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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.
Capital Blue Cross Basic (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 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. 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 $8200.00 (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 $8200.00 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 Basic (PPO)
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Drug Coverage
The Capital Blue Cross Basic (PPO) prescription drug plan features an annual drug deductible of $550. For Tier 1 (Preferred Generic) and Tier 2 (Generic) drugs, you will pay no copay when using a preferred pharmacy or preferred mail order service. If you utilize standard pharmacies or standard mail order, Tier 1 copays range from $10 to $30, while Tier 2 copays range from $15 to $45 depending on the supply fill. Higher tier medications are subject to coinsurance rather than flat copays across all pharmacy and mail order options. You will pay a 16% coinsurance for Tier 3 (Preferred Brand) drugs, a 39% coinsurance for Tier 4 (Non-Preferred) drugs, and a 26% coinsurance for Tier 5 (Specialty Tier) drugs, which are restricted to a one-month supply. This dual-structure system offers significant savings on generic medications when utilizing preferred network providers.
Additional Benefits
The Capital Blue Cross Basic (PPO) plan offers comprehensive medical coverage with no coinsurance for many core services, including inpatient hospital stays, outpatient services, and primary care visits. Inpatient hospital stays require a 275 dollar daily copay for the first four days followed by no copay for days five through 90, while primary care visits feature no copay. Emergency room visits carry a 115 dollar copay, and specialist visits require a 35 dollar copay, both with no coinsurance. For supplemental care, the plan provides routine dental and vision services with no copay up to specified annual limits, alongside hearing aid coverage with copays starting at 499 dollars. Skilled nursing facility stays have no copay for the first 20 days, whereas medical equipment and dialysis services require no copay but are subject to a 20 percent coinsurance. Additionally, members benefit from a quarterly over-the-counter allowance with no copay.
Inpatient Hospital See details
Capital Blue Cross Basic (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $275 daily copay for days 1 through 4 and no copay for days 5 through 90. Unlimited additional days are covered for acute stays, though 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 copay of $0 to $450 for outpatient hospital services and $400 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 and 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 to receive this covered benefit.
Ambulance and Transportation Services See details
Capital Blue Cross Basic (PPO) covers ground and air ambulance services with a $330 copay and no coinsurance, subject to prior authorization. While some transportation services are covered, transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Capital Blue Cross Basic (PPO) covers emergency services with a $115 copay (waived if admitted within 24 hours) and urgent care 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, but worldwide emergency transportation is not covered.
Primary Care See details
Capital Blue Cross Basic (PPO) covers primary care physician visits and opioid treatment with no copay or coinsurance, while physical, occupational, and speech therapies require a $30 copay and no coinsurance. Specialist visits, mental health, and psychiatric services have a $35 copay with no coinsurance, but chiropractic and podiatry services 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 covered services such as annual physical exams, kidney disease education, and diabetes self-management training. Sub-services not covered under this benefit include health education, in-home safety assessments, personal emergency response systems, medication reconciliation, re-admission prevention, chemotherapy wigs, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional benefits, palliative care, in-home support, caregiver support, tobacco cessation counseling, fitness benefits, disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Capital Blue Cross Basic (PPO) offers partially covered hearing services, including annual routine hearing exams for a $35 copay and no coinsurance. Up to two OTC hearing aids are covered yearly for a $499 copay and no coinsurance, and up to two 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) partially covers vision services with no deductibles or coinsurance, offering eye exams with a $0 to $35 copay and eyewear with no copay up to a $125 annual limit. While routine eye exams, contact lenses, and eyeglasses are covered, other eye exam services, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Capital Blue Cross Basic (PPO) covers Medicare-covered dental services for a $35.00 copay and no coinsurance, and partially covers other dental services with no copay and no coinsurance up to a $1,200 annual maximum. While two oral exams, cleanings, and fluoride treatments are covered each year, dental x-rays, diagnostic, restorative, endodontic, periodontic, prosthodontic, and oral surgery services are not covered.
Home Infusion bundled Services See details
Capital Blue Cross Basic (PPO) covers home infusion bundled services with no copay and no coinsurance, subject to prior authorization. Under this benefit, Medicare Part B insulin drugs require a $35 copay and no coinsurance, while Part B chemotherapy, radiation, and other drugs have no copay and a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by Capital Blue Cross Basic (PPO) 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 diabetic equipment, with no copay and a 20% coinsurance (ranging from no coinsurance to 20% 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 Basic (PPO) covers diagnostic and radiological services with prior authorization, offering diagnostic procedures, lab tests, and diagnostic radiology with no copay and no coinsurance. Outpatient x-rays require a $25 copay, while therapeutic radiological services are subject to a 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the Capital Blue Cross Basic (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered in practice under the Capital Blue Cross Basic (PPO) plan, as all major sub-services are excluded from coverage. These non-covered services, including intensive cardiac, pulmonary, and SET for PAD rehabilitation, require copayments ranging from $10 to $25 and have no coinsurance.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Capital Blue Cross Basic (PPO) with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, a $150 copay for days 21 through 100, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by Capital Blue Cross Basic (PPO), which offers an over-the-counter (OTC) benefit with no copay and no coinsurance up to $30 every three months. Acupuncture and meal benefits are not covered under this plan.
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