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Community Blue Medicare HMO Merit (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Community Blue Medicare HMO Merit (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 Merit (HMO) in 2026, please refer to our full plan details page.
Community Blue Medicare HMO Merit (HMO) is a HMO plan offered by Highmark Health available for enrollment in 2026 to people living in Western, NY. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Community Blue Medicare HMO Merit (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 Merit (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 Merit (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $81.00. You must continue to pay paying your reduced 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 $8300.00 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 Merit (HMO) plan features an annual prescription drug deductible of $615. For Tier 1 preferred generic drugs, you pay no copay for 1-month or 3-month fills at preferred pharmacies, while standard pharmacies require a $7 copay for a 1-month supply. Tier 2 generic drugs are available for a $3 copay for a 1-month supply at preferred pharmacies, compared to a $17 copay at standard pharmacies. For higher-tier medications, cost-sharing transitions to coinsurance. Tier 3 preferred brand drugs require a 20% coinsurance at both preferred and standard pharmacies. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance across all pharmacy options.
Additional Benefits
The Community Blue Medicare HMO Merit (HMO) plan offers comprehensive medical coverage with no copay and no coinsurance for primary care visits, preventive services, and home health care. Specialist visits require a copay ranging from $15 to $50, while emergency room visits carry a $115 copay that is waived upon hospital admission. For inpatient hospital stays, members pay a daily copay for the first seven days with no copay thereafter, while outpatient hospital services require a $475 copay. Ancillary benefits include preventive dental care and routine eye exams with no copay, as well as a $100 annual allowance for eyewear. Routine hearing exams carry a $45 to $50 copay, and covered prescription hearing aids require a copay between $699 and $999. Additionally, diagnostic lab services feature low copays of $10 to $20, while durable medical equipment is covered with no copay and coinsurance up to 20 percent.
Inpatient Hospital See details
Community Blue Medicare HMO Merit (HMO) covers inpatient hospital services with no coinsurance, subject to prior authorization. For acute stays, there is a $345 daily copay for days 1 to 7 and no copay thereafter (excluding room upgrades), while psychiatric stays require a $295 daily copay for days 1 to 7 and no copay for days 8 to 90 (excluding additional days and non-Medicare-covered stays).
Outpatient Services See details
Community Blue Medicare HMO Merit (HMO) covers outpatient hospital and daily observation services with a $475 copay and no coinsurance, and ambulatory surgical center services with a $425 copay and no coinsurance. Outpatient substance abuse sessions require a $40 copay and no coinsurance, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Partial hospitalization is covered by the Community Blue Medicare HMO Merit (HMO) plan with a $55.00 copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered under the Community Blue Medicare HMO Merit (HMO) plan, where Medicare-covered ground and air ambulance services require prior authorization and have a $450 copay with no coinsurance. Non-emergency transportation services to health-related locations are not covered in practice under this plan.
Emergency Services See details
Community Blue Medicare HMO Merit (HMO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within one day, and urgently needed care with a $40 copay and no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance, featuring copays of $115, $40, and $450 respectively.
Primary Care See details
Community Blue Medicare HMO Merit (HMO) offers primary care physician services with no copay and no coinsurance, while specialist visits and therapy services require copays ranging from $15 to $50 with no coinsurance. Chiropractic benefits are partially covered, with a $15 copay for routine care (limited to 3 visits per year) while other chiropractic services are not covered.
Preventive Services See details
Community Blue Medicare HMO Merit (HMO) covers preventive services, including annual physical exams, kidney disease education, and diabetes self-management training, with no copay and no coinsurance. Additional preventive benefits are partially covered, offering memory fitness and remote access technologies, while excluding services such as health education, in-home safety assessments, and personal emergency response systems.
Hearing Services See details
Community Blue Medicare HMO Merit (HMO) partially covers hearing services, with routine hearing exams and evaluations requiring a $45 to $50 copay and no coinsurance. Covered prescription hearing aids carry a $699 to $999 copay and no coinsurance, though OTC hearing aids and inner ear, outer ear, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Vision services are covered by Community Blue Medicare HMO Merit (HMO), with eye exams being partially covered because other eye exam services are not covered. Routine eye exams are covered once per year with no copay to a $50 copay, no coinsurance, and no deductible, while eyewear is covered with no copay, no coinsurance, no deductible, and a $100 annual limit.
Dental Services See details
Community Blue Medicare HMO Merit (HMO) dental benefits are partially covered, offering Medicare-covered dental services for a $50 copay and no coinsurance, alongside preventive care with no copay or coinsurance up to a $1,500 annual limit. Comprehensive dental services, such as restorative care and periodontics, are covered with no copay and 50% coinsurance, though other diagnostic, other preventive, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Community Blue Medicare HMO Merit (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and insulin, carry a coinsurance ranging from no coinsurance up to 20%, with insulin also requiring a $35 copay.
Dialysis Services See details
Dialysis Services are covered by Community Blue Medicare HMO Merit (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered under Community Blue Medicare HMO Merit (HMO) with no copays, though coinsurance ranges from no coinsurance to 20% for durable medical equipment and is 20% for prosthetics and medical supplies. Diabetic equipment is partially covered with no copay or coinsurance, but 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 Merit (HMO), with prior authorization required for all services. Outpatient diagnostic procedures and lab services feature no coinsurance and copays ranging from $10 to $20, while radiological services require a $50 copay for X-rays, a minimum $300 copay for diagnostic radiology, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
Community Blue Medicare HMO Merit (HMO) covers home health services with no copay and no coinsurance.
Cardiac Rehabilitation Services See details
Community Blue Medicare HMO Merit (HMO) covers Cardiac Rehabilitation Services with no coinsurance. A $10 copayment applies to cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by Community Blue Medicare HMO Merit (HMO) with no coinsurance, requiring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Community Blue Medicare HMO Merit (HMO) partially covers Other Services, which includes a meal benefit for chronic illnesses with no copay and no coinsurance. Acupuncture and over-the-counter (OTC) items are not covered under this plan.
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