A non-government entity
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 2026, 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 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 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.
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 $375.00 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:
Sign up for Capital Blue Cross Essential (HMO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Capital Blue Cross Essential (HMO) prescription drug plan features an annual drug deductible of $375. Beneficiaries enjoy no copay for Tier 1 preferred generics and Tier 2 generics when using preferred pharmacies or preferred mail-order services. Standard pharmacies and standard mail-order options require copays ranging from $10 to $30 for Tier 1 and $15 to $45 for Tier 2 depending on the supply fill. For brand-name and specialty medications, costs are structured as coinsurance across all pharmacy types. Tier 3 preferred brand drugs require a 19% coinsurance, while Tier 4 non-preferred drugs have a 40% coinsurance. Tier 5 specialty drugs require a 28% coinsurance and are restricted to a one-month supply.
Additional Benefits
Capital Blue Cross Essential (HMO) provides affordable healthcare coverage with no copay and no coinsurance for primary care visits, annual physicals, and routine eye exams. Specialist consultations, physical therapy, and mental health services are highly accessible with a $20 copay and no coinsurance. Inpatient hospital stays require a $135 daily copay for the first four days and no copay for days five through 90, while emergency room visits carry a $130 copay that is waived upon admission. This plan also features valuable dental, vision, and hearing benefits, including up to $3,000 annually for dental services with no copay and a $200 yearly allowance for eyewear. Hearing aids are covered up to two per year with copays between $499 and $999, and members receive a $45 quarterly allowance for over-the-counter items with no copay. Additionally, home health services are covered with no copay or coinsurance, while durable medical equipment and dialysis require a 20% coinsurance.
Inpatient Hospital See details
Capital Blue Cross Essential (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $135 daily copay for days 1 through 4 and no copay for days 5 through 90. This benefit is partially covered as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Capital Blue Cross Essential (HMO) covers outpatient services with no coinsurance, featuring a $0 to $325 copay for outpatient hospital services and a $250 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 require a $20 copay with no coinsurance.
Partial Hospitalization See details
Capital Blue Cross Essential (HMO) covers partial hospitalization services with a $55.00 copay and no coinsurance, although prior authorization is required.
Ambulance and Transportation Services See details
Capital Blue Cross Essential (HMO) covers ground and air ambulance services with a $200 copay and no coinsurance, requiring prior authorization. While some transportation services are covered, transportation to plan-approved health-related locations and any health-related locations is not covered.
Emergency Services See details
Capital Blue Cross Essential (HMO) covers emergency services with a $130 copay (waived if admitted within 24 hours) and urgent care with a $40 copay, with no coinsurance required for either service. Worldwide emergency and urgent care are partially covered up to a $20,000 limit with no coinsurance, but worldwide emergency transportation is not covered.
Primary Care See details
Capital Blue Cross Essential (HMO) offers primary care physician and opioid treatment services with no copay and no coinsurance, while specialist visits, physical and occupational therapies, and mental health services require a $20 copay and no coinsurance. Chiropractic services are covered with a $15 copay and no coinsurance, but routine chiropractic and podiatry services are not covered.
Preventive Services See details
Capital Blue Cross Essential (HMO) preventive services are partially covered with no copay and no coinsurance for covered benefits like annual physicals, kidney disease education, and diabetes self-management training. However, several sub-services are not covered, including health education, in-home safety assessments, personal emergency response systems, post-discharge medication reconciliation, readmission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Hearing services offered by Capital Blue Cross Essential (HMO) are partially covered, featuring a $20 copay and no coinsurance for an annual routine hearing exam, alongside unlimited fitting evaluations. Prescription hearing aids are covered up to two per year with no coinsurance and copays ranging from $499 to $999, though inner ear, outer ear, and over-the-ear models are not covered. Up to two over-the-counter (OTC) hearing aids are also covered annually for a $499 copay and no coinsurance.
Vision Services See details
Capital Blue Cross Essential (HMO) partially covers vision services, offering one routine eye exam per year with no copay or coinsurance, though other eye exams are not covered. Covered eyewear, including contact lenses and eyeglasses (lenses and frames), features no copay or coinsurance up to a $200 annual maximum, but upgrades, individual lenses, and individual frames are not covered.
Dental Services See details
Capital Blue Cross Essential (HMO) partially covers dental services, offering Medicare-covered dental with a $20 copay and no coinsurance, plus other preventive and comprehensive services up to a $3,000 annual limit with no copay and either no coinsurance or 50% coinsurance. Non-covered services under this plan include other diagnostic, other preventive, adjunctive general, endodontics, periodontics, prosthodontics, maxillofacial prosthetics, implants, and orthodontics.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Capital Blue Cross Essential (HMO) with no copay, although prior authorization is required. Covered Medicare Part B insulin drugs require a $35 copay and no coinsurance, while other Part B chemotherapy and prescription drugs carry a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by Capital Blue Cross Essential (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Capital Blue Cross Essential (HMO) covers medical equipment with no copay, though prior authorization is required. Durable medical equipment, prosthetics, medical supplies, and diabetic shoes carry a 20% coinsurance, while diabetic supplies range from no coinsurance up to 20% coinsurance.
Diagnostic and Radiological Services See details
Capital Blue Cross Essential (HMO) covers diagnostic and radiological services, offering diagnostic procedures and lab services with no copay and no coinsurance. Radiological services require prior authorization and include no copay for diagnostic radiology, a $5 copay for outpatient X-rays, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home Health Services are covered by Capital Blue Cross Essential (HMO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Capital Blue Cross Essential (HMO) provides Cardiac Rehabilitation Services with no coinsurance, although only some services are covered. Sub-services including cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) are not covered and require a $10 copay.
Skilled Nursing Facility (SNF) See details
Capital Blue Cross Essential (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring a $5 daily copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, and while a prior three-day inpatient hospital stay is not required, additional days beyond the 100-day Medicare limit are not covered.
Other Services See details
Capital Blue Cross Essential (HMO) partially covers other services, offering over-the-counter (OTC) items with no copay and no coinsurance up to a $45 maximum benefit every three months. Acupuncture, meal benefits, and nicotine replacement therapy are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved