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Community Blue Medicare Plus PPO Distinct (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Community Blue Medicare Plus 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 Plus PPO Distinct (PPO) in 2025, please refer to our full plan details page.
Community Blue Medicare Plus PPO Distinct (PPO) is a PPO plan offered by Highmark Health available for enrollment in 2025 to people living in Counties: TA, LG, SN, CN. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Community Blue Medicare Plus 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 Plus 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 Plus PPO Distinct (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $20.00. 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 Plus PPO Distinct (PPO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay 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 at both preferred and standard pharmacies. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Community Blue Medicare Plus PPO Distinct (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services, including primary care, have copays depending on the specific service. Emergency services and ambulance services are covered with copays. This plan also covers preventive, hearing, vision, and dental services. Hearing exams and eye exams have copays, and eyewear and hearing aids are covered up to a certain amount annually. Dental services include a copay for Medicare dental services, and other dental services are covered with coinsurance.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute, and Inpatient Hospital Psychiatric services. Inpatient Hospital-Acute has a $300 copay per admission or stay, and additional days have no copay. Inpatient Hospital Psychiatric has a $425 copay for days 1-3, and no copay for days 4-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, as well as additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services 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 Individual and Group Sessions for Outpatient Substance Abuse have a $45 copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Community Blue Medicare Plus PPO Distinct (PPO) plan. There is no information available about the cost of services.
Ambulance and Transportation Services See details
The Community Blue Medicare Plus PPO Distinct (PPO) plan covers ambulance services with a $325 copay for both ground and air ambulance services, with no coinsurance. Transportation services to a plan-approved health-related location are covered, but transportation to any other health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Community Blue Medicare Plus PPO Distinct (PPO) plan. Emergency Services have a $125 copay and no coinsurance, while Urgently Needed Services have a $30 copay and no coinsurance. Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $30 copay, and Worldwide Emergency Transportation has a $325 copay; all have no coinsurance.
Primary Care See details
The Community Blue Medicare Plus PPO Distinct (PPO) plan covers primary care physician services, chiropractic services (with a $15 copay), occupational therapy services (with a $25 copay), physician specialist services (with a $15 copay), mental health specialty services (with a $30 copay for individual or 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 or 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).
Preventive Services See details
Preventive services, including annual physical exams, are covered. Additional preventive services include coverage for remote access technologies, home and bathroom safety devices and modifications; remote access technologies have a copay up to $15, and home and bathroom safety devices and modifications have a 20% coinsurance. However, health education, in-home safety assessments, personal emergency response systems, 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 benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, counseling services, and telemonitoring services are not covered.
Hearing Services See details
Hearing Services include routine hearing exams with a $15 copay, and prescription hearing aids with a copay between $699 and $999 per year, with a maximum plan benefit of $500 per year for both in-network and out-of-network services. 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 coverage for eye exams with a $15 copay, and eyewear with a combined maximum of $400 per year for both in-network and out-of-network services. This plan also covers contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
Dental services include a $15 copay for Medicare dental services. Other dental services are covered, with a maximum benefit of $3,000 per year, and Oral Exams, Dental X-Rays, Prophylaxis (Cleaning), and Fluoride Treatments are covered. Restorative Services, Endodontics, Periodontics, Prosthodontics (removable & 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, and prior authorization is required. Medicare Part B Insulin Drugs have a $35 copay, with coinsurance between 0% and 20%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Community Blue Medicare Plus PPO Distinct (PPO) plan. You will pay a 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered by the Community Blue Medicare Plus PPO Distinct (PPO) plan, with a 20% coinsurance for Durable Medical Equipment, Prosthetic Devices, and Medical Supplies, and no copay. Diabetic Supplies have a 0-20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic procedures and tests, and lab services are not covered. Outpatient X-Ray Services have a $20 copay, Diagnostic Radiological Services have a copay of at most $175, and Therapeutic Radiological Services have a copay of at most $60.
Home Health Services See details
Home Health Services are covered by the Community Blue Medicare Plus PPO Distinct (PPO) 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 technically covered, but 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, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered for SNF, and non-Medicare-covered stays for SNF, are not covered.
Other Services See details
Other Services includes Over-the-Counter (OTC) Items, covered up to $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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