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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 $49.00. 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 an annual drug deductible of $100. Under this plan, you will pay no copay for Tier 1 preferred generics and Tier 2 generics when using preferred retail pharmacies or preferred mail-order services. If you choose standard pharmacies or standard mail-order options, copays start at $10 for Tier 1 and $15 for Tier 2 for a one-month supply. Brand-name and specialty medications are subject to coinsurance rather than flat copays, regardless of your pharmacy choice. You will pay an 18% coinsurance for Tier 3 preferred brands, a 40% coinsurance for Tier 4 non-preferred drugs, and a 31% coinsurance for Tier 5 specialty drugs.
Additional Benefits
Capital Blue Cross Complete (PPO) offers robust medical coverage with predictable costs, featuring no copays and no coinsurance for primary care visits and home health services. Inpatient hospital stays require a $200 copay for the first four days followed by no copay, while outpatient services carry no coinsurance and copays ranging from nothing up to $400. Specialist visits, physical therapy, and urgent care require low copays ranging from $15 to $40, while emergency room visits have a $130 copay that is waived if you are admitted. The plan also includes valuable supplemental benefits, including preventive dental care and routine vision exams with eyewear up to $300 covered with no copay or coinsurance. Diagnostic labs and procedures are available with no copay, while durable medical equipment requires no copays but carries a 20% to 40% coinsurance. Additionally, members can access routine hearing exams for a $20 copay and receive a $75 quarterly allowance for over-the-counter items with no copay.
Inpatient Hospital See details
Capital Blue Cross Complete (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $200 copay for days 1 through 4 and no copay for days 5 through 90. Prior authorization is required, and while unlimited additional acute days are covered at 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 which also have no copays. Outpatient hospital services carry a $0 to $400 copay, observation services have a $200 copay per stay, and outpatient substance abuse sessions require a $20 copay.
Partial Hospitalization See details
Partial hospitalization is covered by Capital Blue Cross Complete (PPO) with a $55.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Capital Blue Cross Complete (PPO) covers ground and air ambulance services with a $340.00 copay and no coinsurance, requiring prior authorization. Transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Capital Blue Cross Complete (PPO) covers emergency services with a $130 copay (waived if admitted within 24 hours) and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency and urgent services are also 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 services and opioid treatment with no copay and no coinsurance, while specialist, mental health, and psychiatric visits require a $20 copay and no coinsurance. Chiropractic services are partially covered, offering routine care for a $15 copay and no coinsurance while excluding other chiropractic services. Physical, occupational, and speech therapies have a $15 copay, and telehealth benefits range from a $0 to $20 copay, all featuring no coinsurance.
Preventive Services See details
Capital Blue Cross Complete (PPO) offers partially covered preventive services with no copay and no coinsurance for covered benefits including annual physical exams, kidney disease education, medical nutrition therapy, memory fitness, remote access technologies, and select screenings. However, sub-services such as health education, in-home safety assessments, personal emergency response systems, post-discharge medication reconciliation, readmission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, additional tobacco cessation, enhanced disease management, telemonitoring, home safety devices, and counseling are not covered.
Hearing Services See details
Capital Blue Cross Complete (PPO) covers hearing services, including annual routine hearing exams for a $20 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 a copay ranging from $499 to $999, though inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Capital Blue Cross Complete (PPO) partially covers vision services with no copay, no coinsurance, and no deductible, providing one routine eye exam and eyewear up to a $300 annual limit. Covered eyewear includes contact lenses and eyeglasses, while other eye exam services, individual eyeglass lenses, eyeglass 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 limit, featuring a $20 copay and no coinsurance for Medicare-covered dental, no copay and no coinsurance for preventive services, and no copay with 50% coinsurance for comprehensive services. Other preventive dental, 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, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy and other drugs require no copay and a 0% to 20% coinsurance, while Medicare Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis Services are covered under 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 copays, though prior authorization is required and coinsurance applies to all services. Coinsurance ranges from 20% to 40% for durable medical equipment, is set at 40% for prosthetics and medical supplies, and ranges from no coinsurance to 20% for diabetic equipment and supplies.
Diagnostic and Radiological Services See details
Capital Blue Cross Complete (PPO) covers diagnostic and radiological services, with prior authorization required for these benefits. Diagnostic procedures, lab services, and diagnostic radiological services are offered with no copay and no coinsurance, while outpatient x-rays require a $30 copay and therapeutic radiological services carry a 20% coinsurance.
Home Health Services See details
Capital Blue Cross Complete (PPO) covers Home Health Services 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, though only some services are covered. Standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered under this benefit 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, 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, offering over-the-counter (OTC) items with no copay and no coinsurance up to a maximum of $75 every three months. Acupuncture, meal benefits, and nicotine replacement therapy are not covered under this plan.
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