Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company^®, Capital Advantage Assurance Company^® and Keystone Health Plan^® Central. Independent licensees of the BlueCross BlueShield Association serving 21 counties in Central Pennsylvania and the Lehigh Valley. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

© 2025 Capital BlueCross All Rights Reserved.

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Plan documents

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2025 plan year

HMO plans (Available in 21 counties)

Bronze HMO 7450/0/50

Benefit contracts

Summary of benefits and coverage (SBCs)

Highlight sheet

Off Pennie- English

Off Pennie- Spanish

Off Pennie- English

Off Pennie- Spanish

Catastrophic HMO 9200/0/0

Benefit contracts

Summary of benefits and coverage (SBCs)

Highlight sheet

Off Pennie- English

Off Pennie- Spanish

Off Pennie- English

Off Pennie- Spanish

PPO Plans (Available in all Capital counties except Lancaster)

Gold Simple PPO 0/0/25

Benefit contracts

Summary of benefits and coverage (SBCs)

Highlight sheet

On/Off Pennie- English

On/Off Pennie- English

On/Off Pennie- Spanish

On/Off Pennie- Spanish

Gold QHDHP PPO 1700/0/10

Benefit contracts

Summary of benefits and coverage (SBCs)

Highlight sheet

Off Pennie- English

Off Pennie- English

Off Pennie- Spanish

Off Pennie- Spanish

Gold PPO 1800/10/20

Benefit contracts

Summary of benefits and coverage (SBCs)

Highlight sheet

On/Off Pennie- English

On/Off Pennie- English

On/Off Pennie- Spanish

On/Off Pennie- Spanish

Gold PPO 2300/10/20

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	On/Off Pennie- English	On/Off Pennie- English
On Pennie	On/Off Pennie- Spanish	On/Off Pennie- Spanish

Silver QHDHP PPO 2900/10/40

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	Off Pennie- English	Off Pennie- English
	Off Pennie- Spanish	Off Pennie- Spanish

Silver PPO 3450/0/40 RX 250

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	Off Pennie- English	Off Pennie- English
	Off Pennie- Spanish	Off Pennie- Spanish

Silver PPO 3500/0/40 RX 250

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	On/Off Pennie- English	On/Off Pennie- English
On Pennie	On/Off Pennie- Spanish	On/Off Pennie- Spanish
On Pennie 3400/0/30 Rx 200 73% CSR	On Pennie 3400/0/30 Rx 200 73% CSR- English On Pennie 3400/0/30 Rx 200 73% CSR- Spanish	On Pennie 3400/0/30 Rx 200 73% CSR- English On Pennie 3400/0/30 Rx 200 73% CSR- Spanish
On Pennie 1400/0/5 Rx 150 87% CSR	On Pennie 1400/0/5 Rx 150 87% CSR- English On Pennie 1400/0/5 Rx 150 87% CSR- Spanish	On Pennie 1400/0/5 Rx 150 87% CSR- English On Pennie 1400/0/5 Rx 150 87% CSR- Spanish
On Pennie 450/0/3 Rx 100 94% CSR	On Pennie 450/0/3 Rx 100 94% CSR- English On Pennie 450/0/3 Rx 100 94% CSR- Spanish	On Pennie 450/0/3 Rx 100 94% CSR- English On Pennie 450/0/3 Rx 100 94% CSR- Spanish

Bronze QHDHP PPO 6400/0/50

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	On/Off Pennie- English	On/Off Pennie- English
On Pennie	On/Off Pennie- Spanish	On/Off Pennie- Spanish

Bronze PPO 7450/0/50

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	On/Off Pennie- English	On/Off Pennie- English
On Pennie	On/Off Pennie- Spanish	On/Off Pennie- Spanish

Catastrophic PPO 9200/0/0

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	On/Off Pennie- English	On/Off Pennie- English
On Pennie	On/Off Pennie- Spanish	On/Off Pennie- Spanish

