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Capital Blue Cross Premier (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Blue Cross Premier (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Capital Blue Cross Premier (HMO) in 2026, please refer to our full plan details page.
Capital Blue Cross Premier (HMO) is a HMO plan offered by CAPITAL BLUE CROSS available for enrollment in 2025 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 Premier (HMO) 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 Premier (HMO).
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 Premier (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $86.00. 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 Maximum Out-Of-Pocket cost of $5000.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network 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:
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Drug Coverage
The Capital Blue Cross Premier (HMO) prescription drug plan features an affordable annual drug deductible of $100. For Tier 1 preferred generic and Tier 2 generic drugs, members pay no copay for any supply length when filled through preferred pharmacies or preferred mail-order services. If using standard pharmacies or standard mail order, Tier 1 drugs require a copay starting at $10 and Tier 2 drugs start at a $15 copay for a one-month supply. For brand-name and specialty medications, the plan offers consistent pricing across all pharmacy and mail-order options. Tier 3 preferred brand drugs cost a $47 copay for a one-month supply, while Tier 4 non-preferred drugs require a $100 copay. Tier 5 specialty tier medications are covered with a 31% coinsurance for a one-month supply.
Additional Benefits
The Capital Blue Cross Premier (HMO) plan offers comprehensive medical coverage with no copay and no coinsurance for primary care visits, preventive services, and home health care. Specialist visits and outpatient therapies require a $15 copay, while inpatient hospital stays incur a $125 daily copay for the first four days and no copay for days five through 90. Outpatient hospital services feature a copay ranging from $0 to $250, and emergency room visits carry a $130 copay with no coinsurance. For specialty care, the plan provides dental coverage up to a $3,000 annual limit, featuring no copay for preventive services and a 50% coinsurance for restorative work. Vision benefits include routine annual exams and up to $200 for eyewear with no copay or coinsurance, while routine hearing exams require a $15 copay. Additionally, members can take advantage of an over-the-counter benefit that provides up to $90 every three months with no copay and no coinsurance.
Inpatient Hospital See details
Capital Blue Cross Premier (HMO) partially covers inpatient hospital services with no coinsurance, requiring a $125 daily copay for days 1 to 4 and no copay for days 5 to 90. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered under this benefit.
Outpatient Services See details
Capital Blue Cross Premier (HMO) covers outpatient services with no coinsurance, featuring a $0 to $250 copay for outpatient hospital services and a $200 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 have a $15 copay and no coinsurance.
Partial Hospitalization See details
Capital Blue Cross Premier (HMO) covers partial hospitalization services with a $55.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Capital Blue Cross Premier (HMO) covers ground and air ambulance services with a $150 copay and no coinsurance, subject to prior authorization. For transportation services, only some services are covered, as transportation to plan-approved health-related locations and any other health-related locations are not covered.
Emergency Services See details
Capital Blue Cross Premier (HMO) covers emergency services with a $130 copay (waived if admitted within 24 hours) and urgently needed services with a $30 copay, both featuring no coinsurance. Worldwide emergency and urgent care are partially covered up to a $20,000 maximum limit with no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Capital Blue Cross Premier (HMO) offers primary care and opioid treatment services with no copay and no coinsurance, while specialist visits, therapies, psychiatric care, and mental health services require a $15 copay and no coinsurance. Telehealth benefits are covered with a $0 to $20 copay and no coinsurance, but podiatry is not covered, and routine or other chiropractic services are not covered.
Preventive Services See details
Capital Blue Cross Premier (HMO) covers preventive services with no copay and no coinsurance, including annual physical exams, kidney disease education, and medical nutrition therapy. However, this benefit is only partially covered as several supplemental services, such as health education, weight management programs, and in-home safety assessments, are not covered.
Hearing Services See details
Capital Blue Cross Premier (HMO) hearing services are partially covered with no coinsurance, featuring a $15 copay for routine annual exams and a $499 copay for up to two OTC hearing aids per year. Prescription hearing aids are covered with copays ranging from $499 to $999 for up to two devices per year, though inner ear, outer ear, and over the ear models are not covered.
Vision Services See details
Capital Blue Cross Premier (HMO) provides partially covered vision services with no deductible, no copays, and no coinsurance for covered benefits. One routine eye exam per year and complete eyeglasses or contact lenses are covered up to a $200 annual maximum, while other eye exam services, individual eyeglass lenses, individual frames, and upgrades are not covered.
Dental Services See details
Capital Blue Cross Premier (HMO) partially covers dental services up to a $3,000 annual limit, offering Medicare-covered dental with a $15 copay and no coinsurance. Preventive services like cleanings and exams are available with no copay and no coinsurance, while other diagnostic, restorative, and surgical services have no copay and a 50% coinsurance. Other preventive dental services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Capital Blue Cross Premier (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Under this plan, Medicare Part B insulin drugs are covered with a $35 copay and no coinsurance, while chemotherapy and other Part B drugs require no copay and a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Capital Blue Cross Premier (HMO) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Capital Blue Cross Premier (HMO) covers medical equipment with no copay, though prior authorization is required. Durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes or inserts carry a 20% coinsurance, while diabetic supplies range from no coinsurance to a 20% coinsurance.
Diagnostic and Radiological Services See details
Capital Blue Cross Premier (HMO) covers diagnostic and radiological services, offering diagnostic tests, lab work, and diagnostic radiology with no copay and no coinsurance. Outpatient X-rays require a $15 copay, therapeutic radiological services incur a 20% coinsurance, and prior authorization is required for these services.
Home Health Services See details
Home Health Services are covered under the Capital Blue Cross Premier (HMO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered by Capital Blue Cross Premier (HMO) with no coinsurance, and although some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy for PAD are not covered. These uncovered services require copays of $20 for cardiac and intensive cardiac rehabilitation, $15 for pulmonary rehabilitation, and $10 for supervised exercise therapy.
Skilled Nursing Facility (SNF) See details
Capital Blue Cross Premier (HMO) 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, and while a prior three-day inpatient hospital stay is not necessary, additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Capital Blue Cross Premier (HMO) partially covers Other Services, offering an Over-the-Counter (OTC) benefit with no copay and no coinsurance up to $90 every three months. Acupuncture and meal benefits are not covered under this plan.
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