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Capital Blue Cross Essential (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Blue Cross Essential (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 Essential (HMO) in 2025, please refer to our full plan details page.
Capital Blue Cross Essential (HMO) is a HMO plan offered by CAPITAL BLUE CROSS available for enrollment in 2025 to people living in 21 Counties in Central PA. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Capital Blue Cross Essential (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 Essential (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 Essential (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $2.00. You must continue to pay paying your reduced 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 $250.00 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 $6000.00 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 Essential (HMO) plan has a $250 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For preferred generic drugs, there is no copay at preferred pharmacies and mail order pharmacies, and a $15 copay at standard pharmacies. For standard generic drugs, you pay 20% coinsurance, and for preferred brand drugs, you pay 50% coinsurance.
Additional Benefits
The Capital Blue Cross Essential (HMO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services with varying copays, and ambulance services with copays. Emergency services, primary care, and preventive services are covered, with some services having no copay. Vision and dental services are also included, with copays and coinsurance applying to specific services. This plan also covers home infusion, dialysis, and medical equipment with coinsurance or copays. Additional benefits include diagnostic and radiological services, home health services, and skilled nursing facility stays with copays. There is also an allowance for over-the-counter items. However, certain services like cardiac rehabilitation, and additional hours of care are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered with a copay of $135 for days 1-4, and no copay for days 5-90. Additional days for Inpatient Hospital-Acute are covered with no copay, while non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a copay between $0 and $275, and observation services with a $250 copay per stay. Ambulatory Surgical Center (ASC) Services have no copay, and Outpatient Blood Services also have no copay. Outpatient Substance Abuse Services have a $25 copay for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered by the Capital Blue Cross Essential (HMO) plan. This benefit requires prior authorization and has a copay of $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Capital Blue Cross Essential (HMO) plan. Ground and air ambulance services each have a $275 copay, and transportation services to a plan-approved health-related location are covered for up to 8 one-way trips per year, with no copay or coinsurance. Transportation services to any health-related location is not covered.
Emergency Services See details
Emergency Services for the Capital Blue Cross Essential (HMO) plan include a $125 copay, but no coinsurance. Urgently Needed Services have a $40 copay with no coinsurance, and Worldwide Emergency Coverage has a $125 copay with no coinsurance. Worldwide Urgent Coverage has a $40 copay with no coinsurance, while Worldwide Emergency Transportation is not covered.
Primary Care See details
Under the Capital Blue Cross Essential (HMO) plan, primary care physician services have no copay, and chiropractic services have a $20 copay. Occupational therapy services, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy, and speech-language pathology services all have a $25 copay. Additional telehealth benefits range from no copay to a $25 copay, and routine chiropractic care is not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, an annual physical exam with no copay, and additional preventive services including Medical Nutrition Therapy, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit with no copay. This plan does not cover In-Home Safety Assessment, Personal Emergency Response System (PERS), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services. The plan also covers Fitness Benefit, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), and Kidney Disease Education Services.
Hearing Services See details
Hearing services include hearing exams with a $25 copay, fitting/evaluation for hearing aids with no copay, and OTC hearing aids with a $499 copay. Prescription hearing aids are partially covered, as only Prescription Hearing Aids (all types) are covered, with a copay between $499 and $999.
Vision Services See details
Vision Services include eye exams with a copay of $0-$25, and eyewear with no copay, including contact lenses. Eyeglass lenses, eyeglass frames, and upgrades are not covered. You are eligible for one routine eye exam and one pair of contact lenses or eyeglasses every year, with a combined maximum of $225 for eyewear.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a $25 copay, and Other Dental Services with no copay. Other Diagnostic Dental Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), and Oral and Maxillofacial Surgery are covered with a 50% coinsurance, while Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered. This plan has a maximum benefit coverage of $3,500 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Capital Blue Cross Essential (HMO) plan. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Capital Blue Cross Essential (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, while Prosthetic Devices and Medical Supplies have a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance, but Diabetic Supplies have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests with no copay, Lab Services with no copay, and Diagnostic Radiological Services with a copay of up to $150.00. Therapeutic Radiological Services have a coinsurance of at least 20%, and Outpatient X-Ray Services have a $15 copay.
Home Health Services See details
Home Health Services are covered under the Capital Blue Cross Essential (HMO) plan with no copay and no coinsurance. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Capital Blue Cross Essential (HMO) plan. Specifically, Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the Capital Blue Cross Essential (HMO) plan, but require prior authorization. For days 1-20, the copay is $10, and for days 21-100, the copay is $214.
Other Services See details
Other Services include Over-the-Counter (OTC) Items, which are covered with a maximum benefit of $90 every three months; however, acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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