2027 Medicare Advantage plan

Capital Blue Cross Premier (HMO): 2027 benefits and costs

Capital Blue Cross HMO

CMS plan ID: H3962-001-0 · Plan year: 2027

Capital Blue Cross Premier (HMO) is a 2027 Medicare Advantage plan offered by Capital Blue Cross. It is listed in Pennsylvania.

2027 plan costs at a glance

Monthly plan premium$90.00

Drug deductible$350.00

In-network medical out-of-pocket maximum$5,000.00

Organization: Capital Blue Cross
Plan organization: KEYSTONE HEALTH PLAN CENTRAL, INC.
Parent company: CAPITAL BLUE CROSS
Plan type: HMO
Part C premium: $62.00
Part D premium: $28.00
Prescription drug coverage: Yes
2027 CMS Star Rating

Standard monthly Medicare Part B premium: $209.50 (estimated)

You must continue to pay your Medicare Part B premium.

In-network medical deductible: None
In-network medical maximum: $5,000.00
Applies to certain in-network supplemental services.

2027 benefit summary

Doctor visits and medical care

Common medical services and member costs
Service	In-network	What to know
Primary care doctor	$0.00 copay Service-specific deductible No
Specialist visit	$15.00 copay Service-specific deductible No	Approval required No Referral required No
Telehealth	$0.00 to $20.00 copay Service-specific deductible No	Approval required No Referral required No
Emergency care	$130.00 copay
Urgent care	$30.00 copay
Home health	$0.00 copay Service-specific deductible No	Approval required No Referral required No
Dialysis	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Part B chemotherapy and radiation drugs	0% to 20% coinsurance Deductible applies No	Approval required Yes
Other Part B drugs	0% to 20% coinsurance Deductible applies No	Approval required Yes
Kidney disease education services	$0.00 copay Service-specific deductible No	Approval required No Referral required No
Medicare-covered chiropractic	$15.00 copay Service-specific deductible No	Approval required No Referral required No
Medicare-covered foot care	$15.00 copay Service-specific deductible No	Approval required No Referral required No
Other health professionals	$15.00 copay Service-specific deductible No	Approval required No Referral required No

Hospital, outpatient surgery and observation care

Inpatient stays and skilled nursing care

In-network stays. Charges can depend on the number of days and the benefit period.
Care	Your share of the cost	What to know
Inpatient hospital stay	$0.00 copay per stay Days 1–5: $125.00 copay per day Days 6–90: $0.00 copay per day	Approval required Yes Referral required No Benefit period Per Admission or Per Stay
Inpatient mental health care	$0.00 copay per stay Days 1–5: $125.00 copay per day Days 6–90: $0.00 copay per day	Approval required Yes Referral required No Benefit period Per Admission or Per Stay
Skilled nursing facility	Days 1–20: $10.00 copay per day Days 21–100: $218.00 copay per day	Approval required Yes Referral required No Benefit period Original Medicare

See plan documents for out-of-network hospital and skilled nursing costs.

Hospital, outpatient surgery and observation care and member costs
Service	In-network	What to know
Outpatient hospital care	$0.00 to $250.00 copay Service-specific deductible No
Hospital observation services	$200.00 copay Service-specific deductible No
Ambulatory surgical center	$0.00 to $175.00 copay Service-specific deductible No	Approval required Yes Referral required No
Outpatient blood	$0.00 copay Service-specific deductible No	Approval required No Referral required No

Tests, imaging and laboratory services

Tests, imaging and laboratory services and member costs
Service	In-network	What to know
Diagnostic procedures and tests	$0.00 copay Service-specific deductible No	Approval required Yes Referral required No
Laboratory services	$0.00 to $100.00 copay Service-specific deductible No	Approval required Yes Referral required No
Diagnostic radiology (CT, MRI)	$0.00 to $100.00 copay Service-specific deductible No	Approval required Yes Referral required No
Therapeutic radiology	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
X-rays	$5.00 copay Service-specific deductible No	Approval required Yes Referral required No

