A non-government entity
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:
Sign up for Community Blue Medicare PPO Distinct (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Community Blue Medicare PPO Distinct (PPO) plan has an enhanced alternative drug benefit with no deductible. During the initial coverage phase, you will pay a $0 copay for preferred generic drugs at a preferred pharmacy, with higher costs for other tiers and pharmacies. Once your total drug costs reach $2000, you enter the next coverage phase. In the catastrophic coverage phase, you pay nothing for Part D covered drugs after your yearly out-of-pocket costs reach $2000. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. If you qualify for the low-income subsidy, you will pay $10.60.
Additional Benefits
The Community Blue Medicare PPO Distinct (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $250 copay per admission, while outpatient services range from $15 to $245 depending on the service. Primary care visits are $15, and the plan includes coverage for hearing and vision services, with copays for exams and allowances for hearing aids and eyewear. This plan also covers ambulance and emergency services, with copays for each, as well as certain dental services with a $15 copay for Medicare-covered services and 10% coinsurance for other services. It also provides coverage for home health services with no copay and offers additional benefits like home infusion, dialysis, and medical equipment with varying coinsurance amounts.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $250 copay per admission for a Medicare-covered stay, and for additional days, there is no copay. For Inpatient Hospital Psychiatric, the copay is $425 for days 1-3, and no copay for days 4-90.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital and observation services have a $245 copay, while ambulatory surgical center services have a $175 copay. Individual and group sessions for outpatient substance abuse have a copay between $45 and $45.
Partial Hospitalization See details
Partial Hospitalization benefits are covered by the Community Blue Medicare PPO Distinct (PPO) plan. The specific costs associated with this benefit are not described in the provided information.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Community Blue Medicare PPO Distinct (PPO) plan. Ground and air ambulance services each have a copay of $275, with no coinsurance. Transportation services to a plan-approved health-related location are covered, but transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Community Blue Medicare PPO Distinct (PPO) plan. Emergency Services have a $125 copay with no coinsurance, Urgently Needed Services have a $30 copay with no coinsurance, and Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $30 copay, and Worldwide Emergency Transportation has a $275 copay.
Primary Care See details
The Community Blue Medicare PPO Distinct (PPO) plan covers primary care physician services, chiropractic services, occupational therapy, 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, occupational therapy services have a $30 copay, physician specialist services have a $15 copay, individual and group mental health and psychiatric sessions have a $30 copay, podiatry services have a $15 copay, other health care professional services have a copay between $0 and $15, additional telehealth benefits have a copay between $0 and $45, and opioid treatment program services have a $45 copay.
Preventive Services See details
Preventive Services includes coverage for Medicare-covered services, annual physical exams, and additional preventive services. The plan covers Remote Access Technologies with a copay between $0-$15, and Home and Bathroom Safety Devices with 20% coinsurance. However, Health Education, In-Home Safety Assessment, Personal Emergency Response System, Medical Nutrition Therapy, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Telemonitoring Services, and Counseling Services are not covered.
Hearing Services See details
Hearing Services include routine hearing exams with a $15 copay, and prescription hearing aids with a plan-specified amount of $500 per year with a copay between $699 and $999. Fitting/evaluation for hearing aids, OTC hearing aids, and prescription hearing aids (inner ear, outer ear, and over the ear) are not covered.
Vision Services See details
Vision services are covered, including routine eye exams with a $15 copay. Eyewear is covered with a combined maximum benefit of $400 every year for both in-network and out-of-network services, and contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
The Community Blue Medicare PPO Distinct (PPO) plan covers dental services, including Medicare Dental Services with a $15 copay. Other dental services are covered up to a maximum of $3,000 per year. The plan covers oral exams (1 every six months), dental x-rays (1 per year), prophylaxis (cleaning) (1 every six months), and fluoride treatment (1 every six months). Restorative Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), and Oral and Maxillofacial Surgery are covered with 10% coinsurance, while Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, requiring prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay, with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Community Blue Medicare PPO Distinct (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment are covered. Durable Medical Equipment has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance, and Diabetic Supplies have a 0-20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, but 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 and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Community Blue Medicare PPO Distinct (PPO) plan, but require prior authorization. There is no copay for days 1-20, and a $214 copay for days 21-100, but additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services offers coverage for Over-the-Counter (OTC) Items with a maximum benefit coverage of $100 every three months, but does not cover Acupuncture, Meal Benefits, 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, or Self-Directed Personal Assistance Services.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved