Capital Blue Cross Prime (PPO)
Available to residents of Cumberland County, PA for 2026. Contract H3923, plan 017, segment 0.
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- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Cumberland County
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- Browse the Capital Blue Cross Prime (PPO) formulary
Renewed for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $177.00 |
|---|---|
| — medical (Part C) part | $99.70 |
| — drug (Part D) part | $77.30? |
| Monthly premium with full Extra Help (LIS) | $144.30?drug (Part D) part $44.60; Extra Help does not cover the medical (Part C) premium |
| Part B premium reduction (giveback) | None |
| In-network out-of-pocket maximum | $6,700.00? |
| In- and out-of-network out-of-pocket maximum | $6,700.00 |
| Drug deductible | $100.00Tier 1 and 2 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | PPO? |
| Contract / plan | H3923-017-0 |
| Offered by | Capital Blue Cross |
| Parent organization | CAPITAL BLUE CROSS |
| Formulary drugs | 3,539 |
| Formulary exception tier | 4? |
| Pharmacy search | www.capitalbluemedicare.com |
| Member services | (800)990-4201TTY 711 |
CMS star ratings
- Overall
- 4.5 out of 5 stars for Overall
- Health plan (Part C)
- 4.5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 4 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H3923 shares this rating.
Plan health benefits
| Service | In-network | Out-of-network? |
|---|---|---|
| Doctor visits | ||
| Primary care doctor | $0 copay | $0 copay |
| Specialist | $25 copay | $25 copay |
| Other health care professional | $25 copay | $25 copay |
| Additional telehealth services | $0–$25 copay | — |
| Preventive care | ||
| Medicare-covered preventive services | $0 copay | $0 copay |
| Annual physical exam | $0 copay | $0 copay |
| Kidney disease education | $0 copay | $0 copay |
| Glaucoma screening | $0 copay | $0 copay |
| Diabetes self-management training | $0 copay | $0 copay |
| Diagnostic tests, labs and imaging | ||
| Diagnostic tests and procedures | $0 copay(authorization required) | 30% coinsurance |
| Lab services | $0 copay(authorization required) | 30% coinsurance |
| Diagnostic radiology (e.g. MRI, CT) | $0–$200 copay(authorization required) | 30% coinsurance |
| Therapeutic radiology | 20% coinsurance(authorization required) | 30% coinsurance |
| Outpatient x-rays | $25 copay(authorization required) | 30% coinsurance |
| Emergency and urgent care | ||
| Emergency room | $130 copay | — |
| Urgent care | $35 copay | — |
| Worldwide emergency coverage | $130 copay · $20,000 plan limit | — |
| Worldwide urgent care | $35 copay · $20,000 plan limit | — |
| Worldwide emergency transportation | Not covered | — |
| Hospital care | ||
| Inpatient hospital stay | $225 per day for days 1–6; $0 per day for days 7–90(authorization required) | $225 per day for days 1–6; $0 per day for days 7–999 |
| Outpatient hospital services | $0–$375 copay(authorization required) | 30% coinsurance |
| Outpatient observation | $225 copay | $225 copay |
| Ambulatory surgical center | $0–$250 copay(authorization required) | 30% coinsurance |
| Outpatient blood services | $0 copay | 20% coinsurance |
| Skilled nursing and home health | ||
| Skilled nursing facility | $10 per day for days 1–20; $218 per day for days 21–100(authorization required) | $10 per day for days 1–20; $218 per day for days 21–100 |
| Home health care | $0 copay(authorization required) | 30% coinsurance |
| Kidney dialysis | 20% coinsurance | 20% coinsurance |
| Rehabilitation | ||
| Occupational therapy | $25 copay | $25 copay |
| Physical therapy and speech-language therapy | $25 copay | $25 copay |
| Cardiac rehabilitation | $25 copay | $25 copay |
| Pulmonary rehabilitation | $15 copay | $15 copay |
| Mental health and substance use | ||
| Inpatient psychiatric hospital stay | $225 per day for days 1–6; $0 per day for days 7–90(authorization required) | $225 per day for days 1–6; $0 per day for days 7–90 |
| Outpatient mental health, individual session | $25 copay | $25 copay |
| Outpatient mental health, group session | $25 copay | $25 copay |
| Psychiatrist, individual session | $25 copay | $25 copay |
| Psychiatrist, group session | $25 copay | $25 copay |
| Partial hospitalization | $55 copay(authorization required) | 20% coinsurance |
| Intensive outpatient program | $55 copay(authorization required) | 20% coinsurance |
| Outpatient substance use, individual session | $25 copay | $25 copay |
| Outpatient substance use, group session | $25 copay | $25 copay |
| Opioid treatment program | $0 copay | $0 copay |
| Ambulance and transportation | ||
| Ground ambulance | $230 copay(authorization required) | $230 copay |
| Air ambulance | $230 copay(authorization required) | $230 copay |
| Transportation to plan-approved locations | Not covered | — |
| Medical equipment and supplies | ||
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) | 20%–50% coinsurance |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) | 20% coinsurance |
| Medical supplies | 20% coinsurance(authorization required) | 20% coinsurance |
| Diabetes supplies | 0%–20% coinsurance(authorization required) | 50% coinsurance |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) | 20% coinsurance |
