Plan documents
If you’re a Capital Blue Cross member, log in to see the the benefit contracts for your plan.
2027 plan year
HMO plans (Available in 21 counties)
Bronze HMO 7450/0/60 + HSA
| Subscriber agreement | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
PPO plans (Available in all Capital counties except Lancaster)
Benefit contract samples
|
Off Pennie - HSA (applies to: Gold PPO 2000/0/10 + HSA, Silver PPO 3200/10/40 + HSA, Bronze PPO 6500/0/50 + HSA) |
|
|
On Pennie - HSA (applies to: Bronze PPO 6500/0/50 + HSA) |
Gold PPO 0/10/40
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Gold Simple PPO 0/0/30
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Gold PPO 2000/0/10 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Gold PPO 1500/10/20
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Gold PPO 2300/10/25
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver PPO 3200/10/40 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver PPO 3950/0/45 Rx 250
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver PPO 4000/0/45 Rx 250
Bronze PPO 6500/0/50 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze PPO 7450/0/60 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze PPO 10000/0/75 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Zero/Limited Plans (on Pennie)
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Advance PPO (Available in Lancaster county)
Benefit contract samples
|
Off Pennie - HSA (applies to: Gold Advance PPO 2000/0/10 + HSA, Silver Advance PPO 3300/10/50 + HSA, Bronze Advance PPO 6600/0/50 + HSA) |
|
|
On Pennie - HSA (applies to: Bronze Advance PPO 6600/0/50 + HSA) |
Gold Advance PPO 2000/0/10 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Gold Advance PPO 1700/0/25
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Gold Advance PPO 2700/0/30
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver Advance PPO 3300/10/50 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver Advance PPO 4450/20/35
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver Advance PPO 4500/20/35
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
|
On Pennie 4100/15/25 73% CSR- English On Pennie 4100/15/25 73% CSR- Spanish On Pennie 1300/0/15 87% CSR- English On Pennie 1300/0/15 87% CSR- Spanish |
On Pennie 4100/15/25 73% CSR- English On Pennie 4100/15/25 73% CSR- Spanish On Pennie 1300/0/15 87% CSR- English On Pennie 1300/0/15 87% CSR- Spanish |
Bronze Advance PPO 6600/0/50 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze Advance PPO 7200/0/50 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze Advance PPO 9000/0/75 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Zero/Limited Plans (on Pennie)
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Capital Advantage PPO (Available in Cumberland, Dauphin, and Perry counties)
Benefit contract samples
|
Off Pennie HSA– (applies to: Gold Capital Advantage PPO 2000/0/10 + HSA, Bronze Capital Advantage PPO 6600/0/50 + HSA) |
|
|
On Pennie HSA Bronze Capital Advantage PPO 6600/0/50 + HSA) |
Gold Capital Advantage PPO 2000/0/10 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Gold Capital Advantage PPO 1700/0/25
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Gold Capital Advantage PPO 2700/0/30
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver Capital Advantage PPO 4450/20/35
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver Capital Advantage PPO 4500/20/35
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
|
On Pennie 4100/15/25 73% CSR- English On Pennie 4100/15/25 73% CSR- Spanish On Pennie 1300/0/15 87% CSR- English On Pennie 1300/0/15 87% CSR- Spanish |
On Pennie 4100/15/25 73% CSR- English On Pennie 4100/15/25 73% CSR- Spanish On Pennie 1300/0/15 87% CSR- English On Pennie 1300/0/15 87% CSR- Spanish |
Bronze Capital Advantage PPO 6600/0/50 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze Capital Advantage PPO 7200/0/50 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze Capital Advantage PPO 9000/0/75 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Zero/Limited Plans (on Pennie)
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Convenience PPO (Available in Adams, Franklin, Lebanon, Lehigh, Northampton and York counties)
Benefit contract samples
|
Off Pennie - HSA (applies to: Gold Convenience PPO 2000/0/10 + HSA, Bronze Convenience PPO 6600/0/50 + HSA) |
|
|
On Pennie - HSA (applies to: Bronze Convenience PPO 6600/0/50 + HSA) |
Gold Convenience PPO 2000/0/10 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Gold Convenience PPO 1700/0/25
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Gold Convenience PPO 2700/0/30
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver Convenience PPO 4450/20/35
