Web Content Viewer - Metadata

Web Content Viewer - Fixed Context

Capital Blue Cross HMO

Select a Capital Blue Cross HMO plan that meets your needs.

Service area	Essential	Value	Premier
	Enroll Online	Enroll Online	Enroll Online
Monthly premium	$0	$60	$116
In-network deductible	N/A	N/A	N/A
Maximum out-of-pocket (MOOP)	$7,500	$5,000	$4,500
Primary Care Physician Office Visits - in person or telehealth	$5 copay	$5 copay	$5 copay
Physician specialist - in person or telehealth	$35 copay	$30 copay	$20 copay
Urgent care	$40 copay	$50 copay	$30 copay
Inpatient hospital stay	$200 per day for days 1-8	$150 per day for days 1-5	$100 per day for days 1-5
Outpatient Surgery	$375 copay	$300 copay	$225 copay
Ambulatory Surgical Center (ASC)	$275 copay	$200 copay	$75 copay
Emergency care	$90 copay	$90 copay	$90 copay
Lab services	$0-$25 copay/visit	$0-$20 copay/visit	$0-$20 copay/visit
X-rays	$50 copay	$25 copay	$25 copay
High-tech imaging (MRI/CT scan)	$250 copay	$150 copay	$75 copay
Diabetes self-monitoring training and supplies	$0 copay	$0 copay	$0 copay
Hearing services (routine fitting and exam)	$0 copay for routine exam $0 copay fitting/3 years	$0 copay for routine exam $0 copay fitting/3 years	$0 copay for routine exam $0 copay fitting/3 years
Hearing aids	$800 allowance/3 years	$800 allowance/3 years	$800 allowance/3 years
Expanded dental benefits (two cleanings per calendar year)	$10 copay in-network cleaning and X-rays covered, 50% coinsurance for nonroutine, restorative, endodontics, and simple extractions services $2,000 annual allowance	$10 copay in-network cleaning and X-rays covered, 50% coinsurance for nonroutine, restorative, endodontics, and simple extractions services $2,000 annual allowance	$10 copay in-network cleaning and X-rays covered, 50% coinsurance for nonroutine, restorative, endodontics, and simple extractions services $2,000 annual allowance
SilverSneakers^®¹	$0 copay	$0 copay	$0 copay
Flexible debit card for over-the-counter drugs and supplies (OTC)²	$25 monthly allowance retail or mail order (cannot be carried over from month to month)	$25 monthly allowance retail or mail order (cannot be carried over from month to month)	$25 monthly allowance retail or mail order (cannot be carried over from month to month)
Vision services hardware allowance and contact lenses coverage	$125 allowance for eyeglass frames or contact lenses every year³	$125 allowance for eyeglass frames or contact lenses every year³	$125 allowance for eyeglass frames or contact lenses every year³
Routine vision(one annual eye exam)	$20 copay	$20 copay	$20 copay

Web Content Viewer - Fixed Context

Plan Info

Web Content Viewer - Fixed Context

Annual Notice of Changes - Capital Blue Cross Essential Plan

Annual Notice of Changes - BlueJourney Premier Plan

Annual Notice of Changes - BlueJourney Value Plan

Evidence of Coverage - Capital Blue Cross Essential Plan

Evidence of Coverage - BlueJourney Premier Plan

Evidence of Coverage - BlueJourney Value Plan

Summary of Benefits - Capital Blue Cross Essential Plan

Summary of Benefits - BlueJourney Premier Plan

Summary of Benefits - BlueJourney Value Plan

Out-of-Network Coverage Rules

Web Content Viewer - Fixed Context

Must use a SilverSneakers^® facility.

Qualifying OTC retailers: Walmart, Rite Aid, CVS, and Walgreens.

Members pay the balance of charges after a $125 routine vision allowance is applied. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.

Web Content Viewer - Fixed Context

Updated October 1, 2025

Y0016_26WBST_M