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Capital Blue Cross | WellSpan Health Value (PPO)

H3923 - 031 - 0
4.5 out of 5 stars (4.5 / 5)

Capital Blue Cross | WellSpan Health Value (PPO) is a Medicare Advantage Plan by Capital Blue Cross.

This page features plan details for 2025 Capital Blue Cross | WellSpan Health Value (PPO) H3923 – 031 – 0 available in 7 County South Central PA.

Locations

Capital Blue Cross | WellSpan Health Value (PPO) is offered in the following locations.

Adams County, Pennsylvania
Cumberland County, Pennsylvania
Franklin County, Pennsylvania

Click to see more locations

Plan Overview

Capital Blue Cross | WellSpan Health Value (PPO) offers the following coverage and cost-sharing.

Insurer:Capital Blue Cross
Health Plan Deductible:$0
MOOP:$9,000 In and Out-of-network
$9,000 In-network
Drugs Covered:Yes

Ready to sign up for Capital Blue Cross | WellSpan Health Value (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Medicare Part B Give Back Benefit

The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans. 

Capital Blue Cross | WellSpan Health Value (PPO) qualifies for a monthly Medicare Give Back Benefit of $28.00.

Premium Reduction:$28.00

Premium Breakdown

Capital Blue Cross | WellSpan Health Value (PPO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $0.00 $28.00 $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Capital Blue Cross | WellSpan Health Value (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $200.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$0.00$0.00

Initial Coverage Phase

After you pay your $200.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Capital Blue Cross | WellSpan Health Value (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: 50 Coins – No Co pay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Endodontics
    • In-Network: 50 Coins – No Co pay
    • Out-of-Network: 50% Coins – No Copay
  • Oral and Maxillofacial Surgery
    • In-Network: 50 Coins – No Co pay
    • Out-of-Network: 50% Coins – No Copay
  • Periodontics
    • In-Network: 50 Coins – No Co pay
    • Out-of-Network: 50% Coins – No Copay
  • Prosthodontics, fixed
    • In-Network: 50 Coins – No Co pay
    • Out-of-Network: 50% Coins – No Copay
  • Prosthodontics, removable
    • In-Network: 50 Coins – No Co pay
    • Out-of-Network: 50% Coins – No Copay
  • Restorative Services
    • In-Network: 50 Coins – No Co pay
    • Out-of-Network: 50% Coins – No Copay

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – – Copay
    • Out-of-Network: 50% Coins – No Copay
  • Fluoride Treatment
    • In-Network: No Coins – – Copay
    • Out-of-Network: 50% Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – – Copay
    • Out-of-Network: 50% Coins – No Copay
  • Other Diagnostic Dental Services
    • In-Network: 50 Coins – No Copay
    • Out-of-Network: 50% Coins – No Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – – Copay
    • Out-of-Network: 50% Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic tests and procedures
    • In-Network: $0 copay (Authorization Required)
  • Lab services
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Outpatient x-rays
    • In-Network: $35 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $0-285 copay (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Diagnostic tests and procedures
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Lab services
    • In-Network: $0 copay (Authorization Required)

Doctor visits

  • Primary
    • Out-of-Network: $0 copay
    • In-Network: $0 copay
  • Specialist
    • In-Network: $40 copay per visit
    • Out-of-Network: $40 copay per visit

Emergency care/Urgent care

  • Emergency
    • $110 copay per visit (always covered)
  • Urgent care
    • $45 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • Out-of-Network: $40 copay
  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • In-Network: $40 copay

Ground ambulance

    • In-Network: $305 copay
    • Out-of-Network: $305 copay

Health plan deductible

    • $0

Hearing

  • Hearing aids
    • Out-of-Network: $499-999 copay (Limits Apply)
  • Hearing aids OTC
    • Out-of-Network: $499 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • Out-of-Network: $40 copay
  • Fitting/evaluation
    • In-Network: $0 copay
  • Hearing aids
    • In-Network: $499-999 copay (Limits Apply)
  • Hearing aids OTC
    • In-Network: $499 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • In-Network: $40 copay
  • Fitting/evaluation
    • Out-of-Network: $0 copay

Inpatient hospital coverage

    • In-Network: $200 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)
    • Out-of-Network: $200 per day for days 1 through 4
      $0 per day for days 5 and beyond (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $9,000 In and Out-of-network
      $9,000 In-network

Medical equipment/supplies

  • Diabetes supplies
    • Out-of-Network: 50% coinsurance per item (Authorization Required)
    • In-Network: $0 copay per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 20-50% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • Out-of-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: 0-20% coinsurance (Authorization Required)
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)

Mental health services

  • Inpatient hospital – psychiatric
    • In-Network: $200 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: $40 copay
  • Outpatient group therapy visit
    • Out-of-Network: $40 copay
  • Outpatient individual therapy visit
    • Out-of-Network: $40 copay
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $40 copay
    • Out-of-Network: $40 copay
  • Inpatient hospital – psychiatric
    • Out-of-Network: $200 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $40 copay
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $40 copay
    • Out-of-Network: $40 copay

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $0-450 copay per visit (Authorization Required)
    • Out-of-Network: 30% coinsurance per visit (Authorization Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: $0 copay

Rehabilitation services

  • Occupational therapy visit
    • In-Network: $35 copay
    • Out-of-Network: $35 copay
  • Physical therapy and speech and language therapy visit
    • In-Network: $35 copay
    • Out-of-Network: $35 copay

Skilled Nursing Facility

    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 100 (Authorization Required)
    • Out-of-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 100 (Authorization Required)

Transportation

    • Not covered

Vision

  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • Not covered
  • Upgrades
    • Not covered
  • Eyeglass lenses
    • Not covered
  • Eyeglasses (frames and lenses)
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • Out-of-Network: 50% coinsurance (Limits Apply)
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Other
    • Not covered

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for Capital Blue Cross | WellSpan Health Value (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on Capital Blue Cross | WellSpan Health Value (PPO)? See 2025 Capital Blue Cross | WellSpan Health Value (PPO) at MedicareAdvantageRX.com.

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Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint

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