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) Medicare plan features an annual prescription drug deductible of $375. For Tier 1 preferred generics and Tier 2 generics, members enjoy no copay for one-, two-, or three-month supplies when using preferred pharmacies or preferred mail-order services. If you use standard pharmacies or standard mail-order services, Tier 1 copays start at $10 and Tier 2 copays start at $15 for a one-month supply. For higher-tier medications, coverage costs are based on coinsurance regardless of whether you use preferred or standard pharmacies. Tier 3 preferred brand drugs require a 19% coinsurance, while Tier 4 non-preferred drugs carry a 40% coinsurance. Specialty Tier 5 prescriptions are available as a one-month supply with a 28% coinsurance.
Additional Benefits
The Capital Blue Cross Essential (HMO) plan offers robust coverage for essential medical services with manageable out-of-pocket costs. Primary care physician visits, preventive screenings, and home health services are available with no copay and no coinsurance, while specialist visits require a $20 copay. For hospital stays, inpatient services feature a daily copay of $135 for the first four days followed by no copay for days five through ninety, and emergency room visits carry a $130 copay. This plan also includes valuable dental, vision, and hearing benefits to help you maintain your overall well-being. Routine eye exams and preventive dental care feature no copay, and members receive up to $200 annually for eyewear. Additionally, the plan offers a $45 quarterly allowance for over-the-counter items with no copay, alongside covered medical equipment and dialysis services that generally require a twenty percent coinsurance.
Inpatient Hospital See details
Capital Blue Cross Essential (HMO) partially covers inpatient hospital services with no coinsurance and a daily copay of $135 for days 1 through 4, followed by no copay for days 5 through 90. Unlimited additional acute care days are covered with no copay, but additional psychiatric days, upgrades, and non-Medicare-covered stays 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 require no copay and no coinsurance, while outpatient substance abuse sessions have a $20 copay and no coinsurance.
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 to access this benefit.
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. Some transportation services are covered, but trips to plan-approved or any health-related locations are 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 no coinsurance, 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 limit with similar copays and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Capital Blue Cross Essential (HMO) offers primary care physician services and opioid treatment with no copay and no coinsurance, while specialist visits, therapy services, and outpatient mental health sessions require a $20 copay and no coinsurance. Telehealth benefits are available with a $0 to $20 copay and no coinsurance, but chiropractic and podiatry services are not covered.
Preventive Services See details
Capital Blue Cross Essential (HMO) partially covers preventive services with no copay and no coinsurance for covered benefits like annual physical exams, kidney disease education, and various screenings. Supplemental sub-services that are not covered include health education, in-home safety assessments, personal emergency response systems, post-discharge medication reconciliation, re-admission prevention, chemotherapy wigs, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, additional smoking cessation sessions, enhanced disease management, telemonitoring, home safety modifications, and counseling services.
Hearing Services See details
Capital Blue Cross Essential (HMO) covers annual routine hearing exams with a $20 copay and no coinsurance. Hearing aid benefits are partially covered with no coinsurance, offering up to two OTC hearing aids for a $499 copay and up to two prescription hearing aids for a $499 to $999 copay, though inner ear, outer ear, and over the ear prescription models are not covered.
Vision Services See details
Capital Blue Cross Essential (HMO) provides partially covered vision services with no deductible, no copay, and no coinsurance for covered services. Beneficiaries receive one routine eye exam and up to a $200 annual limit for one pair of contact lenses or eyeglasses (lenses and frames) per year, while other eye exams, individual eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services are partially covered by Capital Blue Cross Essential (HMO) up to a $3,000 annual maximum, with Medicare-covered dental requiring a $20 copay and no coinsurance. Preventive services such as cleanings, exams, x-rays, and fluoride feature no copay and no coinsurance, while restorative fillings and simple extractions are covered with no copay and 50% coinsurance. Other diagnostic, other preventive, adjunctive general, endodontic, periodontic, prosthodontic, implant, maxillofacial prosthetic, and orthodontic services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Capital Blue Cross Essential (HMO) with no copay, though prior authorization and step therapy may be required. Under this benefit, Medicare Part B insulin has a $35 copay and no coinsurance, while other Part B chemotherapy and drug services require no copay and a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the Capital Blue Cross Essential (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Capital Blue Cross Essential (HMO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay. A 20% coinsurance applies to most items, though diabetic supplies range from no coinsurance up to 20% coinsurance, and prior authorization is required.
Diagnostic and Radiological Services See details
Capital Blue Cross Essential (HMO) covers diagnostic and radiological services, with prior authorization required for most of these benefits. Outpatient diagnostic procedures, tests, and lab services are provided with no copay and no coinsurance, while radiological services require a $5 copay for X-rays, copays starting at $0 for diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Capital Blue Cross Essential (HMO) covers home health services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under Capital Blue Cross Essential (HMO) with no coinsurance, though only some services are covered. Specifically, Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD services are not covered and require a $10 copay.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Capital Blue Cross Essential (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 necessary, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other services under the Capital Blue Cross Essential (HMO) are partially covered, featuring over-the-counter (OTC) items with no copay and no coinsurance up to a maximum of $45 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