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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 $7.00. 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. After the deductible is met, you will pay a copay or coinsurance depending on the drug tier and pharmacy type. For example, in the initial coverage phase, you may pay $8 for preferred generic drugs at a standard or mail-order pharmacy. For non-preferred drugs, you will pay 25% coinsurance. After your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The CommuniCare Advantage Sapphire (HMO) plan offers a range of benefits, including coverage for inpatient and outpatient hospital services, with varying copays. Primary care visits have no copay, and there are copays for specialist visits, therapies, and other services. The plan also covers vision, dental, and hearing services, with a $1,000 annual maximum for dental care. Additional benefits include ambulance and transportation services, emergency services, and home health services with no copay. The plan also provides coverage for medical equipment, home infusion bundled services, and dialysis services. However, this plan does not cover cardiac rehabilitation services, and has limitations on additional days for inpatient stays and skilled nursing facilities.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For days 1-5, there is a $295 copay, and for days 6-90, there is no copay. Additional days, non-Medicare covered stays, and upgrades for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered by CommuniCare Advantage Sapphire (HMO), including outpatient hospital services with a copay between $0 and $295, observation services with a $295 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services are covered with a copay of $25 for both individual and group sessions, while outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the CommuniCare Advantage Sapphire (HMO) plan, but requires prior authorization. You will have a $55 copay for this service.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required. Ground and air ambulance services have a $220 copay, while ground ambulance services have a $220 copay and a $250 deductible; transportation services to a plan-approved health-related location are covered for 24 one-way trips per year.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered under the CommuniCare Advantage Sapphire (HMO) plan. Emergency Services has a $90 copay, and Urgently Needed Services has a $40 copay, while 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 with no copay, chiropractic services with a $15 copay, occupational therapy services with a $35 copay, physician specialist services with a $25 copay, mental health specialty services with a copay between $15 and $25, podiatry services with a $25 copay, other health care professional services with a $50 copay, psychiatric services with a copay between $25, physical therapy and speech-language pathology services with a $40 copay, additional telehealth benefits, and opioid treatment program services. Routine chiropractic care is not covered.
Preventive Services See details
The CommuniCare Advantage Sapphire (HMO) plan covers preventive services, including glaucoma screening, diabetes self-management training, and barium enemas, with a 10% coinsurance. Kidney disease education services have a $10 copay. Other services like annual physical exams, health education, and in-home safety assessments are not covered.
Hearing Services See details
Hearing services are covered, including routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. The plan covers hearing exams up to $800 every three years, and has no copay or coinsurance for routine hearing exams and fitting/evaluation for hearing aids. Prescription hearing aids are covered, but inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services include routine eye exams and eyewear, with no deductible. Routine eye exams are unlimited, and eyewear is covered under the Eye Exams Category. Contact lenses and eyeglasses (lenses and frames) are covered, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are covered, with a maximum plan benefit of $1,000 per year. 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 are covered, while fluoride treatment, adjunctive general services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. 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. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment. Durable medical equipment has a 20% coinsurance and requires authorization, while durable medical equipment for use outside the home is not covered. Prosthetic devices have a 20% coinsurance, and medical supplies have a 20% coinsurance. Diabetic supplies are not covered, while diabetic therapeutic shoes/inserts have a 20% coinsurance.
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, while Diagnostic Radiological Services have a maximum copay of $110 and Therapeutic Radiological Services have a minimum copay of $60. Outpatient X-Ray Services have a copay of $15.
Home Health Services See details
Home Health Services are covered by the CommuniCare Advantage Sapphire (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the CommuniCare Advantage Sapphire (HMO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the CommuniCare Advantage Sapphire (HMO) plan, but require prior authorization. There is no copay for days 1-20, and a $196 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The "Other Services" benefit for CommuniCare Advantage Sapphire (HMO) covers Over-the-Counter (OTC) Items with a maximum benefit of $50.00 every three months. This plan does not cover Acupuncture, Dual Eligible SNPs with Highly Integrated Services, 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.
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