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Capital Blue Cross Complete (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Blue Cross Complete (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 Complete (PPO) in 2026, please refer to our full plan details page.
Capital Blue Cross Complete (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 Complete (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 Complete (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 Complete (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $45.00. 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 $100.00 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 $6100.00 (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 $6100.00 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:
Sign up for Capital Blue Cross Complete (PPO)
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Drug Coverage
The Capital Blue Cross Complete (PPO) prescription drug plan features an annual drug deductible of $100. You will pay no copay for Tier 1 preferred generic and Tier 2 generic medications when using preferred retail pharmacies or preferred mail-order services. For standard pharmacies and standard mail order, copays range from $10 to $30 for Tier 1 and $15 to $45 for Tier 2 depending on the supply fill. For brand-name and specialty medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require an 18% coinsurance, Tier 4 non-preferred drugs carry a 40% coinsurance, and Tier 5 specialty drugs incur a 31% coinsurance for a one-month supply.
Additional Benefits
Capital Blue Cross Complete (PPO) offers comprehensive medical coverage with affordable cost-sharing, including no copay for primary care visits and a low $15 copay for specialists and therapy. Inpatient hospital stays feature a $130 daily copay for the first four days followed by no copay, while emergency room visits carry a $130 copay. Outpatient services and diagnostic tests are also highly accessible, often requiring no copay or low flat copayments with no coinsurance. The plan also provides robust supplemental benefits, including routine dental cleanings and annual vision exams with no copay, alongside a $300 annual eyewear allowance. Hearing care includes a $15 routine exam copay and coverage for hearing aids, while an over-the-counter benefit provides up to $75 every three months with no copay. Other essential services like home health care require no copay, though certain durable medical equipment and dialysis services are subject to a 20% coinsurance.
Inpatient Hospital See details
Capital Blue Cross Complete (PPO) inpatient hospital care is partially covered with no coinsurance, featuring a $130 daily copay for days 1 through 4 and no copay for days 5 through 90 for acute and psychiatric admissions. Non-Medicare-covered stays, upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
Capital Blue Cross Complete (PPO) covers outpatient services with no coinsurance, including outpatient hospital services with a copay ranging from no copay to $400 and observation services with a $200 copay per stay. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, while outpatient substance abuse sessions require a $15 copay and no coinsurance.
Partial Hospitalization See details
Capital Blue Cross Complete (PPO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization is required for these benefits.
Ambulance and Transportation Services See details
Capital Blue Cross Complete (PPO) covers Medicare-covered ground and air ambulance services with a $285.00 copay and no coinsurance, with prior authorization required. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Capital Blue Cross Complete (PPO) covers emergency services with a $130 copay, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency and urgent services are partially covered up to a $20,000 maximum with no coinsurance and matching copays of $130 and $40 respectively, but worldwide emergency transportation is not covered.
Primary Care See details
Capital Blue Cross Complete (PPO) covers primary care physician services and opioid treatment with no copay and no coinsurance, while telehealth services range from no copay to a $15 copay and no coinsurance. Most other services—including specialists, therapy, mental health, podiatry, and routine chiropractic care (limited to 6 visits per year)—require a $15 copay and no coinsurance, though other chiropractic services are not covered.
Preventive Services See details
Capital Blue Cross Complete (PPO) provides partially covered preventive services with no copay and no coinsurance for covered benefits such as annual physical exams, kidney disease education, and diabetes self-management training. Uncovered sub-services include health education, in-home safety assessments, personal emergency response systems, post-discharge medication reconciliation, re-admission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, smoking cessation counseling, enhanced disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Capital Blue Cross Complete (PPO) covers hearing services, featuring routine hearing exams with a $15 copay and no coinsurance. Hearing aids are partially covered with no coinsurance, offering up to two OTC hearing aids per year for a $499 copay and up to two prescription hearing aids per year with a copay between $499 and $999, 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 Complete (PPO), offering one routine eye exam annually with no copay, coinsurance, or deductible, while other eye exams are not covered. Eyewear is also covered with no copay, coinsurance, or deductible up to a $300 annual limit for one pair of eyeglasses or contact lenses, though separate lenses, frames, and upgrades are not covered.
Dental Services See details
Capital Blue Cross Complete (PPO) partially covers dental services up to a $5,000 annual maximum, offering Medicare-covered dental with a $15 copay and no coinsurance. Other covered dental services, such as cleanings and exams, have no copay and no coinsurance, while comprehensive services have no copay and 50% coinsurance; however, other preventive services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Capital Blue Cross Complete (PPO) covers home infusion bundled services with no copay and no coinsurance, requiring prior authorization. Medicare Part B insulin drugs have a $35 copay and no coinsurance, while other covered Part B chemotherapy and radiation drugs require no copay and a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by Capital Blue Cross Complete (PPO) with no copay and a 20% coinsurance.
Medical Equipment See details
Capital Blue Cross Complete (PPO) covers medical equipment with no copay, though prior authorization is required for these benefits. Durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes or inserts are subject to a 20% coinsurance, while diabetic supplies carry a coinsurance ranging from no coinsurance to 20%.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Capital Blue Cross Complete (PPO) with no copay and no coinsurance for diagnostic tests, procedures, and lab services. Outpatient X-rays require a $15 copay, therapeutic radiological services have a minimum 20% coinsurance, and prior authorization is required.
Home Health Services See details
Home health services are covered by Capital Blue Cross Complete (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered with no coinsurance under Capital Blue Cross Complete (PPO), meaning some services are covered, but standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and require a $10 copay.
Skilled Nursing Facility (SNF) See details
Capital Blue Cross Complete (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and additional days beyond the standard 100-day Medicare benefit period are not covered.
Other Services See details
Other Services are partially covered by Capital Blue Cross Complete (PPO), offering an Over-the-Counter (OTC) benefit with no copay and no coinsurance up to $75 every three months. Acupuncture, meal benefits, and nicotine replacement therapy are not covered under this plan.
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