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) plan features a $375 drug deductible. For Tier 1 preferred generic and Tier 2 generic medications, there is no copay when filled through a preferred pharmacy or preferred mail-order service. If you choose a standard pharmacy or standard mail-order service, Tier 1 drugs require a $10 to $30 copay and Tier 2 drugs require a $15 to $45 copay depending on the supply duration. For brand-name and specialty prescriptions, costs are based on coinsurance across all pharmacy and mail-order options. Tier 3 preferred brand drugs require a 19% coinsurance, and Tier 4 non-preferred drugs require a 40% coinsurance. Tier 5 specialty drugs have a 28% coinsurance for a one-month supply.
Additional Benefits
The Capital Blue Cross Essential (HMO) plan offers robust medical coverage with no coinsurance for inpatient hospital stays, which cost a $135 daily copay for the first four days and no copay for days five through 90. Primary care visits and preventive services are available with no copay, while specialist visits and outpatient routine therapies require a low $20 copay. Emergency care is covered with a $130 copay, and urgent care visits cost $40, both with no coinsurance. This plan also includes essential ancillary benefits, featuring no-copay preventive dental care and routine vision exams, alongside a $200 annual vision hardware allowance. Routine hearing exams carry a $20 copay, and members receive a $45 quarterly allowance with no copay for over-the-counter items. Durable medical equipment and dialysis services are covered with a 20% coinsurance and no copay.
Inpatient Hospital See details
Capital Blue Cross Essential (HMO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a copay of $135 per day for days 1 through 4 and no copay for days 5 through 90. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered, though unlimited additional acute days are covered with no copay.
Outpatient Services See details
Outpatient services are covered under the Capital Blue Cross Essential (HMO) 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 require no copay, while individual and group outpatient substance abuse sessions have a $20 copay.
Partial Hospitalization See details
Capital Blue Cross Essential (HMO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization is required for these covered services.
Ambulance and Transportation Services See details
Capital Blue Cross Essential (HMO) covers ground and air ambulance services with a $195 copay and no coinsurance, though prior authorization is required. Transportation services to plan-approved or other health-related locations are not covered.
Emergency Services See details
Capital Blue Cross Essential (HMO) partially covers emergency services, as worldwide emergency transportation is not covered. Covered emergency services have a $130 copay and urgent care has a $40 copay, both with no coinsurance, while worldwide emergency and urgent services are covered up to a $20,000 maximum with no coinsurance.
Primary Care See details
Capital Blue Cross Essential (HMO) covers primary care physician services and opioid treatment with no copay and no coinsurance, while specialist visits, therapies, and mental health services require a $20 copay and no coinsurance. Telehealth benefits are available with a $0 to $20 copay and no coinsurance, but podiatry is not covered, and chiropractic services are only partially covered with routine and other chiropractic services excluded.
Preventive Services See details
Preventive services are partially covered by Capital Blue Cross Essential (HMO) with no copay and no coinsurance for covered care, including annual physical exams, kidney disease education, and diabetes self-management training. Supplemental benefits like health education, weight management programs, in-home safety assessments, and personal emergency response systems are not covered.
Hearing Services See details
Capital Blue Cross Essential (HMO) covers routine hearing exams with a $20 copay and no coinsurance, and OTC hearing aids with a $499 copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $499 to $999, though inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Capital Blue Cross Essential (HMO) with no deductibles, no coinsurance, and no copays for one annual routine eye exam and one annual pair of contact lenses or eyeglasses (lenses and frames) up to a $200 limit. Other eye exam services, separate eyeglass lenses, separate eyeglass frames, and upgrades are not covered.
Dental Services See details
Capital Blue Cross Essential (HMO) partially covers dental services up to a $3,000 annual limit, featuring Medicare-covered dental for a $20 copay and no coinsurance, and preventive care like cleanings and exams with no copay and no coinsurance. Restorative services and oral surgery are covered with no copay and 50% coinsurance, but other diagnostic, other preventive, endodontics, periodontics, prosthodontics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Capital Blue Cross Essential (HMO) covers Home Infusion bundled Services with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while chemotherapy and other Part B drugs carry no copay and 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
Medical equipment benefits under Capital Blue Cross Essential (HMO) are covered with no copay and require prior authorization. Durable medical equipment, prosthetics, medical supplies, and diabetic shoes or inserts carry a 20% coinsurance, while diabetic supplies range from no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
Capital Blue Cross Essential (HMO) covers diagnostic and radiological services with no copay or coinsurance for lab work, diagnostic tests, and diagnostic radiology. Outpatient X-rays require a $5 copay, therapeutic radiology has a 20% coinsurance, and prior authorization is required for these services.
Home Health Services See details
Capital Blue Cross Essential (HMO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Capital Blue Cross Essential (HMO) provides coverage for Cardiac Rehabilitation Services with no coinsurance, though only some services are covered while Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and Supervised Exercise Therapy (SET) for PAD are not covered and require a $10 copay.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by Capital Blue Cross Essential (HMO) 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, a prior three-day inpatient hospital stay is not required, and additional days beyond the Medicare-covered 100 days are not covered.
Other Services See details
Capital Blue Cross Essential (HMO) partially covers other services, excluding acupuncture and meal benefits, while offering over-the-counter (OTC) items with no copay and no coinsurance. Eligible members receive a $45 allowance every three months for reimbursement of approved OTC items, which includes naloxone but excludes nicotine replacement therapy.
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