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver Convenience PPO 4500/20/35
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
|
On Pennie 4100/15/25 73% CSR- English On Pennie 4100/15/25 73% CSR- Spanish On Pennie 1300/0/15 87% CSR- English On Pennie 1300/0/15 87% CSR- Spanish |
On Pennie 4100/15/25 73% CSR- English On Pennie 4100/15/25 73% CSR- Spanish On Pennie 1300/0/15 87% CSR- English On Pennie 1300/0/15 87% CSR- Spanish |
Bronze Convenience PPO 6600/0/50 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze Convenience PPO 7200/0/50 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze Convenience PPO 9000/0/75 + HSA
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Zero/Limited Plans (on Pennie)
| Outline of coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Dental plans (Available in all 21 counties)
Vision plans (Available in all 21 counties)
| Highlight sheet |
|---|
2026 plan year
HMO plans (Available in 21 counties)
Bronze HMO 7450/0/60
| Subscriber Agreement | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
PPO plans (Available in all Capital counties except Lancaster)
Benefit Contract Samples |
||
|---|---|---|
|
|
||
|
|
||
Gold Simple PPO 0/0/25
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Gold QHDHP PPO 1800/0/10
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Gold PPO 1800/10/20
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Gold PPO 2900/10/30
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver QHDHP PPO 3000/10/40
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver PPO 3450/0/40 Rx 250
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver PPO 3500/0/40 Rx 250
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze QHDHP PPO 6400/0/50
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze PPO 7450/0/60
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze PPO 10000/0/60
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Zero/Limited Plans (on Pennie)
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Advance PPO (Available in Lancaster county)
Benefit Contract Samples |
||
|---|---|---|
|
Off Pennie – HSA (applies to: Gold Advance PPO 2000/0/10 + HSA, Silver Advance PPO 3300/10/50 + HSA, Bronze Advance PPO 6600/0/50 + HSA) |
|
|
|
On Pennie – HSA (applies to: Bronze Advance PPO 6600/0/50 + HSA) |
|
|
Gold QHDHP Advance PPO 1800/0/10
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Gold Advance PPO 1800/0/25
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Gold Advance PPO 3000/0/30
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver QHDHP Advance PPO 3000/10/35
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver Advance PPO 4450/20/35
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver Advance PPO 4500/20/35
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze QHDHP Advance PPO 6400/0/50
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze Advance PPO 7100/0/50
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze Advance PPO 9000/0/75
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Zero/Limited Plans (on Pennie)
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Capital Advantage PPO (Available in Cumberland, Dauphin, and Perry counties)
Benefit Contract Samples |
||
|---|---|---|
|
|
|
|
|
|
|
|
Gold Capital Advantage PPO 1800/0/25
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Gold Capital Advantage PPO 3000/0/30
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver Capital Advantage PPO 4450/20/35
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver Capital Advantage PPO 4500/20/35
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze Capital Advantage PPO 7100/0/50
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze Capital Advantage PPO 9000/0/75
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Zero/Limited Plans (on Pennie)
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Convenience PPO (Available in Adams, Franklin, Lebanon, Lehigh, Northampton and York Counties)
Benefit Contract Samples |
||
|---|---|---|
|
|
|
|
|
|
|
|
Gold Convenience PPO 1800/0/25
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Gold Convenience PPO 3000/0/30
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver Convenience PPO 4450/20/35
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Silver Convenience PPO 4500/20/35
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze Convenience PPO 7100/0/50
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Bronze Convenience PPO 9000/0/75
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Zero/Limited Plans (on Pennie)
| Outline of Coverage (OOC) | Summary of benefits and coverage (SBCs) | Highlight sheet |
|---|---|---|
Dental plans (Available in all 21 counties)
Vision plans (Available in all 21 counties)
| Highlight sheet |
|---|