Capital Blue Cross Basic (PPO)
CAPITAL ADVANTAGE INSURANCE COMPANY · 2027 plan year
Plan ID H3923-049-004
Local PPO★ 4 CMS Stars
- MOOP (in-network)
- $9,800
- MOOP (combined)
- $9,800
- Monthly premium
- $28/mo
- Part C $3 + Part D $25, before Extra Help
- Prescription drugs
- Included
This plan in 2026
- Capital Blue Cross Basic (PPO)
Was plan H3923-048 in 2026.
There were several regional versions of this plan in 2026. Open it to find the one for your area.
Plan information
- Contract / Plan / Segment
- H3923-049-004
- Medical deductible
- $450
- Part D premium
- $25/mo (part of the monthly premium above)Before Extra Help, which can lower or remove it for people with limited income.
- Part D deductible
- $700/yr
- Also owed
- Your Medicare Part B premium, paid separately
Other segments for this plan:
More CAPITAL ADVANTAGE INSURANCE COMPANY plans in PA
Benefits & cost sharing
Hospital
| Benefit | In-network |
|---|---|
| Worldwide Urgent Care Coverage | $40 |
| Inpatient Hospital — Acute | $415/day for days 1–5, $0 after |
| Inpatient Hospital — Additional Days (Acute) | No charge |
| Inpatient Hospital — Psychiatric | $415/day for days 1–5, $0 after |
Pharmacy
| Benefit | In-network |
|---|---|
| Part B Drugs | See plan details |
| Chemotherapy & Radiation Drugs (Part B) | 0%-20% coinsurance |
| Other Part B Drugs | 0%-20% coinsurance |
Mental Health
| Benefit | In-network |
|---|---|
| Mental Health Specialty Services | See plan details |
| Mental Health — Individual Sessions | $35 |
| Mental Health — Group Sessions | $35 |
| Supplemental Health Benefits | See plan details |
Other
| Benefit | In-network |
|---|---|
| Vision — Eyeglasses (Lenses & Frames) | No charge |
| Hearing — Exams | $35 |
| Hearing — Exams | See plan details |
| Podiatry Services | $35 |
| Other Health Care Professional Services | $35 |
| Psychiatric Services | See plan details |
| Psychiatric Services — Individual Sessions | $35 |
| Psychiatric Services — Group Sessions | $35 |
| Physical Therapy & Speech-Language Pathology | $20 |
| Additional Telehealth Services (Part B) | $0-$35 |
| Urgently Needed Services | $40 |
| Worldwide Emergency & Urgent Coverage | See plan details |
| Worldwide Emergency Coverage | $115 |
| Partial Hospitalization Program | $55 |
| Intensive Outpatient Program (IOP) | $55 |
| Home Health Services | No charge |
| Primary Care Physician Services | No charge |
| Chiropractic Services | $15 |
| Occupational Therapy Services | $20 |
| Physician Specialist Services | $35 |
| Opioid Treatment Program Services | No charge |
| Diagnostic Tests & Lab Services | See plan details |
| Diagnostic Procedures & Tests | No charge |
| Laboratory Services | $0-$100 |
| Radiological Services | See plan details |
| Diagnostic Radiology | $0-$350 |
| Therapeutic Radiology | 20% coinsurance |
| X-Ray Services | $20 |
| Diabetes Self-Management Training | No charge |
| Digital Rectal Exams | No charge |
| Dental — Prophylaxis (Cleaning) | See plan details |
| Welcome to Medicare EKG | No charge |
| Insulin (Part B) | $35 |
| Dental — Medicare-Covered Services | $35 |
| Skilled Nursing Facility (SNF) | $0/day for days 1–20, $221/day for days 21–100 |
| Cardiac & Pulmonary Rehabilitation | See plan details |
| Cardiac Rehabilitation — Additional Sessions | $25 |
| Intensive Cardiac Rehabilitation — Additional Sessions | $25 |
| Pulmonary Rehabilitation — Additional Sessions | $25 |
| Supervised Exercise Therapy (SET) | $10 |
| Emergency Services | $115 |
| Outpatient Hospital Services | $0-$475 |
| Hospital Observation Services | $400 per stay |
| Ambulatory Surgical Center (ASC) | $0-$375 |
| Outpatient Substance Abuse Services | See plan details |
| Substance Abuse — Individual Sessions | $35 |
| Substance Abuse — Group Sessions | $35 |
| Outpatient Blood Services | No charge |
| Ambulance Services | See plan details |
| Ground Ambulance | $235 |
| Air Ambulance | $235 |
| Durable Medical Equipment (DME) | 20% coinsurance |
| Prosthetics & Orthotics | See plan details |
| Prosthetic Devices | 20% coinsurance |
| Medical Supplies | 20% coinsurance |
| Diabetic Supplies & Services | See plan details |
| Diabetic Supplies | No charge |
| Diabetic Therapeutic Shoes & Inserts | 20% coinsurance |
| Diabetic Monitors | 0%-20% coinsurance |
| Dialysis Services | 20% coinsurance |
| Glaucoma Screening | No charge |
| Over-the-Counter (OTC) Items | No charge |
| Medicare-Covered Preventive Services | See plan details |
| Annual Physical Exam | No charge |
| Remote Access Technologies | No charge |
| Medical Nutrition Therapy | No charge |
| Kidney Disease Education Services | No charge |
| Dental — Preventive | No charge per office visit (combined preventive services) |
| Dental — Oral Exams | See plan details |
| Dental — X-Rays | See plan details |
| Dental — Diagnostic Services | 50% coinsurance |
| Dental — Fluoride Treatment | See plan details |
| Dental — Comprehensive | See plan details |
| Dental — Restorative Services | 50% coinsurance |
| Dental — Oral & Maxillofacial Surgery | 50% coinsurance |
| Vision — Eye Exams | $0-$35 |
| Vision — Eye Exams | See plan details |
| Vision — Routine Eye Exams | No charge |
| Vision — Eyewear | No charge |
| Vision — Eyewear | See plan details |
| Vision — Contact Lenses | No charge |
| Hearing — Routine Exams | No charge |
| Hearing — Fitting & Evaluation for Hearing Aid | No charge |
| Hearing — Prescription Hearing Aids | See plan details |
| Hearing — Hearing Aids (All Types) | $499-$999 |
Service area
- PA: 4 counties
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