Mental health and substance use treatment

Mental health and substance use treatment and member costs
Service	In-network	What to know
Partial hospitalization	$55.00 copay Service-specific deductible No	Approval required Yes Referral required No
Intensive outpatient program	$55.00 copay Service-specific deductible No	Approval required Yes Referral required No
Substance use treatment, individual sessions	$15.00 copay Service-specific deductible No	Approval required No Referral required No
Substance use treatment, group sessions	$15.00 copay Service-specific deductible No	Approval required No Referral required No
Opioid treatment program	$0.00 copay Service-specific deductible No	Approval required No Referral required No
Mental health, individual sessions	$15.00 copay Service-specific deductible No	Approval required No Referral required No
Mental health, group sessions	$15.00 copay Service-specific deductible No	Approval required No Referral required No
Psychiatry, individual sessions	$15.00 copay Service-specific deductible No	Approval required No Referral required No
Psychiatry, group sessions	$15.00 copay Service-specific deductible No	Approval required No Referral required No

Therapy and rehabilitation

Therapy and rehabilitation and member costs
Service	In-network	What to know
Occupational therapy	$15.00 copay Service-specific deductible No	Approval required No Referral required No
Physical and speech therapy	$15.00 copay Service-specific deductible No	Approval required No Referral required No
Cardiac rehabilitation	$20.00 copay Service-specific deductible No	Approval required No Referral required No
Intensive cardiac rehabilitation	$20.00 copay Service-specific deductible No	Approval required No Referral required No
Pulmonary rehabilitation	$15.00 copay Service-specific deductible No	Approval required No Referral required No
Supervised exercise for peripheral artery disease	$10.00 copay Service-specific deductible No	Approval required No Referral required No

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
Service	In-network	What to know
Ground ambulance	$125.00 copay Service-specific deductible No	Approval required Yes
Air ambulance	$125.00 copay Service-specific deductible No	Approval required Yes
Durable medical equipment	20% coinsurance Service-specific deductible No	Approval required Yes
Prosthetic devices	20% coinsurance Service-specific deductible No	Approval required Yes
Medical supplies	20% coinsurance Service-specific deductible No	Approval required Yes
Diabetic supplies	0% coinsurance Service-specific deductible No	Approval required Yes
Diabetic shoes and inserts	20% coinsurance Service-specific deductible No	Approval required Yes
Diabetic monitors	0% to 20% coinsurance Service-specific deductible No	Approval required Yes

Dental benefits

Dental benefits and member costs
Service	In-network	What to know
Medicare-covered dental	$15.00 copay
Oral examsAdditional plan benefit	Confirm with the plan (copay)
Dental X-raysAdditional plan benefit	Confirm with the plan (copay)
Other diagnostic dentalAdditional plan benefit	50% coinsurance
Dental cleaningAdditional plan benefit	Confirm with the plan (copay)
FluorideAdditional plan benefit	Confirm with the plan (copay)
Restorative dental careAdditional plan benefit	50% coinsurance
Root canal treatment (endodontics)Additional plan benefit	50% coinsurance
Gum treatment (periodontics)Additional plan benefit	50% coinsurance
Removable dentures (prosthodontics)Additional plan benefit	50% coinsurance
Fixed dental restorations (prosthodontics)Additional plan benefit	50% coinsurance
Oral surgeryAdditional plan benefit	50% coinsurance
Other dental servicesAdditional plan benefit	50% coinsurance

Vision benefits

Vision benefits and member costs
Service	In-network	What to know
Medicare-covered eye exams	$0.00 to $15.00 copay Service-specific deductible No	Approval required No Referral required No
Routine eye examsAdditional plan benefit	$0.00 copay	Approval required No Referral required No
Medicare-covered eyewear	$0.00 copay Service-specific deductible No	Approval required No Referral required No
Contact lensesAdditional plan benefit	$0	Approval required No Referral required No
Eyeglasses, lenses and framesAdditional plan benefit	$0	Approval required No Referral required No

Hearing benefits

Hearing benefits and member costs
Service	In-network	What to know
Medicare-covered hearing exams	$15.00 copay Service-specific deductible No	Approval required No Referral required No
Routine hearing examsAdditional plan benefit	$0	Approval required No Referral required No
Hearing aid fitting and evaluationAdditional plan benefit	$0	Approval required No Referral required No
Prescription hearing aids (all types)Additional plan benefit	$499.00 to $999.00 copay Service-specific deductible No	Approval required No Referral required No

