Capital Blue Cross | WellSpan Health AdvantagePlus (PPO)
H3923 - 030 - 0
(4.5 / 5)
Capital Blue Cross | WellSpan Health AdvantagePlus (PPO) is a Medicare Advantage (Part C) Plan by Capital Blue Cross.
This page features plan details for 2023 Capital Blue Cross | WellSpan Health AdvantagePlus (PPO) H3923 – 030 – 0 available in 7 County South Central PA.
IMPORTANT: This page features the 2023 version of this plan. See the 2024 version using the link below:
Locations
Capital Blue Cross | WellSpan Health AdvantagePlus (PPO) is offered in the following locations.
Plan Overview
Capital Blue Cross | WellSpan Health AdvantagePlus (PPO) offers the following coverage and cost-sharing.
| Insurer: | Capital Blue Cross |
| Health Plan Deductible: | $0.00 |
| MOOP: | $5,900 In and Out-of-network $5,900 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Capital Blue Cross | WellSpan Health AdvantagePlus (PPO) ?
Premium Breakdown
Capital Blue Cross | WellSpan Health AdvantagePlus (PPO) has a monthly premium of $19.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $164.90 | $0.00 | $19.00 | $0.00 | $183.90 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Capital Blue Cross | WellSpan Health AdvantagePlus (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $4,660.00 |
| Catastrophic Coverage Limit: | $7,400.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | No |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $19.00 | $43.40 | $34.80 | $26.30 | $17.70 |
Initial Coverage Phase
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $10.00 copay | $0.00 copay | |
| 2 (Generic) | $0.00 copay | $20.00 copay | $0.00 copay | |
| 3 (Preferred Brand) | $40.00 copay | $47.00 copay | $40.00 copay | |
| 4 (Non-Preferred Drug) | $93.00 copay | $100.00 copay | $93.00 copay | |
| 5 (Specialty Tier) | 33% | 33% | 33% |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $30.00 copay | $0.00 copay | |
| 2 (Generic) | $0.00 copay | $60.00 copay | $0.00 copay | |
| 3 (Preferred Brand) | $120.00 copay | $141.00 copay | $120.00 copay | |
| 4 (Non-Preferred Drug) | $279.00 copay | $300.00 copay | $279.00 copay | |
| 5 (Specialty Tier) |
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.
30 Day
90 Day
30 Day
90 Day
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | $4.15 copay or 5% (whichever costs more) |
| Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
Capital Blue Cross | WellSpan Health AdvantagePlus (PPO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | In-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Diagnostic services: | Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Endodontics: | In-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Endodontics: | Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Extractions: | In-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Extractions: | Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Non-routine services: | In-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Non-routine services: | Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Periodontics: | In-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Periodontics: | Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | In-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Restorative services: | In-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Restorative services: | Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
Dental (preventive)
| Cleaning: | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
| Fluoride treatment: | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
| Office visit: | In-Network: $10.00 (authorization not required) (referral not required) |
| Office visit: | Out-of-Network: 50% coinsurance (authorization not required) (referral not required) |
| Oral exam: | Covered under office visit (limits may apply) (authorization not required) (referral not required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | In-Network: $180 copay (authorization required) (referral not required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: 20% coinsurance (authorization required) (referral not required) |
| Diagnostic tests and procedures: | In-Network: $0-20 copay (authorization required) (referral not required) |
| Diagnostic tests and procedures: | Out-of-Network: 20% coinsurance (authorization required) (referral not required) |
| Lab services: | In-Network: $0-20 copay (authorization required) (referral not required) |
| Lab services: | Out-of-Network: 20% coinsurance (authorization required) (referral not required) |
| Outpatient x-rays: | In-Network: $20 copay (authorization required) (referral not required) |
| Outpatient x-rays: | Out-of-Network: 20% coinsurance (authorization required) (referral not required) |
Doctor visits
| Primary: | In-Network: $0 copay |
| Primary: | Out-of-Network: $5 copay per visit |
| Specialist: | In-Network: $25 copay per visit (authorization not required) (referral not required) |
| Specialist: | Out-of-Network: $25 copay per visit (authorization not required) (referral not required) |
Emergency care/Urgent care
| Emergency: | $100 copay per visit (always covered) |
| Urgent care: | $50 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | In-Network: $25 copay (authorization not required) (referral not required) |
| Foot exams and treatment: | Out-of-Network: $25 copay (authorization not required) (referral not required) |
| Routine foot care: | In-Network: $25 copay (limits may apply) (authorization not required) (referral not required) |
| Routine foot care: | Out-of-Network: $25 copay (limits may apply) (authorization not required) (referral not required) |
Ground ambulance
| In-Network: $250 copay | |
| Out-of-Network: $250 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Fitting/evaluation: | Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Hearing aids: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing aids: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing exam: | In-Network: $25 copay (authorization not required) (referral not required) |
| Hearing exam: | Out-of-Network: $25 copay (authorization not required) (referral not required) |
Hospital coverage (inpatient)
| In-Network: $275 per stay (authorization required) (referral not required) | |
| Out-of-Network: $275 per stay (authorization required) (referral not required) |
Hospital coverage (outpatient)
| In-Network: $0-275 copay per visit (authorization required) (referral not required) | |
| Out-of-Network: $0-275 copay per visit (authorization required) (referral not required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $5,900 In and Out-of-network $5,900 In-network |
Medical equipment/supplies
| Diabetes supplies: | In-Network: $0 copay per item (authorization not required) |
| Diabetes supplies: | Out-of-Network: 20% coinsurance per item (authorization not required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 20% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | In-Network: 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
| Chemotherapy: | Out-of-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | Out-of-Network: 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | In-Network: $275 per stay (authorization required) (referral not required) |
| Inpatient hospital – psychiatric: | Out-of-Network: $275 per stay (authorization required) (referral not required) |
| Outpatient group therapy visit: | In-Network: $25 copay (authorization not required) (referral not required) |
| Outpatient group therapy visit: | Out-of-Network: $25 copay (authorization not required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | In-Network: $25 copay (authorization not required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | Out-of-Network: $25 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit: | In-Network: $25 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit: | Out-of-Network: $25 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | In-Network: $25 copay (authorization not required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: $25 copay (authorization not required) (referral not required) |
Optional supplemental benefits
| No |
Preventive care
| In-Network: $0 copay (authorization not required) (referral not required) | |
| Out-of-Network: 20% coinsurance (authorization not required) (referral not required) |
Rehabilitation services
| Occupational therapy visit: | In-Network: $25 copay (authorization required) (referral not required) |
| Occupational therapy visit: | Out-of-Network: $25 copay (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | In-Network: $25 copay (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: $25 copay (authorization required) (referral not required) |
Skilled Nursing Facility
| In-Network: $0 per day for days 1 through 20 $196 per day for days 21 through 100 (authorization required) (referral not required) | |
| Out-of-Network: $0 per day for days 1 through 20 $196 per day for days 21 through 100 (authorization required) (referral not required) |
Transportation
| In-Network: $0 copay (limits may apply) (authorization required) (referral not required) | |
| Out-of-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
Vision
| Contact lenses: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Contact lenses: | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass frames: | Not covered (no limits) |
| Eyeglass lenses: | Not covered (no limits) |
| Eyeglasses (frames and lenses): | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglasses (frames and lenses): | Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Other: | Not covered (no limits) |
| Routine eye exam: | In-Network: $0 copay (limits may apply) (authorization not required) (referral not required) |
| Routine eye exam: | Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral not required) |
Ready to sign up for Capital Blue Cross | WellSpan Health AdvantagePlus (PPO) ?