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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 $18.00. 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 an enhanced alternative drug benefit with no deductible. In the initial coverage phase, you will pay varying copays or coinsurance based on the drug tier and pharmacy used. For example, preferred generic drugs have no copay at a preferred pharmacy, while standard generic drugs have 25% coinsurance at either pharmacy. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs. This plan may also have a reduced premium if you qualify for the low-income subsidy, also known as "Extra Help".
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 include copays between $45 and $245 depending on the service. Emergency services have a $125 copay, and primary care services have copays between $5 and $45, depending on the specific service. This plan also covers preventive, hearing, vision, and dental services with specific copays and coinsurance amounts. Home health, skilled nursing, and medical equipment are covered with no copay or with 20% coinsurance, while diagnostic and radiological services have copays up to $175. The plan also offers an OTC benefit, and covers ambulance, and dialysis services.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $250 copay per admission, and for Additional Days, there is no copay. 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 with Community Blue Medicare PPO Distinct (PPO) include coverage for all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient Hospital Services and Observation Services have a $245 copay, Ambulatory Surgical Center Services have a $175 copay, and both Individual and Group Sessions for Outpatient Substance Abuse have a copay between $45 and $45.
Partial Hospitalization See details
Partial Hospitalization benefits are covered under the Community Blue Medicare PPO Distinct (PPO) plan. The specific costs for this benefit are not detailed 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 $250 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 the Community Blue Medicare PPO Distinct (PPO) plan. Emergency Services have a $125 copay and no coinsurance, Urgently Needed Services have a $10 copay and no coinsurance, Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $10 copay, and Worldwide Emergency Transportation has a $250 copay.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered. Chiropractic and Podiatry Services require prior authorization, and Occupational Therapy and Physical Therapy require authorization. Chiropractic services have a $15 copay. Routine Chiropractic Care has a $15 copay for up to 4 visits per year. Occupational Therapy has a $30 copay, while Physician Specialist Services has a $5 copay. Individual and Group Sessions for Mental Health Specialty Services and Psychiatric Services each have a $30 copay. Podiatry Services have a $5 copay, and Routine Foot Care has a $5 copay for up to 4 visits per year. Other Health Care Professional services have a copay between $0 and $5. Physical Therapy and Speech-Language Pathology Services have a $15 copay. Additional Telehealth Benefits have a copay between $0 and $45, while Opioid Treatment Program Services have a $45 copay.
Preventive Services See details
Preventive Services are covered, including Medicare-covered services, annual physical exams, and additional preventive services. The plan covers Remote Access Technologies with a copay of $0-$5, and Home and Bathroom Safety Devices and Modifications with 20% coinsurance.
Hearing Services See details
Hearing Services includes routine hearing exams with a $5 copay, and prescription hearing aids with a copay between $699 and $999, up to a maximum of $500 per year. Fitting/Evaluation for Hearing Aids, Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, Prescription Hearing Aids - Over the Ear, and OTC Hearing Aids are not covered.
Vision Services See details
Vision Services include eye exams with a $5 copay, and eyewear with a combined maximum benefit of $400 every year, covering contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Routine eye exams are also covered, once every year.
Dental Services See details
The Community Blue Medicare PPO Distinct (PPO) plan covers dental services, including oral exams with a $5 copay, dental x-rays, prophylaxis (cleaning), and fluoride treatments. The plan also covers restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery with a 10% coinsurance, but maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0-20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, coinsurance applies between 0-20%.
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 is covered by the Community Blue Medicare PPO Distinct (PPO) plan. 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, while medical supplies have a 20% coinsurance. Diabetic supplies have a coinsurance between 0% and 20%, and diabetic therapeutic shoes/inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under this plan, 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 $15 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 technically covered, but not in practice; cardiac rehabilitation services, intensive cardiac rehabilitation services, pulmonary rehabilitation services, and SET for PAD services are not 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. You will have no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items, with a maximum benefit of $95 every three months, but does not cover acupuncture, meal benefits, or Dual Eligible SNPs with Highly Integrated Services. Also, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and other services are not covered.
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