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New Medicare HMO and PPO plans

Take a closer look at your options

Coverage you can trust from the doctors you prefer … and so much more. Check out the plan details, then choose the plan that’s right for you. You can enroll today, or call for more information at any time: 1-888-888-8888 (TTY: 711).

Capital Blue Cross | WellSpan HealthScroll to compare your plan options
Service Area Advantage PPO Advantage Plus PPO Inspire HMO
In Network Out of Network In Network Out of Network In Network
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Monthly Premium $0 $19 $0
Deductible $0 $0 NA
Maximum Out-of-Pocket (MOOP) $6,600 $11,300
(combined) 		$5,900 $11,300
(combined) 		$6,000
True Out-of-Pocket (TrOOP) $7,050 $7,050 $7,050
Primary Care Physician Office Visits - in person and telehealth $0 $5 $0 $5 $0
Specialty Office Visit - in person and telehealth $40 $40 $30 $30 $30
Urgent Care $50 $50 $50 $50 $35
Inpatient Hospital Stay $300 copay per stay $300 copay per stay $275 copay per stay $275 copay per stay $190 copay per stay
Ambulatory Surgical Center (ASC) $300 copay per stay $300 copay per stay $225 copay per stay $225 copay per stay $250 copay per stay
Outpatient Surgery $315 copay per stay $315 copay per stay $275 copay per stay $275 copay per stay $300 copay per stay
Emergency Care - copayment waived if admitted $90 copay $90 copay $90 copay $90 copay $90 copay
Labs $0 routine monitoring $25 all other 20% coinsurance $0 routine monitoring $25 all other 20% coinsurance $0 routine monitoring
$25 all other
X-rays $25 copay 20% coinsurance $50 copay 20% coinsurance $50 copay
Diagnostic Radiology - not including x-rays $250 copay 20% coinsurance $205 copay per visit 20% coinsurance $250 copay
Diabetes Self-Monitoring Training and Supplies $0 copay 20% coinsurance $0 copay 20% coinsurance $0 copay
Hearing Services $0 copay 50% coinsurance $0 copay 50% coinsurance $0 copay
For 1 routine hearing exam/year 1 fitting every 3 years For 1 routine hearing exam/year 1 fitting every 3 years For 1 routine hearing exam/year 1 fitting every 3 years
$400 hearing aid allowance both ears combined every 3 years $800 hearing aid allowance both ears combined every 3 years $800 hearing aid allowance both ears combined every 3 years
Routine Vision Services $0 copay 50% coinsurance $0 copay 50% coinsurance $0 copay
1 routine exam per year 1 routine exam per year 1 routine exam per year
Eyewear (eyeglass lens, eyeglass frame, or contacts) $125 max allowance every year $125 max allowance every year $125 max allowance every year
For eyeglasses frames or contact lenses For eyeglasses frames or contact lenses For eyeglasses frames or contact lenses
Routine Dental Services $0 copay 50% coinsurance $0 copay 50% coinsurance $0 copay
Includes oral exam, and set bitewing x-rays - 2 visits per year
Comprehensive Dental Services $2,000 Maximum allowance/year
50% coinsurance includes:
Teeth Fillings - Amalgam & Composite Simple Extractions only
Restorative Services:
Endodontics (Crowns, Inlays, Onlays) Prosthodontics (Dentures, Bridges, Partials)
Palliative Emergency Treatments Adjustments and Repairs of Prosthetic
