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Community Blue Medicare PPO Distinct (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Community Blue Medicare PPO Distinct (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Community Blue Medicare PPO Distinct (PPO) in 2025, please refer to our full plan details page.
Community Blue Medicare PPO Distinct (PPO) is a PPO plan offered by Highmark Health available for enrollment in 2025 to people living in North Central PA. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Community Blue Medicare PPO Distinct (PPO) 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 PPO Distinct (PPO).
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 PPO Distinct (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $15.00. 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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $8950.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $8950.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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 PPO Distinct (PPO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay varying costs depending on the drug tier and pharmacy. For example, preferred generic drugs have no copay at preferred pharmacies, while standard generic drugs have a 25% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase and pay nothing for covered Part D drugs. If you qualify for the low-income subsidy (LIS), your monthly premium will be $10.60.
Additional Benefits
The Community Blue Medicare PPO Distinct (PPO) plan offers a wide range of benefits with varying cost-sharing options. Inpatient hospital stays have a copay, while outpatient services and emergency services also have copays. Primary care, vision, and dental services are covered with copays, along with other services like hearing aids and home infusion. This plan also includes coverage for ambulance services and transportation, and offers additional benefits like hearing aids, vision, and dental services. Preventive services are covered with no copay for Medicare-covered services. However, some services, such as cardiac rehabilitation and certain other services, are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, with prior authorization required. Inpatient Hospital-Acute has a $250 copay per admission for Medicare-covered stays, and no copay for additional days; however, Non-Medicare-covered stays and upgrades are not covered. Inpatient Hospital Psychiatric has a $425 copay for days 1-3, and no copay for days 4-90, while additional days and Non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, Outpatient Substance Abuse Services, and Outpatient Blood Services. Outpatient Hospital Services and Observation Services have a $245 copay, while Ambulatory Surgical Center (ASC) Services have a $175 copay. Outpatient Substance Abuse Services have a $45 copay for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization benefits are covered by Community Blue Medicare PPO Distinct (PPO). There is no information about the cost of services in the provided snippet.
Ambulance and Transportation Services See details
The Community Blue Medicare PPO Distinct (PPO) plan covers ambulance and transportation services. Ground and air ambulance services each have a $275 copay, but there is no coinsurance. Transportation services to a plan-approved health-related location are covered, but transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Community Blue Medicare PPO Distinct (PPO) plan. Emergency Services have a $125 copay, and Urgently Needed Services have a $30 copay. Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $30 copay, and Worldwide Emergency Transportation has a $275 copay. There is no coinsurance for any of these services.
Primary Care See details
The Community Blue Medicare PPO Distinct (PPO) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $30 copay, physician specialist services with a $15 copay, mental health specialty services with a $30 copay for individual and group sessions, podiatry services with a $15 copay, other health care professional services with a $0-$15 copay, psychiatric services with a $30 copay for individual and group sessions, physical therapy and speech-language pathology services with a $15 copay, additional telehealth benefits with a $0-$45 copay, and opioid treatment program services with a $45 copay. Routine chiropractic care is limited to 4 visits per year.
Preventive Services See details
Preventive services include Medicare-covered services with no copay, an annual physical exam, and additional preventive services. Additional preventive services may have a copay or coinsurance, with Home and Bathroom Safety Devices and Modifications having 20% coinsurance and Remote Access Technologies having a copay from $0 to $15.
Hearing Services See details
Hearing Services include hearing exams with a $15 copay, and prescription hearing aids, which are covered up to a maximum of $500 per year and have a copay between $699 and $999 depending on the type of hearing aid. Fitting/evaluation for hearing aids, OTC hearing aids, and prescription hearing aids for the inner, outer, and over the ear are not covered.
Vision Services See details
Vision services include eye exams with a $15 copay, and eyewear with a combined maximum of $400 per year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Dental Services are covered, with a $15 copay for Medicare Dental Services. Other dental services are also covered, with a maximum plan benefit of $3,000 per year. Oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatments are covered, with limitations on the number of visits. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with a 10% coinsurance. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Community Blue Medicare PPO Distinct (PPO) plan and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%; for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Community Blue Medicare PPO Distinct (PPO) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical equipment is covered by Community Blue Medicare PPO Distinct (PPO). Durable Medical Equipment has a 20% coinsurance, and requires authorization. Prosthetic devices and medical supplies have a 20% coinsurance, while diabetic supplies have between 0-20% coinsurance, and diabetic therapeutic shoes/inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered under the Community Blue Medicare PPO Distinct (PPO) plan. Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of at most $175, Therapeutic Radiological Services have a copay of at most $60, and Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by the Community Blue Medicare PPO Distinct (PPO) plan, with no copay or coinsurance; however, additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but not in practice. This plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. There is no copay for days 1-20, and a $214 copay per day for days 21-100; additional days beyond Medicare-covered SNF stays and non-Medicare-covered SNF stays are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items, with a maximum benefit of $100 every three months. Acupuncture, Meal Benefit, 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 are not covered.
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