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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) Medicare plan features a $100 prescription drug deductible. For Tier 1 preferred generics and Tier 2 generics, members enjoy no copay when using a preferred retail pharmacy or preferred mail-order service. If you use a standard pharmacy or standard mail order, Tier 1 copays range from $10 to $30 and Tier 2 copays range from $15 to $45 depending on the fill duration. For higher-tier medications, cost sharing is based on coinsurance regardless of the pharmacy type you choose. Tier 3 preferred brand drugs require an 18% coinsurance and Tier 4 non-preferred drugs require a 40% coinsurance for one, two, or three-month supplies. Specialty Tier 5 drugs have a 31% coinsurance for a one-month supply.
Additional Benefits
Capital Blue Cross Complete (PPO) offers robust medical coverage with affordable out-of-pocket costs, featuring no copay for primary care visits and a low $15 copay for specialist appointments. For hospital stays, members pay a $130 daily copay for the first four days of inpatient care and no copay for days five through 90. Outpatient surgical services and routine preventive care are also highly accessible, with many services requiring no copay or coinsurance. The plan also includes valuable extra benefits, such as dental coverage with a $5,000 annual maximum and no copay for preventive dental services. Routine vision exams and eyewear are covered with no copay up to a $300 annual limit, while routine hearing exams require a $15 copay. Additionally, members receive a quarterly over-the-counter allowance of $75 with no copay to purchase health-related items.
Inpatient Hospital See details
Capital Blue Cross Complete (PPO) provides partially covered inpatient hospital services with no coinsurance, featuring a $130 daily copay for days 1 through 4 and no copay for days 5 through 90. While unlimited additional acute care days are covered with no copay, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Capital Blue Cross Complete (PPO) covers outpatient services with no coinsurance, including ambulatory surgical center and blood services at no copay. Outpatient hospital services require a $0 to $400 copay, observation services have a $200 copay per stay, and outpatient substance abuse sessions carry a $15 copay.
Partial Hospitalization See details
Capital Blue Cross Complete (PPO) covers partial hospitalization services with a $55.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Capital Blue Cross Complete (PPO), with both ground and air ambulance services requiring a $285 copay and no coinsurance. While transportation services are technically covered, only some services are covered, as trips to plan-approved health-related locations and any health-related locations are not covered.
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, with no coinsurance required for either. Worldwide emergency and urgent services are partially covered up to a $20,000 benefit limit with no coinsurance, although worldwide emergency transportation is not covered.
Primary Care See details
Capital Blue Cross Complete (PPO) covers primary care physician and opioid treatment services with no copay and no coinsurance, while telehealth services have a $0 to $15 copay and no coinsurance. Specialist visits, therapy, podiatry, and mental health services require a $15 copay and no coinsurance, and chiropractic benefits are partially covered as non-routine chiropractic services are excluded.
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 physicals, kidney disease education, and diabetes training. However, several sub-services are not covered, including health education, in-home safety assessments, PERS, medication reconciliation, re-admission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, caregiver support, in-home support, smoking cessation, enhanced disease management, telemonitoring, safety devices, and counseling.
Hearing Services See details
Capital Blue Cross Complete (PPO) features partially covered hearing services, including annual routine hearing exams for a $15 copay and no coinsurance, with no deductible. Up to two prescription hearing aids (copays from $499 to $999) and two OTC hearing aids ($499 copay) are covered per year with no coinsurance, though inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Capital Blue Cross Complete (PPO) offers partially covered vision services with no deductibles, no coinsurance, and no copays for covered routine exams and eyewear, subject to a $300 annual limit. Other eye exam services, individual eyeglass lenses, individual eyeglass frames, and upgrades are not covered.
Dental Services See details
Capital Blue Cross Complete (PPO) offers partially covered dental services with a $5,000 annual maximum for both in- and out-of-network care. Medicare-covered dental services require a $15 copay and no coinsurance, preventive services have no copay and no coinsurance, and comprehensive services have no copay and 50% coinsurance. 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 Complete (PPO) with no copay and no coinsurance, subject to prior authorization. Medicare Part B insulin drugs require a $35 copay with no coinsurance, while chemotherapy and other Part B drugs have no copay and a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the Capital Blue Cross Complete (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Capital Blue Cross Complete (PPO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay and a 20% coinsurance (ranging from no coinsurance to 20% for diabetic supplies). Prior authorization is required for these services, and coverage may be limited to preferred vendors or manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Capital Blue Cross Complete (PPO), though prior authorization is required. Medicare-covered diagnostic tests, lab services, and diagnostic radiological services are offered with no copay and no coinsurance, while outpatient X-rays require a $15 copay and therapeutic radiological services incur a minimum 20% coinsurance.
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 by Capital Blue Cross Complete (PPO) with no coinsurance; however, some services are covered while standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) 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 prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Capital Blue Cross Complete (PPO) partially covers other services, providing over-the-counter (OTC) items with no copay and no coinsurance up to a maximum of $75 every three months. Acupuncture and meal benefits are not covered under this plan.
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