A non-government entity
Community Blue Medicare HMO Distinct (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Community Blue Medicare HMO Distinct (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Community Blue Medicare HMO Distinct (HMO) in 2026, please refer to our full plan details page.
Community Blue Medicare HMO Distinct (HMO) is a HMO plan offered by Highmark Health available for enrollment in 2026 to people living in Western New York. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Community Blue Medicare HMO Distinct (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Community Blue Medicare HMO Distinct (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Community Blue Medicare HMO Distinct (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $49.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $615.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6750.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
Sign up for Community Blue Medicare HMO Distinct (HMO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Community Blue Medicare HMO Distinct (HMO) plan features an annual prescription drug deductible of $615. For Tier 1 preferred generics, members pay no copay for a 1-month or 3-month supply at a preferred pharmacy, as well as for a 3-month preferred mail-order supply. Tier 2 generic medications are also highly affordable, costing as little as a $3 copay for a 1-month supply at preferred pharmacies compared to up to $45 for standard pharmacy fills. Higher-tier medications under this plan require coinsurance rather than flat copayments. Tier 3 preferred brand-name drugs have a 20% coinsurance across all pharmacy and mail-order channels. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance, ensuring consistent cost-sharing regardless of whether you use preferred, standard, or mail-order services.
Additional Benefits
The Community Blue Medicare HMO Distinct (HMO) plan offers comprehensive medical coverage with no copay or coinsurance for primary care visits, while specialist visits require a $30 copay. For inpatient hospital stays, members pay a $345 daily copay for the first five days with no copay for subsequent days, and emergency care is available for a $130 copay. Outpatient services, including surgery and observation, are covered with copays ranging from $250 to $350 and no coinsurance. Additionally, the plan features no copay or coinsurance for home health services and preventive dental care, alongside a $200 annual allowance for eyewear and comprehensive dental coverage up to $2,000 with a 50% coinsurance. Skilled nursing facility care starts with no copay for the first 20 days, followed by a $218 daily copay up to day 100. Members also benefit from a quarterly over-the-counter allowance of $55 and no copay for routine preventive services.
Inpatient Hospital See details
Inpatient hospital services are covered by Community Blue Medicare HMO Distinct (HMO) with no coinsurance, though prior authorization is required. For acute care, there is a $345 copay per day for days 1 to 5 and no copay for additional days, although room upgrades are not covered; psychiatric care requires a $260 copay per day for days 1 to 6 and no copay for days 7 to 90, with additional days and non-Medicare-covered stays not covered.
Outpatient Services See details
Community Blue Medicare HMO Distinct (HMO) covers outpatient services with no coinsurance, including outpatient hospital and daily observation services for a $350 copay, and ambulatory surgical center services for a $250 copay. Outpatient substance abuse services require a $40 copay with no coinsurance, while outpatient blood services are provided with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Community Blue Medicare HMO Distinct (HMO) with a $55.00 copay and no coinsurance.
Ambulance and Transportation Services See details
Community Blue Medicare HMO Distinct (HMO) covers ground and air ambulance services with a $395 copay per service and no coinsurance, though prior authorization is required. Routine transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Emergency services are covered by Community Blue Medicare HMO Distinct (HMO) with a $130 copay, which is waived if admitted to the hospital within one day, and no coinsurance. Urgently needed services have a $40 copay with no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $130, $40, and $395 respectively.
Primary Care See details
Community Blue Medicare HMO Distinct (HMO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $30 copay and no coinsurance. Additional services like therapy, podiatry, and mental health care feature copays ranging from $0 to $40 with no coinsurance, though chiropractic care is only partially covered as other chiropractic services are not covered.
Preventive Services See details
Community Blue Medicare HMO Distinct (HMO) offers partial coverage for preventive services with no copay and no coinsurance, including annual physical exams, kidney disease education, and select screenings. While specific additional benefits like memory fitness, enhanced disease management, and remote access technologies are covered, other sub-services such as health education, personal emergency response systems, and in-home safety assessments are not covered.
Hearing Services See details
Community Blue Medicare HMO Distinct (HMO) partially covers hearing services, offering exams with a $25 to $30 copay and no coinsurance. Prescription hearing aids are covered with a $699 to $999 copay and no coinsurance, but OTC hearing aids and inner ear, outer ear, and over-the-ear prescription models are not covered.
Vision Services See details
Vision services are partially covered by Community Blue Medicare HMO Distinct (HMO) because other eye exam services are not covered. Routine eye exams are available with a $0 to $30 copay and no coinsurance, while covered eyewear has no copay, no coinsurance, and a $200 annual maximum limit.
Dental Services See details
Dental services are partially covered by Community Blue Medicare HMO Distinct (HMO), offering Medicare-covered dental with a $30 copay and no coinsurance, and preventive services like exams and cleanings with no copay and no coinsurance. Comprehensive services are covered up to a $2,000 annual limit with no copay and 50% coinsurance (0% to 50% for adjunctive services), though fluoride, implants, orthodontics, maxillofacial prosthetics, and other diagnostic or preventive services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Community Blue Medicare HMO Distinct (HMO) with no copay, though prior authorization is required. Covered Medicare Part B drugs, including chemotherapy, radiation, and insulin, require coinsurance ranging from no coinsurance to 20% coinsurance, with insulin also carrying a $35 copay.
Dialysis Services See details
Dialysis Services are covered under the Community Blue Medicare HMO Distinct (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical Equipment covered by Community Blue Medicare HMO Distinct (HMO) features no copays, with coinsurance ranging from 0% to 50% for durable medical equipment and 20% for prosthetics and medical supplies. Diabetic equipment has no copay or coinsurance but is only partially covered, as diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Community Blue Medicare HMO Distinct (HMO) and require prior authorization. Diagnostic procedures and tests have no coinsurance and a $0 to $10 copay, lab services have no copay, and radiological services require a $45 copay for outpatient X-rays, a minimum $175 copay for diagnostic radiological services, and a minimum 20% coinsurance for therapeutic radiological services.
Home Health Services See details
Home health services are covered by Community Blue Medicare HMO Distinct (HMO) with no copay and no coinsurance.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by Community Blue Medicare HMO Distinct (HMO) with no coinsurance, though only some services are covered. Standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered and require a $15 copay.
Skilled Nursing Facility (SNF) See details
Community Blue Medicare HMO Distinct (HMO) covers Skilled Nursing Facility (SNF) care with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, with additional days beyond the standard Medicare limit not covered.
Other Services See details
Community Blue Medicare HMO Distinct (HMO) partially covers other services, providing a meal benefit for chronic illness and up to $55 every three months for over-the-counter items with no copay and no coinsurance. Acupuncture is not covered under this benefit.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved