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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 $59.00. 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:
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Drug Coverage
The Community Blue Medicare HMO Distinct (HMO) plan features an annual 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, whereas standard pharmacies charge a $7 copay for a 1-month supply. Tier 2 generic drugs carry a $3 copay for a 1-month supply at preferred pharmacies and a $15 copay at standard pharmacies. Higher-tier medications on this plan require coinsurance instead of flat copayments. You will pay 20% coinsurance for Tier 3 preferred brand drugs, and 25% coinsurance for Tier 4 non-preferred drugs and Tier 5 specialty drugs. Utilizing preferred pharmacies or preferred mail-order options helps maximize your savings on prescription fills.
Additional Benefits
The Community Blue Medicare HMO Distinct (HMO) plan offers robust core medical coverage with predictable costs, including no copay and no coinsurance for primary care visits and preventive services. Specialists require a $35 copay, while inpatient hospital stays carry a daily copay for the first six days before transitioning to no copay for subsequent days. Outpatient hospital services require a $400 copay, and emergency room visits feature a $130 copay, which is waived if you are admitted. This plan also includes valuable supplemental benefits like routine dental and home health services with no copay, alongside comprehensive dental coverage with a 50% coinsurance up to a $2,000 annual limit. Vision care features routine exams with a $10 copay and a $200 annual allowance for eyewear, while hearing exams require a $35 copay. Additionally, members benefit from a $50 quarterly over-the-counter allowance with no copay and skilled nursing facility stays with no copay for the first 20 days.
Inpatient Hospital See details
Community Blue Medicare HMO Distinct (HMO) offers partially covered inpatient hospital services with no coinsurance, though prior authorization is required. Acute care requires a $345 daily copay for days 1 to 6 and no copay for days 7 and beyond (upgrades are not covered), while psychiatric care requires a $260 daily copay for days 1 to 6 and no copay for days 7 to 90 (additional days and non-Medicare-covered stays are not covered).
Outpatient Services See details
Community Blue Medicare HMO Distinct (HMO) covers outpatient services with no coinsurance, requiring a $400 copay for outpatient hospital and observation services and a $300 copay for ambulatory surgical center services. Outpatient substance abuse services carry a $40 copay with no coinsurance, while outpatient blood services are provided with no copay, no coinsurance, and no deductible.
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 Medicare-approved ground and air ambulance services with a $395 copay and no coinsurance, though prior authorization is required. Transportation services to health-related locations are not covered.
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 require a $40 copay with no coinsurance, while worldwide coverage is available 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) offers primary care physician services with no copay and no coinsurance, while specialist visits require a $35 copay and no coinsurance. Other covered services like physical therapy, mental health, and podiatry feature copays ranging from $0 to $40 and no coinsurance, though chiropractic care is only partially covered as other chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by Community Blue Medicare HMO Distinct (HMO) with no copay and no coinsurance for covered care such as annual physicals, kidney disease education, and glaucoma screenings. Covered supplemental benefits include memory fitness and remote access technologies, but many other services are excluded. Not covered services include health education, PERS, in-home safety assessments, medical nutrition therapy, medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, tobacco cessation counseling, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Community Blue Medicare HMO Distinct (HMO) covers hearing exams with a $35 copay and no coinsurance, which includes one routine exam per year and unlimited fitting evaluations. Prescription hearing aids are partially covered with copays between $699 and $999 and no coinsurance, but OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Community Blue Medicare HMO Distinct (HMO) covers vision services with no deductibles, including eye exams with a copay ranging from $0 to $35 (routine exams have a $10 copay) and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay or coinsurance, providing a $200 annual maximum benefit for contacts, eyeglasses, frames, lenses, and upgrades.
Dental Services See details
Community Blue Medicare HMO Distinct (HMO) offers partially covered dental services, including Medicare-covered dental care for a $35 copay and no coinsurance, and preventive services like exams and cleanings for no copay and no coinsurance. Comprehensive services like endodontics and periodontics are covered with no copay and a 50% coinsurance up to a $2,000 annual limit, while fluoride, implants, orthodontics, maxillofacial prosthetics, and other diagnostic or preventive services are not covered.
Home Infusion bundled Services See details
Community Blue Medicare HMO Distinct (HMO) covers home infusion bundled services with no copay, subject to prior authorization. Under this benefit, covered Part B chemotherapy, radiation, and other drugs have no coinsurance to 20% coinsurance, while Part B insulin has a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by Community Blue Medicare HMO Distinct (HMO) 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 a 0% to 50% coinsurance for durable medical equipment and a 20% coinsurance for prosthetics and medical supplies. Prior authorization is required for most items, and while diabetic equipment has no coinsurance, diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the Community Blue Medicare HMO Distinct (HMO) plan, subject to prior authorization. Diagnostic tests carry a $0 to $10 copay and lab services have no copay, both with no coinsurance, while radiological services require a $45 copay for X-rays, a minimum $225 copay for diagnostic radiology, and a minimum 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
Cardiac Rehabilitation Services are covered by Community Blue Medicare HMO Distinct (HMO) with no coinsurance, though only some services are covered as cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered and carry a $15 copay.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by Community Blue Medicare HMO Distinct (HMO) with no coinsurance and no prior three-day hospital stay requirement. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, though prior authorization is required and additional days are not covered.
Other Services See details
Community Blue Medicare HMO Distinct (HMO) partially covers other services, offering over-the-counter (OTC) items and a chronic illness meal benefit with no copay and no coinsurance. The OTC benefit provides up to $50 of coverage every three months, while acupuncture is not covered.
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