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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. Additionally, this plan comes with a Part B Premium reduction of $3.00. 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 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. During the initial coverage phase, you will pay either a copay or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs have no copay at preferred pharmacies, while standard generic drugs have 25% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
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 have copays from $45 to $245. Emergency services have a $125 copay, and primary care visits cost $15. This plan also includes coverage for preventive, hearing, vision, and dental services, with specific copays and maximum benefits for each. Additionally, it covers home health services with no copay, and offers benefits for medical equipment, dialysis, and skilled nursing facilities.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, you will pay a $250 copay per admission for a Medicare-covered stay, and there is no copay for additional days. For Inpatient Hospital Psychiatric, you will pay a $425 copay for days 1-3, and no copay for days 4-90.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered under the Community Blue Medicare PPO Distinct (PPO) plan. Outpatient hospital services and observation services have a $245 copay, ambulatory surgical center services have a $175 copay, and outpatient substance abuse services have a $45 copay for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization benefits are covered by this plan. There is no information about the cost of this benefit.
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 $275 copay, and there is 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 Community Blue Medicare PPO Distinct (PPO). Emergency Services have a $125 copay, Urgently Needed Services have a $30 copay, and 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 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, and mental health specialty services with a $30 copay for individual and group sessions. Podiatry services are covered with a $15 copay, other health care professional services have a copay between $0 and $15, psychiatric services have a $30 copay for individual and group sessions, physical therapy and speech-language pathology services have a $15 copay, 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 include coverage for Medicare-covered services, annual physical exams, and additional preventive services, as well as kidney disease education services and other preventive services. Some services, such as health education, in-home safety assessments, and counseling services are not covered, and there is a 20% coinsurance for Home and Bathroom Safety Devices and Modifications and a copay of $0-$15 for Remote Access Technologies.
Hearing Services See details
Hearing Services includes coverage for hearing exams with a $15 copay, and prescription hearing aids with a maximum benefit of $500 per year and 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 - inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a $15 copay, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Eyewear has a combined maximum benefit of $400 every year.
Dental Services See details
The Community Blue Medicare PPO Distinct (PPO) plan covers dental services with a $15 copay for Medicare dental services. Other dental services have a maximum benefit of $3,000 per year, with oral exams covered once every six months, x-rays covered once per year, cleaning and fluoride treatments covered once every six months, restorative services with 10% coinsurance, and prosthodontics (removable, fixed) and oral and maxillofacial surgery with 10% coinsurance. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. With this plan, you may have to pay a $35 copay for Medicare Part B Insulin Drugs. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, you may have to pay coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Community Blue Medicare PPO Distinct (PPO) plan. You are responsible for 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered by Community Blue Medicare PPO Distinct (PPO). Durable Medical Equipment (DME) has a 20% coinsurance, and 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 have a 0-20% coinsurance, and 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 $175.00, Therapeutic Radiological Services have a copay of at most $60.00, 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. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Community Blue Medicare PPO Distinct (PPO), but Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Because some services are not covered, you may want to check with the plan for details.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Community Blue Medicare PPO Distinct (PPO) plan, but require prior authorization. For days 1-20, there is no copay, while for days 21-100, the copay is $214.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) items with a maximum benefit of $95 every three months, while acupuncture, meal benefits, 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. Nicotine Replacement Therapy and Naloxone coverage are not available as part of the OTC benefit.
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