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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 $6600.00 (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 $6600.00 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. Under this plan, you will pay no copay for Tier 1 preferred generics and Tier 2 generics when filled through a preferred pharmacy or preferred mail-order service. Standard pharmacies and standard mail-order options are also available, with copays ranging from $10 to $30 for Tier 1 and $15 to $45 for Tier 2 depending on the supply. For brand-name and specialty medications, the plan utilizes coinsurance instead of flat copays across all pharmacy types. Tier 3 preferred brands require an 18% coinsurance, while Tier 4 non-preferred drugs carry a 40% coinsurance. Specialty drugs in Tier 5 are covered at a 31% coinsurance for a one-month supply.
Additional Benefits
The Capital Blue Cross Complete (PPO) plan offers robust medical coverage with predictable out-of-pocket costs, featuring no copay and no coinsurance for primary care visits, preventive services, and home health care. For inpatient hospital stays, members pay a $200 daily copay for the first four days and no copay for days five through 90, with no coinsurance. Outpatient services and emergency care are also covered with no coinsurance, requiring copays ranging from no copay up to $400 depending on the specific service. This plan also includes valuable supplemental benefits, such as dental coverage up to a $5,000 annual limit with no copay for preventive care and a 50% coinsurance for comprehensive services. Vision and hearing benefits feature no coinsurance, offering low copays for routine exams alongside allowances for eyewear and hearing aids. Additionally, members can access over-the-counter items with no copay or coinsurance up to a maximum benefit of $75 every three months.
Inpatient Hospital See details
Capital Blue Cross Complete (PPO) covers inpatient acute and psychiatric hospital services with no coinsurance, requiring a $200 daily copay for days 1 to 4 and no copay for days 5 to 90. While unlimited additional acute 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, featuring a copay of $0 to $400 for outpatient hospital services and $200 per stay for observation services. There are no copays or coinsurance for ambulatory surgical center and outpatient blood services, while individual and group 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, with prior authorization required.
Ambulance and Transportation Services See details
Ambulance services under Capital Blue Cross Complete (PPO) are covered with a $345 copay and no coinsurance for both ground and air transport, though prior authorization is required. Transportation services to plan-approved or 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 (waived if admitted within 24 hours) and urgent care with a $40 copay, with no coinsurance for either service. Worldwide emergency and urgent services are partially covered with similar copays and no coinsurance up to a $20,000 maximum limit, but worldwide emergency transportation is not covered.
Primary Care See details
Capital Blue Cross Complete (PPO) provides primary care physician services and opioid treatment programs with no copay and no coinsurance. Most other primary care benefits, such as specialist visits, therapy, and mental health services, require a $15 copay and no coinsurance, though chiropractic care is only partially covered with routine visits costing $15 (up to 6 per year) and other chiropractic services not covered.
Preventive Services See details
Preventive services under Capital Blue Cross Complete (PPO) are partially covered with no copay and no coinsurance for covered services such as annual physicals, kidney disease education, and diabetes self-management. Sub-services that are not covered include health education, in-home safety assessments, personal emergency response systems, post-discharge medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, home/bathroom safety modifications, and counseling.
Hearing Services See details
Hearing services are covered by Capital Blue Cross Complete (PPO), offering annual routine exams for a $15 copay and no coinsurance, alongside unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $499 to $999 for up to two aids per year, though inner ear, outer ear, and over the ear types are not covered. Up to two over-the-counter (OTC) hearing aids are also covered annually with a $499 copay and no coinsurance.
Vision Services See details
Capital Blue Cross Complete (PPO) partially covers vision services with no deductible or coinsurance, offering eye exams with a $0 to $15 copay and eyewear with no copay up to a $300 annual limit. One routine eye exam and one pair of eyeglasses or contact lenses are covered yearly, but other eye exam services, separate eyeglass lenses, separate eyeglass frames, and upgrades are not covered.
Dental Services See details
Capital Blue Cross Complete (PPO) provides partially covered dental services up to a $5,000 annual limit, with Medicare-covered dental requiring a $15 copay and no coinsurance. Preventive care is available with no copay and no coinsurance, while covered comprehensive services have no copay and a 50% coinsurance; however, other preventive dental, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Capital Blue Cross Complete (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Covered Medicare Part B insulin drugs require a $35 copay and no coinsurance, while Part B chemotherapy, radiation, and other drugs feature a coinsurance ranging from 0% to 20%.
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
Medical equipment is covered by Capital Blue Cross Complete (PPO) with no copays, though prior authorization is required. Durable medical equipment carries a 20% to 40% coinsurance, prosthetics and medical supplies require a 40% coinsurance, and diabetic equipment and supplies range from no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
Capital Blue Cross Complete (PPO) covers diagnostic and radiological services, which require prior authorization. Diagnostic procedures, lab tests, and diagnostic radiological services are available with no copay and no coinsurance, while outpatient X-rays require a $30 copay and therapeutic radiological services have a 20% coinsurance.
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 in practice only some services are covered. Standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for peripheral artery disease (PAD) are not covered, carrying a $10 copay.
Skilled Nursing Facility (SNF) See details
Capital Blue Cross Complete (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $10 daily copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by Capital Blue Cross Complete (PPO), which features 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.
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