Zero/Limited Plans (on Pennie)

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
PPO Zero/Limited CSR	PPO Zero/Limited CSR- English	PPO Zero/Limited CSR- English
	PPO Zero/Limited CSR- Spanish	PPO Zero/Limited CSR- Spanish

PPO Choice (Available in Lancaster county)

Gold QHDHP PPO Choice 1700/0/10

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	Off Pennie- English	Off Pennie- English
	Off Pennie- Spanish	Off Pennie- Spanish

Gold PPO Choice 1800/0/25

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	On/Off Pennie- English	On/Off Pennie- English
On Pennie	On/Off Pennie- Spanish	On/Off Pennie- Spanish

Gold PPO Choice 2400/0/25

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	On/Off Pennie- English	On/Off Pennie- English
On Pennie	On/Off Pennie- Spanish	On/Off Pennie- Spanish

Silver QHDHP PPO Choice 3000/10/35

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	Off Pennie- English	Off Pennie- English
	Off Pennie- Spanish	Off Pennie- Spanish

Silver PPO Choice 4450/20/35

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	Off Pennie- English	Off Pennie- English
	Off Pennie- Spanish	Off Pennie- Spanish

Silver PPO Choice 4500/20/35

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	On/Off Pennie- English	On/Off Pennie- English
On Pennie	On/Off Pennie- Spanish	On/Off Pennie- Spanish
On Pennie 4000/15/25 73% CSR	On Pennie 4000/15/25 73% CSR- English On Pennie 4000/15/25 73% CSR- Spanish	On Pennie 4000/15/25 73% CSR- English On Pennie 4000/15/25 73% CSR- Spanish
On Pennie 1200/0/15 87% CSR	On Pennie 1200/0/15 87% CSR- English On Pennie 1200/0/15 87% CSR- spanish	On Pennie 1200/0/15 87% CSR- English On Pennie 1200/0/15 87% CSR- spanish
On Pennie 475/0/5 94% CSR	On Pennie 475/0/5 94% CSR- English On Pennie 475/0/5 94% CSR- Spanish	On Pennie 475/0/5 94% CSR- English On Pennie 475/0/5 94% CSR- Spanish

Bronze QHDHP PPO Choice 6400/0/50

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	On/Off Pennie- English	On/Off Pennie- English
On Pennie	On/Off Pennie- Spanish	Off/On Pennie- Spanish

Bronze PPO Choice 7100/0/50

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	On/Off Pennie- English	On/Off Pennie- English
On Pennie	Off/On Pennie- Spanish	Off/On Pennie- Spanish

Zero/Limited Plans (on Pennie)

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
PPO Choice Zero/Limited CSR	PPO Choice Zero/Limited CSR- English	PPO Choice Zero/Limited CSR- English
	PPO Choice Zero/Limited CSR- Spanish	PPO Choice Zero/Limited CSR- Spanish

PPO Choice Select (Available in Cumberland, Dauphin, and Perry counties)

Gold PPO Choice Select 1800/0/25

Benefit contracts

Summary of benefits and coverage (SBCs)

Highlight sheet

On/Off Pennie- English

On/Off Pennie- English

On/Off Pennie- Spanish

On/Off Pennie- Spanish

Gold PPO Choice Select 2400/0/25

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	On/Off Pennie- English	On/Off Pennie- English
On Pennie	On/Off Pennie- Spanish	On/Off Pennie- Spanish

Silver PPO Choice Select 4450/20/35

Benefit contracts

Summary of benefits and coverage (SBCs)

