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2026 Benefit Information for Members
View and download information for your 2026 plan through December 31, 2026.
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Capital Blue Cross Medicare HMO
All 21 Counties
- Continuous Glucose Monitor (CGM) Coverage
- Out-of-Network Coverage Rule
- Pre Enrollment Checklist
- Preauthorization Form
- Annual Notice of Changes - Capital Blue Cross Value Plan
- Annual Notice of Changes - Capital Blue Cross Premier Plan
- Summary of Benefits - Capital Blue Cross Value Plan
- Summary of Benefits - Capital Blue Cross Premier Plan
- Evidence of coverage - Capital Blue Cross Value Plan
- Evidence of coverage - Capital Blue Cross Premier Plan
001 - Centre, Dauphin, Juniata, Mifflin, Perry Counties
- Annual Notice of Changes - Capital Blue Cross Essential Plan 001
- Summary of Benefits - Capital Blue Cross Essential Plan 001
- Evidence of coverage - Capital Blue Cross Essential Plan 001
002 - Columbia, Montour, Northumberland, Snyder, Union Counties
- Annual Notice of Changes - Capital Blue Cross Essential Plan 002
- Summary of Benefits - Capital Blue Cross Essential Plan 002
- Evidence of coverage - Capital Blue Cross Essential Plan 002
003 - Berks, Lehigh, Northampton, Schuylkill Counties
- Annual Notice of Changes - Capital Blue Cross Essential Plan 003
- Summary of Benefits - Capital Blue Cross Essential Plan 003
- Evidence of coverage - Capital Blue Cross Essential Plan 003
004 - Cumberland, Fulton, Lancaster, Lebanon Counties
- Annual Notice of Changes - Capital Blue Cross Essential Plan 004
- Annual Notice of Changes - Capital Blue Cross Essential Plan 004 (PREVIOUSLY CAPITAL BLUE CROSS | WELLSPAN HEALTH PLAN)
- Summary of Benefits - Capital Blue Cross Essential Plan 004
- Evidence of coverage - Capital Blue Cross Essential Plan 004
- EOC errata
005 - Adams, Franklin, York Counties
- Annual Notice of Changes - Capital Blue Cross Essential Plan 005
- Annual Notice of Changes - Capital Blue Cross Essential Plan 005 (PREVIOUSLY CAPITAL BLUE CROSS | WELLSPAN HEALTH PLAN)
- Summary of Benefits - Capital Blue Cross Essential Plan
- Evidence of coverage - Capital Blue Cross Essential Plan 005
- EOC errata
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Capital Blue Cross Medicare PPO
All 21 Counties
- Continuous Glucose Monitor (CGM) Coverage
- Out-of-Network Coverage Rule
- Pre Enrollment Checklist
- Preauthorization Form
- Annual Notice of Changes - Capital Blue Cross Classic Plan
- Annual Notice of Changes - Capital Blue Cross Prime Plan
- Summary of Benefits - Capital Blue Cross Classic Plan
- Summary of Benefits - Capital Blue Cross Prime Plan
- Evidence of Coverage - Capital Blue Cross Classic Plan
- Evidence of Coverage - Capital Blue Cross Prime Plan
001 - Centre, Dauphin, Juniata, Mifflin, Perry Counties
- Annual Notice of Changes - Capital Blue Cross Select 001
- Annual Notice of Changes - Capital Blue Cross Value 001
- Annual Notice of Changes - Capital Blue Cross Enhanced 001
- Annual Notice of Changes - Capital Blue Cross Complete 001
- Summary of Benefits - Capital Blue Cross Select 001
- Summary of Benefits - Capital Blue Cross Value 001
- Summary of Benefits - Capital Blue Cross Enhanced 001
- Summary of Benefits - Capital Blue Cross Complete 001
- Evidence of Coverage - Capital Blue Cross Select 001
- Evidence of Coverage - Capital Blue Cross Value 001
- Evidence of Coverage - Capital Blue Cross Enhanced 001
- Evidence of Coverage - Capital Blue Cross Complete 001
002 - Columbia, Montour, Northumberland, Snyder, Union Counties
- Annual Notice of Changes - Capital Blue Cross Select 002
- Annual Notice of Changes - Capital Blue Cross Value 002
- Annual Notice of Changes - Capital Blue Cross Enhanced 002
- Annual Notice of Changes - Capital Blue Cross Complete 002
- Summary of Benefits - Capital Blue Cross Select 002
- Summary of Benefits - Capital Blue Cross Value 002
- Summary of Benefits - Capital Blue Cross Enhanced 002
- Summary of Benefits - Capital Blue Cross Complete 002
- Summary of Benefits - Capital Blue Cross Basic 002
- Evidence of Coverage - Capital Blue Cross Select 002
- Evidence of Coverage - Capital Blue Cross Value 002
- Evidence of Coverage - Capital Blue Cross Enhanced 002
- Evidence of Coverage - Capital Blue Cross Complete 002
- Evidence of Coverage - Capital Blue Cross Basic 002
003 - Berks, Lehigh, Northampton, Schuylkill Counties
- Annual Notice of Changes - Capital Blue Cross Select 003
- Annual Notice of Changes - Capital Blue Cross Value 003
- Annual Notice of Changes - Capital Blue Cross Enhanced 003
- Annual Notice of Changes - Capital Blue Cross Complete 003
- Summary of Benefits - Capital Blue Cross Select 003
- Summary of Benefits - Capital Blue Cross Value 003
- Summary of Benefits - Capital Blue Cross Enhanced 003
- Summary of Benefits - Capital Blue Cross Complete 003
- Summary of Benefits - Capital Blue Cross Basic 003
- Evidence of Coverage - Capital Blue Cross Select 003
- Evidence of Coverage - Capital Blue Cross Value 003
- Evidence of Coverage - Capital Blue Cross Enhanced 003
- Evidence of Coverage - Capital Blue Cross Complete 003
- Evidence of Coverage - Capital Blue Cross Basic 003
004 - Cumberland, Fulton, Lancaster, Lebanon Counties
- Annual Notice of Changes - Capital Blue Cross Select 004
- Annual Notice of Changes - Capital Blue Cross Select 004 (PREVIOUSLY CAPITAL BLUE CROSS | WELLSPAN HEALTH PLAN)
- Annual Notice of Changes - Capital Blue Cross Value 004
- Annual Notice of Changes - Capital Blue Cross Enhanced 004
- Annual Notice of Changes - Capital Blue Cross Complete 004
- Summary of Benefits - Capital Blue Cross Select 004
- Summary of Benefits - Capital Blue Cross Value 004
- Summary of Benefits - Capital Blue Cross Enhanced 004
- Summary of Benefits - Capital Blue Cross Complete 004
- Evidence of Coverage - Capital Blue Cross Select 004
- Evidence of Coverage - Capital Blue Cross Value 004
- Evidence of Coverage - Capital Blue Cross Enhanced 004
- Evidence of Coverage - Capital Blue Cross Complete 004
005 - Adams, Franklin, York Counties
- Annual Notice of Changes - Capital Blue Cross Value 005
- Annual Notice of Changes - Capital Blue Cross Complete 005
- Summary of Benefits - Capital Blue Cross Value 005
- Summary of Benefits - Capital Blue Cross Complete 005
- Summary of Benefits - Capital Blue Cross Basic 005
- Evidence of Coverage - Capital Blue Cross Value 005
- Evidence of Coverage - Capital Blue Cross Complete 005
- Evidence of Coverage - Capital Blue Cross Basic 005
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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 - July 2026:
Colorectal Cancer Screening Tests (210.3)
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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 10/2026)
- Download an Ideal Formulary (Spanish) listing. (updated 10/2026)
- 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 10/2026)
- Download a Classic Formulary (Spanish) listing. (updated 10/2026)
- 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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Medicare Prescription Payment Plan
Eligible members with Medicare Advantage plans that cover prescription drugs or a stand-alone Part D drug plan can use the Medicare Prescription Payment Plan to spread out the out-of-pocket costs of their covered Part D drugs into monthly payments.
You can enroll in the Medicare Prescription Payment Plan now for a January 1, 2026, start date, or at any time throughout the year. There are three easy ways to sign up:
Option 1: Register for a secure account, choose Medicare Prescription Payment Plan, and follow the steps.
Already have a secure account? Sign in, choose Medicare Prescription Payment Plan, and follow the steps.
Option 2: Call 833-247-0639 (TTY: 711),
- October 1 through December 7, seven days a week from 8:00 AM to 1:00 AM ET.
- December 8 through March 31, seven days a week from 8:00 AM to 11:00 PM ET.
- April 1 through September 30, Monday through Friday from 8:00 AM to 11:00 PM ET.
Option 3: Sign up by mail or fax. Download the enrollment form and mail or fax to:
Mail: Mailstop: 1001MPPP Election Dept.13900 N. Harvey AveEdmond, OK 73013
Fax: 440.557.6525
Capital Blue Cross is working with SimplicityRx1 for Medicare Prescription Payment Plan services. Most calls about the Medicare Prescription Payment Plan will be handled by this vendor on behalf of Capital Blue Cross. If you choose to receive email notifications, they will come from from SimplicityRx using this email address: noreplyrx@rxpayments.com.
Questions?
Check out the Medicare Prescription Payment Plan website or call 833-247-0639 (TTY: 711),
- October 1 through December 7, seven days a week from 8:00 AM to 1:00 AM ET.
- December 8 through March 31, seven days a week from 8:00 AM to 11:00 PM ET.
- April 1 through September 30, Monday through Friday from 8:00 AM to 11:00 PM ET.
1SimplicityRx is an independent company that provides Medicare Prescription Payment Plan services for Capital Blue Cross.
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Get the most out of your coverage today.
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Updated October 1, 2026
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