Extra benefits

Extra benefits and member costs
Service	In-network	What to know
Over-the-counter health itemsAdditional plan benefit	$0 Service-specific deductible No
Annual physical examAdditional plan benefit	$0.00 copay Service-specific deductible No	Approval required No Referral required No
Fitness benefitAdditional plan benefit	$0 Service-specific deductible No	Approval required No Referral required No

Prescription drug coverage

Costs shown are for initial coverage.

Drug deductible exceptions: Tier 1; Tier 2 are exempt from the deductible.

Preferred retail costs

On a small screen, scroll the table sideways to compare all fill lengths.

Preferred retail: initial-coverage cost per prescription fill
Drug tier	30 days	60 days	100 days
Tier 1Preferred Generic	$0.00	$0.00	$0.00
Tier 2Generic	$0.00	$0.00	$0.00
Tier 3Preferred Brand	19%	19%	19%
Tier 4Non-Preferred Drug	20%	Not listed	Not listed
Tier 5Specialty Tier	29%	Not listed	Not listed

Standard retail costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard retail: initial-coverage cost per prescription fill
Drug tier	30 days	60 days	100 days
Tier 1Preferred Generic	$10.00	$20.00	$30.00
Tier 2Generic	$15.00	$30.00	$45.00
Tier 3Preferred Brand	19%	19%	19%
Tier 4Non-Preferred Drug	20%	Not listed	Not listed
Tier 5Specialty Tier	29%	Not listed	Not listed

Mail-order and other pharmacies

Out-of-network pricing: You pay the standard retail copay or coinsurance, plus any difference between the pharmacy’s billed charge and the amount the plan allows at a standard retail pharmacy.

Preferred mail order costs

On a small screen, scroll the table sideways to compare all fill lengths.

Preferred mail order: initial-coverage cost per prescription fill
Drug tier	30 days	60 days	100 days
Tier 1Preferred Generic	$0.00	$0.00	$0.00
Tier 2Generic	$0.00	$0.00	$0.00
Tier 3Preferred Brand	19%	19%	19%
Tier 4Non-Preferred Drug	20%	Not listed	Not listed
Tier 5Specialty Tier	29%	Not listed	Not listed

Standard mail order costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard mail order: initial-coverage cost per prescription fill
Drug tier	30 days	60 days	100 days
Tier 1Preferred Generic	$10.00	$20.00	$30.00
Tier 2Generic	$15.00	$30.00	$45.00
Tier 3Preferred Brand	19%	19%	19%
Tier 4Non-Preferred Drug	20%	Not listed	Not listed
Tier 5Specialty Tier	29%	Not listed	Not listed

Long-term care pharmacy costs

Long-term care pharmacy: initial-coverage cost per prescription fill
Drug tier	31 days
Tier 1Preferred Generic	$10.00
Tier 2Generic	$15.00
Tier 3Preferred Brand	19%
Tier 4Non-Preferred Drug	20%
Tier 5Specialty Tier	29%

Out-of-network pharmacy costs

Out-of-network pharmacy: initial-coverage cost per prescription fill
Drug tier	30 days
Tier 1Preferred Generic	$10.00
Tier 2Generic	$15.00
Tier 3Preferred Brand	19%
Tier 4Non-Preferred Drug	20%
Tier 5Specialty Tier	29%

Drug coverage rules and exceptions

Tier 1: Preferred Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 2: Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 3: Preferred Brand

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 4: Non-Preferred Drug

Drugs included in this tier: Part D Drugs Only

Tier 5: Specialty Tier

Drugs included in this tier: Part D Drugs Only

Initial-coverage prices also apply to drugs exempt from the deductible: Yes

Special cost protections apply to covered insulin and recommended adult vaccines.

Where this plan is offered

CMS lists this plan in 1 state or territory. Availability can vary by county and ZIP code.

View all locations 21 county listings across 1 state or territory