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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 $40.00. 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) plan features a $100 annual drug deductible and offers significant savings on generic medications. You will pay no copay for Tier 1 (Preferred Generic) and Tier 2 (Generic) drugs when using a preferred pharmacy or preferred mail-order service. For standard pharmacies and standard mail-order services, Tier 1 copays range from $10 to $30 and Tier 2 copays range from $15 to $45 depending on the supply fill. For brand-name and specialty medications, costs are based on coinsurance across all pharmacy and mail-order options. Tier 3 (Preferred Brand) drugs require an 18% coinsurance and Tier 4 (Non-Preferred) drugs require a 40% coinsurance for up to a 3-month supply. Tier 5 (Specialty) medications are available for a 1-month supply with a 31% coinsurance.
Additional Benefits
Capital Blue Cross Complete (PPO) offers comprehensive medical coverage with predictable cost-sharing, featuring no copay for primary care visits and no coinsurance for inpatient hospital stays, which carry a $100 daily copay for the first three days. Specialist visits, physical therapy, and routine eye exams are highly affordable with a low $15 copay and no coinsurance. Emergency care is available with a $130 copay, while urgent care visits require a $40 copay, with no coinsurance for either service. For supplemental care, the plan provides preventive dental services with no copay and comprehensive dental coverage up to a $5,000 annual limit with a 50% coinsurance. Hearing and vision benefits include routine exams with low copays and allowances for eyewear and hearing aids, alongside a quarterly over-the-counter item allowance of up to $75 with no copay. Additionally, home health services require no copay, while durable medical equipment and dialysis services generally carry a 20% coinsurance.
Inpatient Hospital See details
Capital Blue Cross Complete (PPO) offers partially covered inpatient hospital services with no coinsurance, though prior authorization is required. For both acute and psychiatric stays, you will pay a $100 copay per day for days 1 through 3 and no copay for days 4 through 90. Unlimited additional acute days are covered at no copay, but upgrades, non-Medicare-covered stays, 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 $0 to $400 copay and observation services with a $200 copay per stay. Ambulatory surgical center and outpatient blood services require no copay and no coinsurance, while outpatient substance abuse sessions have 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 to receive these covered services.
Ambulance and Transportation Services See details
Capital Blue Cross Complete (PPO) covers ground and air ambulance services with a $285 copay and no coinsurance, requiring prior authorization. While transportation services are technically covered, only some services are covered, and transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Emergency services are covered by Capital Blue Cross Complete (PPO) with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $40 copay and no coinsurance, and worldwide emergency and urgent services are partially covered up to a $20,000 maximum with no coinsurance, though 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. Specialist visits, mental health sessions, physical therapy, podiatry, and telehealth services feature a $15 copay (up to $15 for telehealth) and no coinsurance, while chiropractic services are partially covered with routine care costing $15 per visit and other chiropractic services not covered.
Preventive Services See details
Capital Blue Cross Complete (PPO) offers partially covered preventive services with no copay and no coinsurance for covered benefits like annual physical exams, kidney disease education, and diabetes training. Services not covered under this plan include health education, in-home safety assessments, personal emergency response systems, medication reconciliation, readmission 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, enhanced disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Capital Blue Cross Complete (PPO) covers hearing services, including one annual routine hearing exam for a $15 copay and no coinsurance, and unlimited hearing aid evaluations with no copay and no coinsurance. Hearing aids are partially covered, offering up to two over-the-counter hearing aids per year for a $499 copay and no coinsurance, and up to two prescription hearing aids per year with a copay between $499 and $999 and no coinsurance. However, prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Capital Blue Cross Complete (PPO) partially covers vision services, providing routine eye exams with no coinsurance and a $0 to $15 copay, though other eye exam services are not covered. Eyewear is also partially covered with no copay or coinsurance up to a combined $300 annual limit for one pair of contact lenses or eyeglasses (lenses and frames), while individual lenses, 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 limit, featuring a $15 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for preventive care. Covered comprehensive services require no copay and 50% coinsurance, though other preventive services, maxillofacial prosthetics, implant services, 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, though prior authorization is required. Under this benefit, Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have no copay and a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Capital Blue Cross Complete (PPO) covers dialysis services 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% coinsurance for diabetic supplies). Prior authorization is required for these benefits, and coverage may be limited to preferred vendors or manufacturers.
Diagnostic and Radiological Services See details
Capital Blue Cross Complete (PPO) covers diagnostic and radiological services, offering lab services, diagnostic procedures, and diagnostic radiological services with no copay and no coinsurance. Outpatient X-rays require a $15 copay and coinsurance, while therapeutic radiological services carry a minimum 20% coinsurance, with prior authorization required for all services.
Home Health Services See details
Home health services are covered by Capital Blue Cross Complete (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Capital Blue Cross Complete (PPO) with no coinsurance, but only some services are covered in practice. Specifically, 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
Skilled Nursing Facility (SNF) care is covered by Capital Blue Cross Complete (PPO) with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20, a $218 daily copay for days 21 through 100, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Capital Blue Cross Complete (PPO) partially covers other services, offering over-the-counter (OTC) items with no copay and no coinsurance up to a maximum benefit of $75 every three months. Acupuncture, meal benefits, and nicotine replacement therapy are not covered under this benefit.
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