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2025 Benefit Information for Members
View and download information for your 2025 plan through December 31, 2025.
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Capital Blue Cross Medicare HMO
- Annual Notice of Changes - Capital Blue Cross Essential Plan
- Annual Notice of Changes - BlueJourney Premier Plan
- Annual Notice of Changes - BlueJourney Value Plan
- Continuous Glucose Monitor (CGM) Coverage
- Evidence of Coverage - Capital Blue Cross Essential Plan
- Evidence of Coverage - BlueJourney Premier Plan
- Evidence of Coverage - BlueJourney Value Plan
- Fitness Program Update - Effective August 1, 2025
- Out-of-Network Coverage Rule
- Pre-Enrollment Checklist
- Preauthorization Form
- Summary of Benefits - Capital Blue Cross Essential Plan
- Summary of Benefits - BlueJourney Premier Plan
- Summary of Benefits - BlueJourney Value Plan
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Capital Blue Cross Medicare PPO
- Annual Notice of Changes - Capital Blue Cross Classic Plan
- Annual Notice of Changes - BlueJourney Prime Plan
- Annual Notice of Changes - Capital Blue Cross Enhanced Plan - Central Region
- Annual Notice of Changes - Capital Blue Cross Enhanced Plan - Lehigh Region
- Annual Notice of Changes - Capital Blue Cross Select Plan
- Annual Notice of Changes - Capital Blue Cross Value Plan
- Continuous Glucose Monitor (CGM) Coverage
- Evidence of Coverage - Capital Blue Cross Classic Plan
- Evidence of Coverage - BlueJourney Prime Plan
- Evidence of Coverage - Capital Blue Cross Enhanced Plan - Central Region
- Evidence of Coverage - Capital Blue Cross Enhanced Plan - Lehigh Region
- Evidence of Coverage - Capital Blue Cross Select Plan
- Evidence of Coverage - Capital Blue Cross Value Plan
- Evidence of Coverage - Capital Blue Cross Complete Plan
- Fitness Program Update - Effective August 1, 2025
- Out-of-Network Coverage Rules
- Pre-Enrollment Checklist
- Preauthorization Form
- Summary of Benefits - Capital Blue Cross Classic Plan
- Summary of Benefits - BlueJourney Prime Plan
- Summary of Benefits - Capital Blue Cross Enhanced Plan - Central Region
- Summary of Benefits - Capital Blue Cross Enhanced Plan - Lehigh Region
- Summary of Benefits - Capital Blue Cross Select Plan
- Summary of Benefits - Capital Blue Cross Value Plan
- Summary of Benefits - Capital Blue Cross Complete Plan
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Capital Blue Cross | WellSpan Health HMO
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Capital Blue Cross | WellSpan Health PPO
- Annual Notice of Changes - Advantage
- Annual Notice of Changes - AdvantagePlus
- Annual Notice of Changes - Value
- Continuous Glucose Monitor (CGM) Coverage
- Evidence of Coverage - Advantage
- Evidence of Coverage - AdvantagePlus
- Evidence of Coverage - Value
- Evidence of Coverage - Complete
- Fitness Program Update - Effective August 1, 2025
- Out-of-Network Coverage Rule
- Pre-Enrollment Checklist
- Preauthorization Form
- Summary of Benefits - Advantage
- Summary of Benefits - AdvantagePlus
- Summary of Benefits - Value
- Summary of Benefits - Complete
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Representation Forms
Appoint a Representative to Discuss Your Options with us
Print, complete and send back this form to allow a family member or friend to communicate with us on your behalf. You can also call the Member Services number on your ID card and request a copy be mailed to you.
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National and Local Medicare Coverage Information
The Centers for Medicare and Medicaid Services (CMS) works to expand and improve coverage for Medicare participants. There are National Coverage Determinations (NCD’s) and Local Coverage Determinations (LCD’s) issued throughout the year that expand health care coverage for various services. Listed below are some of those new coverage determinations.
- January 2022:
Medical Nutrition Therapy - February 2022:
Lung Cancer Screening with Low Dose Computed Tomography (LDCT) - April 2022:
Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease (AD) - September 2022:
Cochlear Implantation Services - January 2023:
Colorectal Cancer Screening Blood Based Biomarker Tests - July 2023:
Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation - September 2023:
Seat Elevation Equipment (Power Operated) on Power Wheelchairs - September 2024:
PrEP for HIV & Related Preventive Services - March 2025:
Transcatheter Tricuspid Valve Replacement (TTVR) - May 2025:
Implantable Pulmonary Artery Pressure Sensors for Heart Failure Management - June 2025:
Noninvasive Positive Pressure Ventilation (NIPPV) in the Home for the Treatment of Chronic Respiratory Failure consequent to COPD - July 2025:
Transcatheter Edge-to-Edge Repair for Tricuspid Valve Regurgitation (T-TEER)
Cardiac Contractility Modulation (CCM) for Heart Failure
Renal Denervation for Uncontrolled Hypertension
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Quality Improvement Organization
You should contact the Quality Improvement Organization if you have a complaint about the quality of care you have received. For example, you can contact the Quality Improvement Organization if you were given the wrong medication or if you were given medications that interact in a negative way.
Livanta (Pennsylvania’s Quality Improvement Organization)
Contact
Phone: 888.396.4646 (TTY: 888.985.2660)
Fax: 1.833.868.4057
Visit the Livanta website.
Write by mail:
Livanta BFCC-QIO Program
10820 Guilford Road, Suite 202
Annapolis Junction, MD 20701
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Publications
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Prescription Drug Information
Compare the cost of your drugs at participating pharmacies.
To access pricing, login to your secure member account.
Search the Ideal Formulary for drugs included on the Capital Blue Cross Ideal formulary. This formulary applies to the following plans: Capital Blue Cross Basic, Complete, Enhanced, Select, Value PPO and Capital Blue Cross HMO Essential.
- Download an Ideal Formulary listing. (updated 10/2025)
- Download an Ideal Formulary (Spanish) listing. (updated 10/2025)
- Ideal Formulary Prior Authorization Criteria
- Ideal Formulary Step Therapy Criteria
Search the Classic Formulary for drugs included in the Capital Blue Cross Classic formulary. This formulary applies to the following plans: Capital Blue Cross Classic and Prime PPO and Capital Blue Cross Premier and Value HMO, as well as our Capital Blue Cross PPO and HMO Group benefit plans.
- Download a Classic Formulary listing. (updated 10/2025)
- Download a Classic Formulary (Spanish) listing. (updated 10/2025)
- Classic Formulary Prior Authorization Criteria
- Classic Formulary Step Therapy Criteria
Add your prescriptions to see how much you will pay each month and save by either switching to a pharmacy that has lower prescription cost or finding a lower cost alternative.
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Updated
Y20170719