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Capital Blue Cross Basic (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Blue Cross Basic (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 Basic (PPO) in 2026, please refer to our full plan details page.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
Capital Blue Cross Basic (PPO) is a PPO plan offered by Capital Advantage Insurance Company available for the 2026 plan year 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 Basic (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 Basic (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 Basic (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $20.00. 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 has a $500.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $550.00 drug deductible that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $8200.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $8200.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
This plan has a Maximum Out-Of-Pocket cost of $8200.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $8200.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
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 Basic (PPO)
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Drug Coverage
The Capital Blue Cross Basic (PPO) plan features an annual drug deductible of $550. Under this plan, you can enjoy no copay for Tier 1 (Preferred Generic) and Tier 2 (Generic) medications when using a preferred pharmacy or preferred mail-order service. If you choose a standard pharmacy or standard mail order, your copayments range from $10 to $30 for Tier 1 drugs and $15 to $45 for Tier 2 drugs, depending on the supply duration. For higher-tier medications, costs transition to coinsurance percentages instead of flat copays. You will pay a 16% coinsurance for Tier 3 (Preferred Brand) drugs and a 39% coinsurance for Tier 4 (Non-Preferred) drugs across all pharmacy and mail-order options. Tier 5 (Specialty Tier) drugs require a 26% coinsurance for a one-month supply at any participating pharmacy or mail-order provider.
Additional Benefits
The Capital Blue Cross Basic (PPO) plan offers affordable healthcare coverage 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 ninety. Specialist visits, physical therapy, and urgent care are also accessible with low copays and no coinsurance. This plan includes essential dental, vision, and hearing benefits, offering routine dental cleanings and select vision care with no copay up to generous annual limits. While many diagnostic and laboratory tests require no copay, other services like durable medical equipment and dialysis require a 20% coinsurance. Members also benefit from a quarterly allowance for over-the-counter items with no copay.
Inpatient Hospital See details
Capital Blue Cross Basic (PPO) covers inpatient hospital services with no coinsurance, requiring a $200 daily copay for days 1 through 4 and no copay for days 5 through 90 for both acute and psychiatric stays. The benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Capital Blue Cross Basic (PPO) covers outpatient services with no coinsurance, featuring a $0 to $450 copay for outpatient hospital services and a $400 copay per stay for observation services. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, while outpatient substance abuse sessions require a $35 copay with no coinsurance.
Partial Hospitalization See details
Capital Blue Cross Basic (PPO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Capital Blue Cross Basic (PPO) covers Medicare-covered ground and air ambulance services with a $330 copay per service, no coinsurance, and prior authorization required. Transportation services to plan-approved or any other health-related locations are not covered under this plan.
Emergency Services See details
Capital Blue Cross Basic (PPO) covers emergency services with a $115 copay (waived if admitted within 24 hours) and urgently needed services with a $40 copay, both featuring no coinsurance. 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 Basic (PPO) primary care benefits feature no copay and no coinsurance for primary care physician visits and opioid treatment, while specialists, mental health, psychiatric, and other professional services require a $35 copay and no coinsurance. Physical and occupational therapy require a $30 copay with no coinsurance, telehealth services range from a $0 to $35 copay with no coinsurance, and podiatry services as well as routine chiropractic care are not covered.
Preventive Services See details
Preventive services are partially covered by Capital Blue Cross Basic (PPO) with no copay and no coinsurance for annual physical exams, kidney disease education, and medical nutrition therapy. However, several supplemental services are not covered, including fitness benefits, health education, weight management, in-home safety assessments, personal emergency response systems, and counseling.
Hearing Services See details
Capital Blue Cross Basic (PPO) hearing services are partially covered, featuring routine hearing exams for a $35 copay and no coinsurance. Prescription hearing aids are covered with a copay ranging from $499 to $999 and no coinsurance, though inner ear, outer ear, and over the ear prescription aids are not covered. OTC hearing aids are also available for a $499 copay and no coinsurance.
Vision Services See details
Capital Blue Cross Basic (PPO) provides partially covered vision services with no deductibles and no coinsurance, featuring a $0 to $35 copay for eye exams and no copay for covered eyewear up to a $125 annual limit. Routine eye exams, contact lenses, and eyeglasses (lenses and frames) are covered, while other eye exam services, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Capital Blue Cross Basic (PPO) dental services are partially covered, offering Medicare-covered dental care for a $35 copay and no coinsurance, as well as routine exams, cleanings, and fluoride treatments with no copay and no coinsurance up to a $1,200 annual limit. However, services such as dental X-rays, restorative care, endodontics, periodontics, prosthodontics, and oral surgery are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Capital Blue Cross Basic (PPO) with no copay, although prior authorization is required. Within this benefit, Medicare Part B insulin has a $35 copay and no coinsurance, while Part B chemotherapy, radiation, and other drugs feature no copay and a 0% to 20% coinsurance.
Dialysis Services See details
Capital Blue Cross Basic (PPO) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Capital Blue Cross Basic (PPO) covers medical equipment, including durable medical equipment, prosthetics, and medical supplies, with no copay and a 20% coinsurance. Diabetic equipment is also covered with no copay, featuring a 20% coinsurance for therapeutic shoes and inserts, and a coinsurance ranging from no coinsurance to 20% for diabetic supplies.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under Capital Blue Cross Basic (PPO), though prior authorization is required. Diagnostic tests, lab services, and diagnostic radiological services feature no copay and no coinsurance, while outpatient X-rays require a $25 copay plus coinsurance, and therapeutic radiological services require a copay and at least 20% coinsurance.
Home Health Services See details
Capital Blue Cross Basic (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 Basic (PPO) with no copay and no coinsurance, though in practice, some services are covered while cardiac, intensive cardiac, pulmonary, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Capital Blue Cross Basic (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 and a $115 daily copay for days 21 through 100, though additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Capital Blue Cross Basic (PPO) partially covers other services, offering over-the-counter (OTC) items with no copay and no coinsurance up to a maximum benefit of $30 every three months. Acupuncture and meal benefits are not covered.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
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