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Community Blue Medicare PPO Premier (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Community Blue Medicare PPO Premier (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 Premier (PPO) in 2025, please refer to our full plan details page.
Community Blue Medicare PPO Premier (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 Premier (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 Premier (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 Premier (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $55.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $1.00. 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 Premier (PPO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay different costs depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have no copay at preferred pharmacies, while standard generic drugs have 25% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs. However, if you qualify for the low-income subsidy (LIS), your monthly premium for Part D is reduced. Check the plan's formulary for specific drug coverage details.
Additional Benefits
The Community Blue Medicare PPO Premier (PPO) plan offers comprehensive coverage with a range of benefits. This plan includes coverage for inpatient and outpatient hospital services, with varying copays depending on the service. It also covers primary care, specialist visits, and mental health services, with copays for specific services like chiropractic and psychiatric care. Additional benefits include coverage for ambulance services, emergency services, vision and hearing services, and dental care. The plan also covers home health services with no copay, and skilled nursing facility care with a copay after the first 20 days. Note that some services like cardiac rehabilitation, and certain other services, may not be covered.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute, with a $250 copay per admission or stay, and Inpatient Hospital Psychiatric, with a $425 copay for days 1-3, and no copay for days 4-90. Additional days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services with a $245 copay, observation services with a $245 copay, ambulatory surgical center (ASC) services with a $175 copay, and outpatient substance abuse services with a $45 copay for both individual and group sessions. The plan also covers outpatient blood services.
Partial Hospitalization See details
Partial Hospitalization is covered by the Community Blue Medicare PPO Premier (PPO) plan. There is no information about the cost of this service in the provided snippet.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Community Blue Medicare PPO Premier (PPO) plan. Ground and air ambulance services have a copay of $260, 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, including Urgently Needed Services and Worldwide Emergency Services, are covered. Emergency Services have a $125 copay and no coinsurance, Urgently Needed Services have a $15 copay and no coinsurance, and Worldwide Emergency Services have a copay of $125 for Worldwide Emergency Coverage, $15 for Worldwide Urgent Coverage, and $260 for Worldwide Emergency Transportation, with no coinsurance.
Primary Care See details
Community Blue Medicare PPO Premier (PPO) covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services, physician specialist services, mental health specialty services with a $30 copay for individual and group sessions, podiatry services, psychiatric services with a $30 copay for individual and group sessions, physical therapy and speech-language pathology services, additional telehealth benefits with a copay between $0 and $45, and opioid treatment program services with a $45 copay. Chiropractic services require prior authorization.
Preventive Services See details
Preventive Services are covered, including Medicare-covered preventive services, annual physical exams, and additional preventive services, with some services like Health Education, Counseling Services, and others not covered. Home and Bathroom Safety Devices and Modifications have a 20% coinsurance.
Hearing Services See details
Community Blue Medicare PPO Premier (PPO) covers hearing exams, including routine hearing exams once per year, and prescription hearing aids with a $699-$999 copay per year, up to a maximum of $500 per year for both in and out-of-network services. Fitting/Evaluation for Hearing Aid, 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
The Community Blue Medicare PPO Premier (PPO) plan covers vision services, including eye exams, with no deductible. Routine eye exams are limited to one visit per year. Eyewear is covered with a combined maximum benefit of $400 every year for in-network and out-of-network services, and includes contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
The Community Blue Medicare PPO Premier (PPO) plan offers a dental benefit with a $3,000 maximum per year for both in-network and out-of-network services. Oral exams, dental x-rays, cleaning, fluoride treatment, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered, but maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Insulin, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Community Blue Medicare PPO Premier (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, and Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance, while 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 partially covered under the Community Blue Medicare PPO Premier (PPO) plan. Diagnostic Procedures/Tests and Lab Services are not covered, while Diagnostic Radiological Services have a copay of at most $150, Therapeutic Radiological Services have a copay of at most $60, and Outpatient X-Ray Services have a copay of $20.
Home Health Services See details
Home Health Services are covered by Community Blue Medicare PPO Premier (PPO) with no copay or coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services are covered, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
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
The Community Blue Medicare PPO Premier (PPO) plan's Other Services benefit covers over-the-counter items with a maximum benefit of $185 every three months; however, 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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