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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. For Tier 1 preferred generics and Tier 2 generics, members pay no copay when using preferred pharmacies or preferred mail order services. If standard pharmacies or standard mail orders are used, copays range from $10 to $30 for Tier 1 and $15 to $45 for Tier 2 depending on the supply duration. For higher-tier medications, the plan utilizes coinsurance rather than flat copayments. Tier 3 preferred brand drugs require a 16% coinsurance and Tier 4 non-preferred drugs have a 39% coinsurance across all pharmacy and mail order channels. Specialty drugs in Tier 5 carry a 26% coinsurance for a one-month supply at both preferred and standard locations.
Additional Benefits
The Capital Blue Cross Basic (PPO) plan offers affordable coverage for core medical services, featuring no coinsurance for many key benefits. Beneficiaries pay no copay for primary care doctor visits, while specialist visits and routine hearing exams require a $35 copay. For hospital care, inpatient stays carry a $215 daily copay for the first four days and no copay for days five through 90, while emergency room services require a $115 copay. In addition to medical care, this plan covers routine dental cleanings, oral exams, and routine eye exams with no copay. Covered dental services are supported by a $1,200 annual maximum, and routine eyewear is covered with no copay up to a $125 annual limit. Members also benefit from no copay on diagnostic lab tests, home health services, and a $30 quarterly allowance for over-the-counter items.
Inpatient Hospital See details
Capital Blue Cross Basic (PPO) covers inpatient hospital services with no coinsurance, requiring a $215 daily copay for days 1 through 4 and no copay for days 5 through 90. While unlimited additional days are covered for acute stays, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Capital Blue Cross Basic (PPO) covers outpatient services with no coinsurance, featuring copays ranging from $0 to $450 for outpatient hospital services, $400 per stay for observation services, and $35 for substance abuse sessions. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Capital Blue Cross Basic (PPO) with a $55.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Capital Blue Cross Basic (PPO) covers Medicare-approved ground and air ambulance services with a $330 copay and no coinsurance per service, requiring prior authorization. Transportation services to plan-approved or any other health-related locations are not covered.
Emergency Services See details
Capital Blue Cross Basic (PPO) covers emergency services with a $115 copay and urgently needed services with a $40 copay, both featuring no coinsurance. Worldwide emergency and urgent care are partially covered up to a $20,000 maximum with no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Primary care benefits under Capital Blue Cross Basic (PPO) feature no copay and no coinsurance for primary care visits, while specialist, mental health, and psychiatric services require a $35 copay and no coinsurance. Physical and occupational therapy have a $30 copay and no coinsurance, podiatry is not covered, and chiropractic services are partially covered with a $15 copay and no coinsurance, excluding routine and other chiropractic services.
Preventive Services See details
Capital Blue Cross Basic (PPO) partially covers preventive services with no copay and no coinsurance for covered services such as annual physical exams, kidney disease education, and glaucoma screenings. Several supplemental benefits are not covered under this plan, including fitness benefits, health education, weight management programs, and in-home safety assessments.
Hearing Services See details
Hearing services are partially covered under Capital Blue Cross Basic (PPO), featuring a routine hearing exam for a $35 copay and no coinsurance, and OTC hearing aids for a $499 copay and no coinsurance. Prescription hearing aids are covered with a $499 to $999 copay and no coinsurance, though inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Capital Blue Cross Basic (PPO) vision services are partially covered with no deductibles and no coinsurance for covered services. Routine eye exams and eyewear are covered with no copay—subject to a $125 annual maximum for eyewear—while other eye exam services, individual eyeglass lenses, individual eyeglass frames, and upgrades are not covered.
Dental Services See details
Capital Blue Cross Basic (PPO) provides partially covered dental services with an annual maximum benefit of $1,200, requiring a $35 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for covered oral exams, cleanings, and fluoride treatments. Dental x-rays, other diagnostic, other preventive, restorative, endodontics, periodontics, prosthodontics, oral surgery, and orthodontic services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Capital Blue Cross Basic (PPO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs require a 0% to 20% coinsurance and no copay.
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 with no copays, though prior authorization is required and manufacturer restrictions apply. Beneficiaries pay a 20% coinsurance for durable medical equipment, prosthetics, and diabetic shoes, while diabetic supplies range from no coinsurance up to 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Capital Blue Cross Basic (PPO), with prior authorization required for these services. Diagnostic tests, procedures, and lab services feature no copay and no coinsurance, while outpatient X-rays require a $25 copay and therapeutic radiological services carry a 20% coinsurance.
Home Health Services See details
Capital Blue Cross Basic (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services under Capital Blue Cross Basic (PPO) feature no coinsurance, but only some services are covered. Specifically, standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and require copays ranging from $10 to $25.
Skilled Nursing Facility (SNF) See details
Capital Blue Cross Basic (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but allowing admission without a prior three-day hospital stay. You will pay no copay for days 1 through 20 and a $120 daily copay for days 21 through 100, while additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by Capital Blue Cross Basic (PPO), which includes over-the-counter (OTC) items with no copay and no coinsurance up to a $30 maximum benefit every three months. However, acupuncture, meal benefits, and nicotine replacement therapy 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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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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