Highlight sheet

Off Pennie- English

Off Pennie- English

On/Off Pennie- Spanish

On/Off Pennie- Spanish

Silver PPO Choice Select 4500/20/35

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	On/Off Pennie- English	On/Off Pennie- English
On Pennie	On/Off Pennie- Spanish	On/Off Pennie- Spanish
On Pennie 4000/15/25 73% CSR	On Pennie 4000/15/25 73% CSR- English On Pennie 4000/15/25 73% CSR- Spanish	On Pennie 4000/15/25 73% CSR- English On Pennie 4000/15/25 73% CSR- Spanish
On Pennie 1200/0/15 87% CSR	On Pennie 1200/0/15 87% CSR- English On Pennie 1200/0/15 87% CSR- Spanish	On Pennie 1200/0/15 87% CSR- English On Pennie 1200/0/15 87% CSR- Spanish
On Pennie 475/0/5 94% CSR	On Pennie 475/0/5 94% CSR- English On Pennie 475/0/5 94% CSR- Spanish	On Pennie 475/0/5 94% CSR- English On Pennie 475/0/5 94% CSR- Spanish

Bronze PPO Choice Select 7100/0/50

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	On/Off Pennie- English	On/Off Pennie- English
On Pennie	On/Off Pennie- Spanish	On/Off Pennie- Spanish

Zero/Limited Plans (on Pennie)

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
PPO Choice Select Zero/Limited CSR	PPO Choice Select Zero/Limited CSR- English	PPO Choice Select Zero/Limited CSR- English
	PPO Choice Select Zero/Limited CSR- Spanish	PPO Choice Select Zero/Limited CSR- Spanish

Performance PPO (Available in Adams, Franklin, Lebanon, Lehigh, Northampton and York counties)

Gold Performance PPO 1800/0/25

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	On/Off Pennie- English	On/Off Pennie-English
On Pennie	On/Off Pennie- Spanish	On/Off Pennie- Spanish

Gold Performance PPO 2400/0/25

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	On/Off Pennie- English	On/Off Pennie- English
On Pennie	On/Off Pennie- Spanish	On/Off Pennie- Spanish

Silver Performance PPO 4450/20/35

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	Off Pennie- English	Off Pennie- English
	Off Pennie- Spanish	Off Pennie- Spanish

Silver Performance PPO 4500/20/35

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	On/Off Pennie- English	On/Off Pennie- English
On Pennie	On/Off Pennie- Spanish	On/Off Pennie- Spanish
On Pennie 4000/15/25 73% CSR	On Pennie 4000/15/25 73% CSR- English On Pennie 4000/15/25 73% CSR- Spanish	On Pennie 4000/15/25 73% CSR- English On Pennie 4000/15/25 73% CSR- Spanish
On Pennie 1200/0/15 87% CSR	On Pennie 1200/0/15 87% CSR- English On Pennie 1200/0/15 87% CSR- Spanish	On Pennie 1200/0/15 87% CSR- English On Pennie 1200/0/15 87% CSR- Spanish
On Pennie 475/0/5 94% CSR	On Pennie 475/0/5 94% CSR- English On Pennie 475/0/5 94% CSR- Spanish	On Pennie 475/0/5 94% CSR- English On Pennie 475/0/5 94% CSR- Spanish

Bronze Performance PPO 7100/0/50

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Off Pennie	On/Off Pennie- English	On/Off Pennie-English
On Pennie	On/Off Pennie- Spanish	On/Off Pennie- Spanish

Zero/Limited Plans (on Pennie)

Benefit contracts	Summary of benefits and coverage (SBCs)	Highlight sheet
Performance PPO Zero/Limited CSR	Performance PPO Zero/Limited CSR- English	Performance PPO Zero/Limited CSR- English
	Performance PPO Zero/Limited CSR- Spanish	Performance PPO Zero/Limited CSR- Spanish

Dental Plans (Available in all 21 counties)

Highlight sheet
Dental Select Basic
Dental PPO Loyalty Plan
Dental PPO Care Plan
Dental PPO Standard Plan
Dental PPO Premium Plan
Dental PPO Preventive Plan

Vision Plans (Available in all 21 counties)

Highlight sheet
Vision Essential Plan

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