SilverSneakers® Fitness Benefit $0 copay $0 copay $0 copay $0 copay $0 copay
Durable Medical Equipment 20% coinsurance 20% coinsurance 20% coinsurance
Over-the-counter $30 OTC allowance per month Retail or Mail-order $30 OTC allowance per month Retail or Mail-order $30 OTC allowance per month Retail or Mail-order
Transportation Benefit $0 copay $0 copay $0 copay
Limit 8 trips per calendar year Limit 24 trips per calendar year Limit 12 trips per calendar year
Medical Nutritional Therapy $0 copay 50% coinsurance $0 copay 50% coinsurance $0 copay
Nutritional/Dietary Benefit $0 copay 50% coinsurance $0 copay 50% coinsurance $0 copay
Virtual Care $0 copay, unlimited visits with Capital Blue Cross Virtual Care
Health Education $0 copay 3-30 minutes sessions with Capital Blue Cross Health Coaches
Prescription Drug Benefits $0 Deductible
Tier 1 - Preferred Generic Drugs
30 day Prf $8 / Stnd $15
60 day Prf $16 / Stnd $30
90 day Prf $24 / Stnd $45
30 day Prf $0 / Stnd $15
60 day Prf $0 / Stnd $30
90 day Prf $0 / Stnd $45
30 day Prf $0 / Stnd $7
60 day Prf $0 / Stnd $14
90 day Prf $0 / Stnd $21
Tier 2 - Generic Drugs
30 day Prf $12 / Stnd $20
60 day Prf $24 / Stnd $40
90 day Prf $36 / Stnd $60
30 day Prf $0 / Stnd $20
60 day Prf $0 / Stnd $40
90 day Prf $0 / Stnd $60
30 day Prf $5 / Stnd $15
60 day Prf $10 / Stnd $30
90 day Prf $15 / Stnd $45
Tier 3 - Preferred Brand Drugs
30 day Prf $40 / Stnd $47
60 day Prf $80 / Stnd $94
90 day Prf $120 / Stnd $141
30 day Prf $40 / Stnd $47
60 day Prf $80 / Stnd $94
90 day Prf $120 / Stnd $141
30 day Prf $40 / Stnd $47
60 day Prf $80 / Stnd $94
90 day Prf $120 / Stnd $141
Tier 4 - Non-Preferred Drugs
30 day Prf $93 / Stnd $100
60 day Prf $186 / Stnd $200
90 day Prf $279 / Stnd $300
30 day Prf $93 / Stnd $100
60 day Prf $186 / Stnd $200
90 day Prf $279 / Stnd $300
30 day Prf $93 / Stnd $100
60 day Prf $186 / Stnd $200
90 day Prf $279 / Stnd $300
Tier 5 - Specialty Drugs 30 day ONLY 33% coins 30 day ONLY 33% coins 30 day ONLY 33% coins
Tier 6 - Select Care Drugs
30 day Prf $0 / Stnd $7
60 day Prf $0 / Stnd $14
90 day Prf $0 / Stnd $21
30 day Prf $0 / Stnd $7
60 day Prf $0 / Stnd $14
90 day Prf $0 / Stnd $21
30 day Prf $0 / Stnd $7
60 day Prf $0 / Stnd $14
90 day Prf $0 / Stnd $21
Part D Senior Savings Model - Insulin
30 day Prf $5 / Stnd $5
60 day Prf $10 / Stnd $10
90 day Prf $15 / Stnd $15
30 day Prf $5 / Stnd $5
60 day Prf $10 / Stnd $10
90 day Prf $15 / Stnd $15
30 day Prf $5 / Stnd $5
60 day Prf $10 / Stnd $10
90 day Prf $15 / Stnd $15
Initial Coverage Limit $4,430 $4,430 $4,430
Coverage Gap (Donut Hole)
Generics 25% coinsurance 25% coinsurance 25% coinsurance
Brand Drugs 25% coinsurance 25% coinsurance 25% coinsurance
Catastrophic Coverage Greater of:
$3.95 - generic/multi source
$9.85 - all other drugs
5% coinsurance
Greater of:
$3.95 - generic/multi source
$9.85 - all other drugs
5% coinsurance
Greater of:
$3.95 - generic/multi source
$9.85 - all other drugs
5% coinsurance
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SilverSneakers® is a program of Tivity Health. On behalf of Capital Blue Cross, Tivity Health assists in the administration of this fitness program. Tivity Health is an independent company.