| Chiropractic, acupuncture and foot care | ||
| Chiropractic (Medicare-covered) | $15 copay | $15 copay |
| Routine chiropractic care | Not covered | — |
| Acupuncture | Not covered | — |
| Foot exams and treatment (Medicare-covered) | $25 copay | $25 copay |
| Routine foot care | Not covered | — |
| Dental? | ||
| Medicare-covered dental services | $25 copay | $25 copay |
| Preventive dental plan limit | $2,000 plan limit every year | — |
| Other diagnostic dental services | 50% coinsurance(limits apply) | 60% coinsurance |
| Other preventive dental services | Not covered | — |
| Restorative services (fillings, crowns) | 50% coinsurance(limits apply) | 60% coinsurance |
| Endodontics (root canals) | 50% coinsurance(limits apply) | 60% coinsurance |
| Periodontics (gum disease) | 50% coinsurance(limits apply) | 60% coinsurance |
| Dentures and other removable prosthodontics | 50% coinsurance(limits apply) | 60% coinsurance |
| Maxillofacial prosthetics | Not covered | — |
| Implants | Not covered | — |
| Bridges and other fixed prosthodontics | 50% coinsurance(limits apply) | 60% coinsurance |
| Oral and maxillofacial surgery | 50% coinsurance(limits apply) | 60% coinsurance |
| Orthodontics | Not covered | — |
| Adjunctive general services | 50% coinsurance | 60% coinsurance |
| Vision? | ||
| Eye exam (Medicare-covered) | $0–$25 copay | $0–$25 copay |
| Routine eye exam | $0 copay(limits apply) | 50% coinsurance |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) | 20% coinsurance |
| Eyewear plan limit | $125 plan limit every year | — |
| Contact lenses | $0 copay(limits apply) | $0 copay |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) | $0 copay |
| Eyeglass lenses | Not covered | — |
| Eyeglass frames | Not covered | — |
| Eyewear upgrades | Not covered | — |
| Hearing? | ||
| Hearing exam (Medicare-covered) | $25 copay | $25 copay |
| Routine hearing exam | $0 copay(limits apply) | $0 copay |
| Hearing aid fitting and evaluation | $0 copay | $0 copay |
| Hearing aids (all types) | $499–$999 copay(limits apply) | $499–$999 copay |
| Hearing aids, inner ear | Not covered | — |
| Hearing aids, outer ear | Not covered | — |
| Hearing aids, over the ear | Not covered | — |
| Medicare Part B drugs | ||
| Part B insulin | $35 copay(authorization required, step therapy may apply) | $35 copay |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 0%–20% coinsurance |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) | 0%–20% coinsurance |
| Other extra benefits? | ||
| Over-the-counter (OTC) allowance | $45 allowance every three months | — |
| Meals after a hospital stay or for a chronic condition | Not covered | — |
| Fitness benefit | $0 copay | $0 copay |
| Health education | Not covered | — |
| Nutritional / dietary benefit | Not covered | — |
| Extra smoking and tobacco cessation counseling | Not covered | — |
| Enhanced disease management | Not covered | — |
| Telemonitoring | Not covered | — |
| Remote access technologies (web/phone, nurse line) | $0 copay | $0 copay |
| Home and bathroom safety devices | Not covered | — |
| Counseling services | Not covered | — |
| In-home safety assessment | Not covered | — |
| Personal emergency response system (PERS) | Not covered | — |
| Medical nutrition therapy | $0 copay | 50% coinsurance |
| Post-discharge in-home medication reconciliation | Not covered | — |
| Re-admission prevention | Not covered | — |
| Wigs for hair loss from chemotherapy | Not covered | — |
| Weight management programs | Not covered | — |
| Alternative therapies | Not covered | — |
| Therapeutic massage | Not covered | — |
| Adult day health services | Not covered | — |
| Home-based palliative care | Not covered | — |
| In-home support services | Not covered | — |
| Support for caregivers | Not covered | — |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | $0.00 |
| Tier 3 | $47.00 |
| Tier 4 | $100.00 |
| Tier 5 | 31% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $10.00 | $0.00 | $0.00 | $30.00 | $0.00 |
| Tier 2: Generic | $0.00 | $15.00 | $0.00 | $0.00 | $45.00 | $0.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $10.00 | $0.00 | $0.00 | $30.00 | $0.00 |
| Tier 2: Generic | $0.00 | $15.00 | $0.00 | $0.00 | $45.00 | $0.00 |
| Tier 3: Preferred Brand | $47.00 | $47.00 | $47.00 | $141.00 | $141.00 | $141.00 |
| Tier 4: Non-Preferred Drug | $100.00 | $100.00 | $100.00 | $300.00 | $300.00 | $300.00 |
| Tier 5: Specialty Tier | 31% | 31% | 31% | n/a | n/a | n/a |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 20 other PA counties
Benefits in plain text
Capital Blue Cross Prime (PPO) (H3923-017-0) is a 2026 PPO Medicare Advantage plan offered by Capital Blue Cross, available to residents of Cumberland County, PA.
The monthly premium is $177.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $144.30.
Its in-network out-of-pocket maximum is $6,700.00.
The combined in- and out-of-network out-of-pocket maximum is $6,700.00.
The drug deductible is $100.00. Tier 1 and 2 exempt.
The plan's formulary lists 3,539 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $0.00; tier 3: $47.00; tier 4: $100.00; tier 5: 31%.
CMS gives the plan's contract (H3923) an overall rating of 4.5 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.