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Capital Blue Cross | WellSpan Health Inspire (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Blue Cross | WellSpan Health Inspire (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 | WellSpan Health Inspire (HMO) in 2025, please refer to our full plan details page.
Capital Blue Cross | WellSpan Health Inspire (HMO) is a HMO plan offered by CAPITAL BLUE CROSS available for enrollment in 2025 to people living in 7 County South 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 | WellSpan Health Inspire (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 | WellSpan Health Inspire (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 | WellSpan Health Inspire (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 $5700.00 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:
Sign up for Capital Blue Cross | WellSpan Health Inspire (HMO)
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Drug Coverage
The Capital Blue Cross | WellSpan Health Inspire (HMO) plan has a $250 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you will have no copay at preferred pharmacies and preferred mail order, but a $15 copay at standard pharmacies and standard mail order. For standard generic drugs, you will pay 20% coinsurance at all pharmacies. For preferred brand drugs, you will pay 50% coinsurance at all pharmacies, and for non-preferred drugs, you will pay 30% coinsurance at all pharmacies.
Additional Benefits
The Capital Blue Cross | WellSpan Health Inspire (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay of $150 for the first four days and then no copay. Outpatient services have varying copays, while emergency services have a $125 copay. This plan includes no copay for primary care, many preventive services, and home health services. It also covers hearing, vision, and dental services, with specific copays and coinsurance for each. Additionally, the plan provides coverage for ambulance, transportation, and diagnostic services, along with other services such as home infusion and medical equipment.
Inpatient Hospital See details
Inpatient Hospital services are covered, with a $150 copay for days 1-4, and no copay for days 5-90. Additional days for Inpatient Hospital-Acute are covered, and Inpatient Hospital Psychiatric services are covered with a $150 copay for days 1-4, and no copay for days 5-90. Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include outpatient hospital services with a copay between $0 and $300, observation services with a $190 copay, and ambulatory surgical center (ASC) services with no copay. Outpatient Substance Abuse services include individual and group sessions with a copay between $25 and $25, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Capital Blue Cross | WellSpan Health Inspire (HMO) plan, with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required. Ground and air ambulance services have a $300 copay, with no coinsurance. Transportation Services to a plan-approved health-related location are covered for 8 one-way trips per year, with no copay or coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency services, including worldwide emergency services, are covered under this plan. Emergency services have a $125 copay and no coinsurance, while urgently needed services have a $35 copay and no coinsurance. Worldwide Emergency Transportation is not covered, and Worldwide Emergency Coverage has a $125 copay, while Worldwide Urgent Coverage has a $35 copay.
Primary Care See details
The Capital Blue Cross | WellSpan Health Inspire (HMO) plan offers primary care services with no copay, chiropractic services with a $20 copay, and occupational therapy with a $20 copay. Physician specialist services have a $25 copay, and mental health specialty services range from $25, as do group and individual psychiatric sessions. This plan also offers physical therapy and speech-language pathology services with a $20 copay, and additional telehealth benefits with a copay between $0 and $25.
Preventive Services See details
Preventive Services include no copay for annual physical exams, Medicare-covered preventive services, and other services like glaucoma screening and diabetes self-management training, while additional preventive services and kidney disease education services have a copay; however, in-home safety assessments, personal emergency response systems, and other services are not covered.
Hearing Services See details
Hearing Services include hearing exams with a $25 copay, routine hearing exams (1 per year), and fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered with a copay between $499 and $999 for 2 hearing aids per year, while OTC hearing aids have a $499 copay for 2 hearing aids per year; however, Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a copay of $0-$25, while routine eye exams have no copay, and are limited to one per year. Eyewear, including contact lenses, is covered with a maximum plan benefit of $225 per year, and contact lenses have no copay. Eyeglasses (lenses and frames) are covered, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services include 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 50% coinsurance. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. 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 by the Capital Blue Cross | WellSpan Health Inspire (HMO) plan. You will pay 20% coinsurance for dialysis services.
Medical Equipment See details
Medical Equipment benefits are covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, while Prosthetic Devices have a 20% coinsurance, and Medical Supplies have a 20% coinsurance; Durable Medical Equipment for use outside the home is not covered. Diabetic Supplies have no copay, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, and may require prior authorization. Diagnostic Procedures/Tests have no copay, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $150.00, Therapeutic Radiological Services have a coinsurance of at most 20%, and Outpatient X-Ray Services have a $15.00 copay.
Home Health Services See details
Home Health Services are covered by the Capital Blue Cross | WellSpan Health Inspire (HMO) plan with no copay and no coinsurance. 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 | WellSpan Health Inspire (HMO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, the copay is $10, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The "Other Services" benefit covers Over-the-Counter (OTC) items with a maximum benefit of $100 every three months, but does not cover acupuncture, meal benefits, Dual Eligible SNPs, 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.
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