Capital Blue Cross Value (HMO) (HMO) 2025 Plan Details for York County, Pennsylvania Residents
Capital Blue Cross Value (HMO) (HMO) 2025 Plan Details for York County, Pennsylvania Residents
Capital Blue Cross Value (HMO) is a HMO Medicare Advantage plan, from Capital Blue Cross, {with_without_pdp} a prescription drug plan. It's CMS Plan ID is: H3962-004-0. It is not available in all areas. The list of locations where this plan is available can be found below.
According to CMS enrollment data (July, 2025), there are approximately 1,014 members enrolled in this plan.
Capital Blue Cross Value (HMO) (HMO) Overview
| CMS Fact | Landscape Value |
|---|---|
| Health Plan ID: | H3962-004-0 |
| CMS Overall Rating: | 0.0 out of 5 stars* |
| Medicare Advantage Plan Type: | HMO |
| Coverage Year: | CY2026 |
| Monthly Premium: | $58.00 Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Annual Out-of-Pocket Maximum: | $6500.00 (In-Network) |
| Part B Give Back: | $0.00/mo |
| Part D Drug Plan Benefit: | Enhanced, $100.00 deductible |
| Additional Benefits: | Dental, Vision, Hearing |
| Availability: | York County, PA |
| Insured By: | Capital Blue Cross |
| Last Plan Content Update: |
Plan Availability by Location
Health Plan Out-of-Pocket Costs
Prescription Drug Costs & Benefits
Capital Blue Cross Value (HMO) includes an enhanced benefit Medicare Part D plan (PDP), which offers greater coverage than basic plans. An enhanced benefit plan has a higher actuarial value, meaning it covers a larger percentage of your healthcare costs.
Part D Plan Premium
The Part D prescription drug plan premium is included in your overall Medicare Advantage plan cost. However, additional expenses or subsidies may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help. LIS, provided by Social Security, helps those with limited income and resources to lower or eliminate Part D costs. LIS benefits are not part of Medicare Advantage coverage.
| Basic Part D Premium: | $$33.90 |
|---|---|
| Supplemental Part D Premium: | $$0.00 |
| Total Part D Premium: | $$33.90 |
| Low-Income Premium Subsidy: | ${part_d_lips_amount} |
| Low-Income Premium Subsidy Paid by CMS: | $$32.70 |
| Low-Income Subsidy Premium: | $$1.20 |
For more details, visit the Social Security Extra Help program.
Prescription Drug Plan Deductible
This plan has a $100.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Capital Blue Cross starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, Capital Blue Cross Value (HMO) may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 | $10.00 |
| Generic | $0.00 | $15.00 |
| Preferred Brand | $47.00 | $47.00 |
| Non-Preferred Drug | 36.00% | 36.00% |
| Specialty Tier | 33.00% | 33.00% |
| *Deductible does not apply. | ||
CMS 5-Star Rating Marks
Each year, the Centers for Medicare & Medicaid Services (CMS) evaluates health and drug plans using a comprehensive 5-star rating system. These ratings offer valuable insights into the quality of care, member satisfaction, and overall plan performance.
When selecting a Medicare Advantage plan, looking at the star ratings can help you gauge how well a plan might meet your healthcare needs, making it easier to choose a plan with confidence.
| CMS Measure | Star Rating |
|---|---|
| 2026 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Need Help Enrolling?
| Website: | Capital Blue Cross Plan Page |
|---|---|
| Providers: | Capital Blue Cross Providers Page |
| Formulary: | Capital Blue Cross Formulary Page |
| Pharmacy: | Capital Blue Cross Pharmacy Page |
| New Member Health Plan Help: | (800)990-4201 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (800)990-4201 |
| New Member Part D TTY Users: | 711 |
Frequently Asked Questions
📘 What does Medicare plan code H3962 004 mean?
Capital Blue Cross Value (HMO) is a Medicare Advantage plan by Capital Blue Cross. The code H3962 is the CMS contract ID, whereas 004 is its plan ID.
- Plan Name: Capital Blue Cross Value (HMO)
- Plan Type: HMO
- Premium: $58.00/mo + your monthly Part B premium
- Out-of-Pocket Max: $6500.00 (in-network)
- Drug Coverage: {pdp_faq_summary}
- CMS Star Rating: 0.0 out of 5
- Contract Year: 2026
This information is based on official CMS data and is provided for educational purposes. Always review your plan’s official documents or contact the provider directly before making enrollment decisions.
📋 What type of plan is H3962 004?
This plan is a HMO — specifically, it's an HMO plan with a Medicare Advantage contract that's offered by Capital Blue Cross. It comes with defined provider network rules you should be aware of.
- Plan Marketing Name: Capital Blue Cross Value (HMO)
- Network Type: {plan_type_expanded}
- Referral Requirement: {referral_required_expanded}
- Prescription Coverage: {pdp_faq_summary}
Plan types like HMOs and PPOs determine whether you can go out-of-network or need referrals to see specialists.
📦 What benefits are included in H3962 004?
This plan covers all Medicare Part A and Part B services. Depending on the plan, it may also include valuable extras like dental, vision, and hearing benefits.
- Medical Services: Hospital, doctor visits, preventive care
- Prescription Drugs: Enhanced, $100.00 deductible
- Dental: {dental_benefit}
- Vision: {vision_benefit}
- Hearing: {hearing_benefit}
Benefit availability may vary by location and plan version. Confirm specific details in your plan's Evidence of Coverage (EOC).