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Capital Blue Cross PPO

Choose a Capital Blue Cross PPO plan that meets your needs.

Office visits to your family doctor are covered at a low co-payment. We reimburse you for all medically necessary benefits. It may cost more to get care from out-of-network provides with the exception of emergency and urgent care.

Service Area	Select	Classic	Prime
	Enroll Online	Enroll Online	Enroll Online
Monthly premium	$0	$50	$172
In-network deductible	N/A	N/A	N/A
Maximum out-of-pocket (MOOP)	$7,000(in-network)/$11,300 (Combined in-network/out-of-network)	$6,700(in-network)/$10,000 (Combined in-network/out-of-network)	$5,000(in-network)/$10,000 (Combined in-network/out-of-network)
Doctor and hospital choice	In and out-of-network benefits, includes visitor/traveler benefits	In and out-of-network benefits, includes visitor/traveler benefits	In and out-of-network benefits, includes visitor/traveler benefits
Primary Care Physician office visits - in person or telehealth	$5 copay	$5 copay	$5 copay
Physician specialist - in person or telehealth	$40 copay	$30 copay	$25 copay
Urgent care	$50 copay	$45 copay	$35 copay
Inpatient hospital stay	$325 copay per stay	$240 per day for days 1-5	$125 per day for days 1-5
Outpatient Surgery	$350 copay	$300 copay	$225 copay
Ambulatory Surgical Center (ASC)	$350 copay	$225 copay	$125 copay
Emergency care	$90 copay	$90 copay	$90 copay
Lab services	$0-$25 copay/visit (in-network) 20% coinsurance (out-of-network)	$0-$20 copay/visit (in-network) 20% coinsurance (out-of-network)	$0-$20 copay/visit (in-network and out-of-network)
X-rays	$40 copay/visit (in-network) 20% coinsurance (out-of-network)	$25 copay visit (in-network) 20% coinsurance (out-of-network)	$20 copay/visit (in-network and out-of-network)
High-tech imaging (MRI/CT scan)	$275 copay/visit (in-network) 20% coinsurance (out-of-network)	$230 copay/visit (in-network) 20% coinsurance (out-of-network)	$125 copay/visit (in-network and out-of-network)
Diabetes self-monitoring training and supplies	$0 copay (in-network) 20% coinsurance (out-of-network)	$0 copay (in-network) 20% coinsurance (out-of-network)	$0 copay (in-network) 20% coinsurance (out-of-network)
Hearing services (routine fitting and exam)	$0 copay annual routine exam $0 copay fitting/3 years (in-network) 50% coinsurance (out-of-network)	$0 copay annual routine exam $0 copay fitting/3 years (in-network) 50% coinsurance (out-of-network)	$0 copay annual routine exam $0 copay fitting/3 years (in-network) 50% coinsurance (out-of-network)
Hearing aids	$800 allowance/3 years	$800 allowance/3 years	$800 allowance/3 years
Vision services routine exam (one annual exam)	$20 copay/visit (in-network) 50% coinsurance (out-of-network)	$20 copay/visit (in-network) 50% coinsurance (out-of-network)	$20 copay/visit (in-network) 50% coinsurance (out-of-network)
Vision services hardware allowance and contact lenses coverage¹	$125 allowance for eyeglass frames or contact lenses every year	$125 allowance for eyeglass frames or contact lenses every year	$125 allowance for eyeglass frames or contact lenses every year
Dental benefits	$10 copay(in-network) cleaning and X-rays covered, two cleanings per calendar year 50% coinsurance out-of-network for preventive 50% coinsurance combined in-network/out-of-network for nonroutine, restorative, endodontics, and non-surgical extractions services $2,000 annual allowance	$10 copay(in-network) cleaning and X-rays covered, two cleanings per calendar year 50% coinsurance out-of-network for preventive 50% coinsurance combined in-network/out-of-network for nonroutine, restorative, endodontics, and non-surgical extractions services $2,000 annual allowance	$10 copay(in-network) cleaning and X-rays covered, two cleanings per calendar year 50% coinsurance out-of-network for preventive 50% coinsurance combined in-network/out-of-network for nonroutine, restorative, endodontics, and non-surgical extractions services $2,000 annual allowance
SilverSneakers^®²	$0 copay	$0 copay	$0 copay
Flexible debit card for over-the-counter drugs and supplies (OTC)³	$25 per month retail or mail order (cannot be carried over from month to month)	$25 per month retail or mail order (cannot be carried over from month to month)	$25 per month retail or mail order (cannot be carried over from month to month)