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CommuniCare Advantage Sapphire (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for CommuniCare Advantage Sapphire (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on CommuniCare Advantage Sapphire (HMO) in 2025, please refer to our full plan details page.
CommuniCare Advantage Sapphire (HMO) is a HMO plan offered by SNP Holdings, LLC available for enrollment in 2025 to people living in Indiana, Maryland, Ohio. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that CommuniCare Advantage Sapphire (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 CommuniCare Advantage Sapphire (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 CommuniCare Advantage Sapphire (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $9.00. 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 $590.00 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 $9350.00 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 CommuniCare Advantage Sapphire (HMO) plan has a $590 deductible for prescription drugs. Once you meet your deductible, you will pay a copay or coinsurance depending on the drug tier and the pharmacy. For example, if you use a standard pharmacy, you will pay a $8 copay for tier 1 drugs, $45 for tier 2, and $95 for tier 3. For non-preferred drugs in a standard pharmacy, you will pay 25% coinsurance. After your yearly out-of-pocket drug costs reach $2000, you will pay nothing for Medicare Part D covered drugs.
Additional Benefits
The CommuniCare Advantage Sapphire (HMO) plan offers a range of benefits with varying cost-sharing options. Inpatient hospital stays have a $370 copay for days 1-5 and no copay for days 6-90, while outpatient services have copays depending on the specific service. The plan also covers emergency services with copays, and primary care services with copays for specialist visits and therapies. Preventive services are covered with no copay for Medicare-covered services, while hearing and vision services are covered with no copays for routine exams. Dental services are covered up to a $1,000 annual maximum, and home health services have no copay. Additional benefits include coverage for medical equipment, home infusion, and skilled nursing facility stays, each with specific cost-sharing arrangements.
Inpatient Hospital See details
Inpatient Hospital services, including acute and psychiatric, are covered by the CommuniCare Advantage Sapphire (HMO) plan. For days 1-5, the copay is $370.00, and for days 6-90, there is no copay.
Outpatient Services See details
Outpatient Services are covered by the CommuniCare Advantage Sapphire (HMO) plan, with varying copays for different services. Outpatient Hospital Services have a copay between $0 and $350, Observation Services have a $350 copay, Ambulatory Surgical Center (ASC) Services have no copay, and Individual and Group Sessions for Outpatient Substance Abuse have a copay of $25. Outpatient Blood Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the CommuniCare Advantage Sapphire (HMO) plan, with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered, including ground and air ambulance services, as well as transportation services to plan-approved health-related locations. Ground and air ambulance services each have a $250 copay. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered under the CommuniCare Advantage Sapphire (HMO) plan. Emergency Services have a $90 copay, Urgently Needed Services have a $40 copay, and Worldwide Emergency Coverage has a $95 copay; all have no coinsurance. Worldwide Urgent Coverage and Worldwide Emergency Transportation are not covered.
Primary Care See details
The CommuniCare Advantage Sapphire (HMO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, podiatry services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have a $15 copay, physician specialist services have a $30 copay, and physical therapy and speech-language pathology services have a $40 copay. Mental health specialty services, psychiatric services, and podiatry services have varying copays depending on the specific service. Routine chiropractic care is not covered.
Preventive Services See details
The CommuniCare Advantage Sapphire (HMO) plan covers preventive services, including Medicare-covered services with no copay. Kidney Disease Education Services have a $10 copay, and other preventive services like Glaucoma Screening and Diabetes Self-Management Training have a 10% coinsurance. However, the plan does not cover annual physical exams, health education, or several other specific services.
Hearing Services See details
Hearing Services include routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Routine hearing exams and fitting/evaluation for hearing aids have no copay or coinsurance. Prescription hearing aids are partially covered, and the plan does not cover prescription hearing aids for the inner ear, outer ear, or over the ear.
Vision Services See details
Vision services are covered, including routine eye exams, and eyewear. Contact lenses and eyeglasses (lenses and frames) are covered, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The CommuniCare Advantage Sapphire (HMO) plan covers a maximum of $1,000 per year for dental services. This plan covers oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), restorative services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, and oral and maxillofacial surgery, but does not cover fluoride treatment, adjunctive general services, or orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the CommuniCare Advantage Sapphire (HMO) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment is covered by the CommuniCare Advantage Sapphire (HMO) plan. Durable Medical Equipment (DME) and Prosthetic Devices have a 20% coinsurance, while Medical Supplies have a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance. Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, but Lab Services are not covered. Diagnostic Procedures/Tests have a copay of $30.00, while Diagnostic Radiological Services have a maximum copay of $170.00, Therapeutic Radiological Services have a $60.00 copay, and Outpatient X-Ray Services have a $25.00 copay.
Home Health Services See details
Home Health Services are covered by the CommuniCare Advantage Sapphire (HMO) plan with no copay and no coinsurance. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the CommuniCare Advantage Sapphire (HMO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $196.
Other Services See details
The CommuniCare Advantage Sapphire (HMO) plan's other services include Over-the-Counter (OTC) items with a $50 benefit every three months, and meal benefits requiring a doctor's referral. Acupuncture, Dual Eligible SNPs, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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