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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:
Sign up for Community Blue Medicare PPO Premier (PPO)
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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 varying costs 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 $2,000, you enter the catastrophic coverage phase, where you will pay nothing for covered drugs. This plan's premium may be reduced if you qualify for the low-income subsidy.
Additional Benefits
The Community Blue Medicare PPO Premier (PPO) plan offers a range of benefits, including coverage for inpatient and outpatient services with varying copays, such as a $250 copay for inpatient hospital stays and a $245 copay for outpatient services. This plan also covers primary care, preventive services, and offers additional benefits like vision and dental care, with a combined maximum benefit of $400 per year for eyewear and a $3,000 annual maximum for dental services. Other key benefits include home health services with no copay, ambulance and transportation services, and coverage for medical equipment and home infusion services.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute with a $250 copay per admission or stay, 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 all outpatient hospital services, with a $245 copay, observation services with a $245 copay, and ambulatory surgical center services with a $175 copay. Outpatient substance abuse services are covered with a $45 copay, and outpatient blood services are covered.
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.
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 $260 copay, and no coinsurance. Transportation Services to plan-approved health-related locations are covered, but transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Community Blue Medicare PPO Premier (PPO) plan. Emergency Services have a $125 copay and no coinsurance, while Urgently Needed Services have a $15 copay and no coinsurance. Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $15 copay, and Worldwide Emergency Transportation has a $260 copay; all have no coinsurance.
Primary Care See details
The Community Blue Medicare PPO Premier (PPO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy, 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. Routine chiropractic care has a $20 copay for up to 8 visits per year.
Preventive Services See details
Preventive Services include Medicare-covered services, annual physical exams, and additional preventive services; however, Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), 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. This plan also covers Fitness Benefits, Enhanced Disease Management, Remote Access Technologies, Home and Bathroom Safety Devices and Modifications with 20% coinsurance, Kidney Disease Education Services, Glaucoma Screenings, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKGs following a Welcome Visit.
Hearing Services See details
The Community Blue Medicare PPO Premier (PPO) plan covers routine hearing exams with one visit per year, and prescription hearing aids with a copay between $699 and $999 for all types, with a maximum benefit of $500 every year for both in-network and out-of-network services. Fitting/evaluation for hearing aids, prescription hearing aids for inner ear, outer ear, and 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 routine eye exams once per year, with no deductible or coinsurance. Eyewear is covered with a combined maximum benefit of $400 per year for both in and out-of-network services, and contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are covered with no limit.
Dental Services See details
The Community Blue Medicare PPO Premier (PPO) plan offers dental services with a maximum benefit of $3,000 per year, covering oral exams, dental x-rays, cleaning, and fluoride treatments, but maxillofacial prosthetics, implant services, and orthodontics are not covered. Other covered services include restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery, each with specific limitations on visits or periodicity.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. The coinsurance for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs is between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Community Blue Medicare PPO Premier (PPO) plan, with a coinsurance of 20%.
Medical Equipment See details
The Community Blue Medicare PPO Premier (PPO) plan covers medical equipment, including Durable Medical Equipment (DME) with a 20% coinsurance, Prosthetic Devices with a 20% coinsurance, and Medical Supplies with a 20% coinsurance, but does not cover Durable Medical Equipment for use outside the home. 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, however, Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of at most $150.00, Therapeutic Radiological Services have a copay of at most $60.00, and Outpatient X-Ray Services have a $20.00 copay.
Home Health Services See details
Home Health Services are covered by the Community Blue Medicare PPO Premier (PPO) plan, with no copay or coinsurance, but require authorization. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Community Blue Medicare PPO Premier (PPO) plan. Specifically, 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 by the Community Blue Medicare PPO Premier (PPO) plan, with a prior authorization required. For days 1-20, there is no copay, and for days 21-100, there is a $214 copay.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) items, with a maximum benefit of $185.00 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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