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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 $55.00. 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)
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Drug Coverage
The Community Blue Medicare HMO Distinct (HMO) plan features an annual prescription drug deductible of $615. For Tier 1 preferred generic drugs, you will pay no copay for a 1-month or 3-month supply at a preferred pharmacy, as well as for a 3-month supply through preferred mail order. Tier 2 generic drugs are also highly affordable, with a $3 copay for a 1-month supply at preferred pharmacies compared to a $15 copay at standard pharmacies. For higher-tier medications, the plan utilizes coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 20% coinsurance across all pharmacy and mail order options. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance at both preferred and standard pharmacies.
Additional Benefits
The Community Blue Medicare HMO Distinct (HMO) plan offers robust coverage with no copay and no coinsurance for primary care visits, home health services, and preventive care. Specialist visits require a $30 copay, while inpatient hospital stays have no coinsurance but require a $345 daily copay for the first six days. Outpatient hospital services feature a $375 copay, and emergency room visits carry a $130 copay, which is waived if you are admitted. For supplemental care, routine dental preventive services and home infusion therapies are available with no copay or coinsurance, while comprehensive dental services feature 0% to 50% coinsurance up to a $2,000 annual limit. Routine vision exams range from no copay up to a $30 copay, and covered eyewear includes a $200 yearly allowance with no copay. Skilled nursing facility stays feature no copay for the first 20 days, followed by a $218 daily copay for days 21 through 100.
Inpatient Hospital See details
Community Blue Medicare HMO Distinct (HMO) covers inpatient hospital services with no coinsurance, though prior authorization is required. Inpatient acute care is partially covered with a $345 daily copay for days 1 to 6 and no copay for additional days (excluding upgrades), while psychiatric care is partially covered with a $260 daily copay for days 1 to 6 and no copay for days 7 to 90 (excluding additional days and non-Medicare-covered stays).
Outpatient Services See details
Outpatient services are covered by Community Blue Medicare HMO Distinct (HMO) with no coinsurance, featuring a $375 copay for outpatient hospital and daily observation services, and a $275 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $40 copay, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Community Blue Medicare HMO Distinct (HMO) covers partial hospitalization services 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 and no coinsurance, although prior authorization is required. Routine transportation services 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 and no coinsurance, which is waived if you are admitted to the hospital within one day. Urgently needed services require a $40 copay and no coinsurance, and worldwide emergency services are covered with no coinsurance and copays of $130 for emergency care, $40 for urgent care, and $395 for emergency transportation.
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. Other services like physical therapy, mental health, and telehealth range from a $0 to $40 copay with no coinsurance, though chiropractic care is only partially covered because other chiropractic services are not covered.
Preventive Services See details
Community Blue Medicare HMO Distinct (HMO) offers preventive services with no copay and no coinsurance, including annual physical exams, kidney disease education, and diabetes self-management. However, additional preventive services are only partially covered, excluding health education, PERS, in-home safety assessments, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, smoking cessation, telemonitoring, home/bathroom safety, and counseling.
Hearing Services See details
Hearing services covered by Community Blue Medicare HMO Distinct (HMO) include one routine hearing exam per year for a $25 copay, fitting evaluations for a $30 copay, and no coinsurance or deductibles. Prescription hearing aids are partially covered with copays ranging from $699 to $999 and no coinsurance for up to two devices per year, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Community Blue Medicare HMO Distinct (HMO) partially covers vision services, offering one routine eye exam annually with a $0 to $30 copay and no coinsurance, though other eye exam services are not covered. Covered eyewear has no copay or coinsurance and includes a $200 yearly maximum allowance for contacts, frames, lenses, and upgrades.
Dental Services See details
Community Blue Medicare HMO Distinct (HMO) offers partially covered dental services, excluding other diagnostic, fluoride, other preventive, maxillofacial prosthetics, implants, and orthodontics. Medicare-covered dental requires a $30 copay and no coinsurance, while covered preventive services have no copay and no coinsurance, and comprehensive services have no copay and 0% to 50% coinsurance up to a $2,000 annual maximum.
Home Infusion bundled Services See details
Community Blue Medicare HMO Distinct (HMO) covers home infusion bundled services with no copay, although prior authorization is required. Medicare Part B chemotherapy, radiation, and other Part B drugs carry a 0% to 20% coinsurance, while Part B insulin requires a $35 copay and 0% to 20% coinsurance.
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 is covered by Community Blue Medicare HMO Distinct (HMO) with no copays, featuring 0% to 50% coinsurance for durable medical equipment and 20% coinsurance for prosthetics and medical supplies. While diabetic equipment has no copay or coinsurance, the benefit is only partially covered because diabetic supplies and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Community Blue Medicare HMO Distinct (HMO) covers diagnostic services with no coinsurance, featuring no copay for lab services and a copay of up to $10 for diagnostic tests. Radiological services are also covered, featuring a $45 copay for outpatient X-rays, a minimum $225 copay for diagnostic radiology, and a 20% coinsurance for therapeutic radiology.
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
Community Blue Medicare HMO Distinct (HMO) covers cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) services. These covered services require no coinsurance and have a $15 copayment per session.
Skilled Nursing Facility (SNF) See details
Community Blue Medicare HMO Distinct (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, though prior authorization is required. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, while additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Community Blue Medicare HMO Distinct (HMO) partially covers other services, offering over-the-counter (OTC) items (up to $55 every three months) and chronic illness meal benefits with no copay and no coinsurance, while acupuncture is not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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