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2027 Benefit Information for Members
View and download information for your 2027 plan through December 31, 2027.
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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 Premier Plan
- Summary of Benefits - Capital Blue Cross Premier 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
- Annual Notice of Changes - Capital Blue Cross Value Plan 001
- Summary of Benefits - Capital Blue Cross Essential Plan 001
- Summary of Benefits - Capital Blue Value Plan 001
- Evidence of coverage - Capital Blue Cross Essential Plan 001
- Evidence of coverage - Capital Blue Cross Value Plan 001
002 - Columbia, Montour, Northumberland, Snyder, Union Counties
- Annual Notice of Changes - Capital Blue Cross Essential Plan 002
- Annual Notice of Changes - Capital Blue Cross Value Plan 002
- Summary of Benefits - Capital Blue Cross Essential Plan 002
- Summary of Benefits - Capital Blue Cross Value Plan 002
- Evidence of coverage - Capital Blue Cross Essential Plan 002
- Evidence of coverage - Capital Blue Cross Value Plan 002
003 - Berks, Lehigh, Northampton, Schuylkill Counties
- Annual Notice of Changes - Capital Blue Cross Essential Plan 003
- Annual Notice of Changes - Capital Blue Cross Value Plan 003
- Summary of Benefits - Capital Blue Cross Essential Plan 003
- Summary of Benefits - Capital Blue Cross Value Plan 003
- Evidence of coverage - Capital Blue Cross Essential Plan 003
- Evidence of coverage - Capital Blue Cross Value 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 Value Plan 004
- Summary of Benefits - Capital Blue Cross Essential Plan 004
- Summary of Benefits - Capital Blue Cross Value Plan 004
- Evidence of coverage - Capital Blue Cross Essential Plan 004
- Evidence of coverage - Capital Blue Cross Value Plan 004
005 - Adams, Franklin, York Counties
- Annual Notice of Changes - Capital Blue Cross Essential Plan 005
- Annual Notice of Changes - Capital Blue Cross Value Plan 005
- Summary of Benefits - Capital Blue Cross Essential Plan
- Summary of Benefits - Capital Blue Cross Value Plan 005
- Evidence of coverage - Capital Blue Cross Essential Plan 005
- Evidence of coverage - Capital Blue Cross Value Plan 005
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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
- Summary of Benefits - Capital Blue Cross Basic 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
- Evidence of Coverage - Capital Blue Cross Basic 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
- Annual Notice of Changes - Capital Blue Cross Basic 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
Capital Blue Cross Enhanced PPO only offered in Berks and Lehigh 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
- Annual Notice of Changes - Capital Blue Cross Basic 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 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
- Summary of Benefits - Capital Blue Cross Basic 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
- Evidence of Coverage - Capital Blue Cross Basic 004
005 - Adams, Franklin, York Counties
- Annual Notice of Changes - Capital Blue Cross Value 005
- Annual Notice of Changes - Capital Blue Cross Basic 005
- Summary of Benefits - Capital Blue Cross Value 005
- Summary of Benefits - Capital Blue Cross Basic 005
- Evidence of Coverage - Capital Blue Cross Value 005
- Evidence of Coverage - Capital Blue Cross Basic 005
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Standard Employer Group Sponsored Health Plan Documents
Standard PPO Option A
- Annual Notice of Changes - Capital Blue Cross Standard Group A PPO
- Evidence of Coverage - Capital Blue Cross Standard Group A PPO
Standard PPO Option B
- Annual Notice of Changes - Capital Blue Cross Standard Group B PPO
- Evidence of Coverage - Capital Blue Cross Standard Group B PPO
Standard HMO Option A
- Annual Notice of Changes - Capital Blue Cross Standard Group A HMO
- Evidence of Coverage - Capital Blue Cross Standard Group A HMO
Standard HMO Option B
- Annual Notice of Changes - Capital Blue Cross Standard Group B HMO
- Evidence of Coverage - Capital Blue Cross Standard Group B HMO
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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
- Over-the-counter catalog
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Get the most out of your coverage today.
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Updated October 1, 2026
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