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Capital Blue Cross Value (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Blue Cross Value (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 Value (HMO) in 2026, please refer to our full plan details page.
Capital Blue Cross Value (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 Value (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 Value (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 Value (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $58.00. 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 $6500.00 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 Value (HMO) Medicare plan features a low $100 annual prescription drug deductible and offers significant savings on generic medications. Members pay no copay for Tier 1 preferred generics and Tier 2 generics when filling prescriptions through preferred pharmacies or preferred mail-order services. Standard pharmacies and standard mail-order options are also available, with Tier 1 copays starting at $10 and Tier 2 copays starting at $15 for a one-month supply. For brand-name and specialty prescriptions, the plan provides consistent coverage across both preferred and standard networks. Tier 3 preferred brand drugs require a flat $47 copay for a one-month supply, while Tier 4 non-preferred drugs have a 37% coinsurance. Specialty medications in Tier 5 are covered with a 31% coinsurance for a one-month supply.
Additional Benefits
The Capital Blue Cross Value (HMO) plan offers affordable medical coverage with no copay for primary care doctor visits and a $20 copay for specialists. Inpatient hospital stays require a $150 daily copay for the first five days and no copay for days six through ninety. Emergency care is covered with a $130 copay, which is waived if you are admitted to the hospital within twenty-four hours. Additionally, the plan features preventive dental care and annual vision exams with no copay, plus up to a $200 annual allowance for eyewear. You also receive a $75 quarterly allowance for over-the-counter health items with no copay and no coinsurance. Covered hearing services include a $20 copay for annual exams and fixed copays for prescription hearing aids.
Inpatient Hospital See details
Capital Blue Cross Value (HMO) inpatient hospital care is partially covered with no coinsurance and a $150 daily copay for days 1 through 5, with no copay for days 6 through 90. Prior authorization is required, and non-Medicare-covered stays, upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by Capital Blue Cross Value (HMO) with no coinsurance, featuring no copays for ambulatory surgical center and blood services. Outpatient hospital services require prior authorization with copays ranging from $0 to $300, while observation services have a $225 copay per stay and substance abuse sessions have a $20 copay.
Partial Hospitalization See details
Partial hospitalization is covered by Capital Blue Cross Value (HMO) with a $55.00 copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Capital Blue Cross Value (HMO) covers ground and air ambulance services with a $200 copay and no coinsurance, with prior authorization required. Routine transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Capital Blue Cross Value (HMO) covers emergency services with a $130 copay and no coinsurance, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $40 copay and no coinsurance. Worldwide emergency and urgent care 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 Value (HMO) covers primary care physician services and opioid treatment with no copay and no coinsurance, while specialist visits, mental health, and psychiatric services require a $20 copay and no coinsurance. Physical, occupational, and speech therapies have a $15 copay and no coinsurance, whereas podiatry and routine chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by Capital Blue Cross Value (HMO) with no copay and no coinsurance for covered benefits like annual physical exams and kidney disease education. However, several sub-services, including health education, weight management programs, and personal emergency response systems, are not covered.
Hearing Services See details
Capital Blue Cross Value (HMO) offers partially covered hearing services, featuring a $20 copay and no coinsurance for annual routine hearing exams. Up to two prescription hearing aids per year are covered with a $499 to $999 copay and no coinsurance (excluding inner ear, outer ear, and over-the-ear models), while up to two OTC hearing aids are covered with a $499 copay and no coinsurance.
Vision Services See details
Capital Blue Cross Value (HMO) covers vision services with no coinsurance, offering no copay for one routine eye exam per year and no copay for eyewear up to a $200 annual limit. This benefit is partially covered, as other eye exams, separate eyeglass lenses or frames, and upgrades are not covered.
Dental Services See details
Capital Blue Cross Value (HMO) dental services are partially covered up to a $2,500 annual maximum, with Medicare-covered dental requiring a $20 copay and no coinsurance. Preventive care like exams and cleanings features no copay and no coinsurance, while covered diagnostic and comprehensive services have no copay and 50% coinsurance; however, other preventive services, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Capital Blue Cross Value (HMO) covers home infusion bundled services with no copay, although 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 carry a 0% to 20% coinsurance.
Dialysis Services See details
Capital Blue Cross Value (HMO) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Capital Blue Cross Value (HMO) covers medical equipment with no copay, though prior authorization is required. Durable medical equipment, prosthetics, medical supplies, and diabetic shoes or inserts require a 20% coinsurance, while diabetic supplies range from no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Capital Blue Cross Value (HMO) with no copay or coinsurance for lab services and diagnostic tests. Outpatient X-rays require a $15 copay, therapeutic radiological services carry a minimum 20% coinsurance, and prior authorization is required.
Home Health Services See details
Home Health Services are covered by Capital Blue Cross Value (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by Capital Blue Cross Value (HMO) with no coinsurance, but only some services are covered while standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Capital Blue Cross Value (HMO) with no coinsurance, requiring a daily copay of $10 for days 1 to 20 and $218 for days 21 to 100. Prior authorization is required, a prior three-day hospital stay is not needed, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Capital Blue Cross Value (HMO) partially covers Other Services, offering 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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