Hospitalization See details
Capital Blue Cross Enhanced (PPO) covers partial hospitalization services 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 Medicare-approved ground and air ambulance services with a $190 copay and no coinsurance, though prior authorization is required. Routine transportation services to health-related locations are not covered by this plan.
Emergency Services See details
Capital Blue Cross Enhanced (PPO) covers emergency services with a $115 copay, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $40 copay, both featuring no coinsurance. Worldwide emergency and urgent care are partially covered up to a $20,000 maximum limit with no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Capital Blue Cross Enhanced (PPO) covers primary care physician services and opioid treatment with no copay and no coinsurance. Primary care benefits are partially covered, excluding other chiropractic services, with remaining covered services like specialists, therapies, and mental health care requiring copays between $15 and $25 and no coinsurance.
Preventive Services See details
Capital Blue Cross Enhanced (PPO) offers partially covered preventive services with no copay and no coinsurance for covered benefits, including annual physical exams, kidney disease education, and diabetes self-management training. While select benefits like medical nutrition therapy and memory fitness 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 Enhanced (PPO) covers hearing services, including one annual routine exam for a $25 copay and no coinsurance. Hearing aids are partially covered with no coinsurance and a limit of two per year, featuring a $499 copay for OTC devices and a $499 to $999 copay for prescription devices, though inner ear, outer ear, and over-the-ear prescription models are not covered.
Vision Services See details
Capital Blue Cross Enhanced (PPO) provides partially covered vision services with no deductibles and no coinsurance, featuring one routine eye exam per year with no copay, though other eye exams are not covered. Eyewear is also partially covered with no copay or coinsurance up to a $225 annual limit for one pair of contact lenses or eyeglasses (lenses and frames) per year, while separate eyeglass lenses, 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, featuring a $25 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for most preventive services. Comprehensive services generally carry no copay and 50% coinsurance, while other preventive dental 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, although prior authorization is required. Medicare Part B insulin is covered with a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have a coinsurance ranging from 0% to 20%.
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, including durable medical equipment, prosthetics, and diabetic supplies, with no copays and prior authorization required. Members will pay a 20% coinsurance for most medical equipment, prosthetics, and diabetic shoes, while diabetic supplies range from no coinsurance up to 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Capital Blue Cross Enhanced (PPO) with no copay or coinsurance for lab work, diagnostic tests, and diagnostic radiological services. Outpatient X-rays require a $25 copay, therapeutic radiological services carry a minimum 20% coinsurance, and prior authorization is required for these benefits.
Home Health Services See details
Home health services are covered under the Capital Blue Cross Enhanced (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Capital Blue Cross Enhanced (PPO) features no coinsurance for Cardiac Rehabilitation Services, but in practice only some services are covered as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation are not covered and require a $10.00 copay.
Skilled Nursing Facility (SNF) See details
Capital Blue Cross Enhanced (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 through 20 and a $195 daily copay for days 21 through 100. Prior authorization is required, and additional days beyond the standard 100-day Medicare benefit are not covered.
Other Services See details
Capital Blue Cross Enhanced (PPO) partially covers Other Services, offering an over-the-counter (OTC) benefit of up to $60 every three months with no copay and no coinsurance. However, acupuncture, meal benefits, and nicotine replacement therapy are not covered under this plan.
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