A non-government entity
Community Blue Medicare HMO Prestige (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Community Blue Medicare HMO Prestige (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Community Blue Medicare HMO Prestige (HMO) in 2025, please refer to our full plan details page.
Community Blue Medicare HMO Prestige (HMO) is a HMO plan offered by Highmark Health available for enrollment in 2025 to people living in Western PA. This plan received an overall rating of 5 out of 5 stars in 2025.
It's important to know that Community Blue Medicare HMO Prestige (HMO) 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 HMO Prestige (HMO).
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 HMO Prestige (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $35.00. 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 Maximum Out-Of-Pocket cost of $5500.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
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 HMO Prestige (HMO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Community Blue Medicare HMO Prestige (HMO) plan has an enhanced alternative drug benefit. There is no deductible for prescription drugs. In the initial coverage phase, you will pay no copay for preferred generic drugs at preferred pharmacies. For standard generic drugs, you will pay 25% coinsurance. For preferred brand drugs, you will pay 50% coinsurance. After your yearly out-of-pocket drug costs reach $2000, you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The Community Blue Medicare HMO Prestige (HMO) plan offers comprehensive coverage, including inpatient and outpatient hospital services, with copays ranging from $30 to $225 depending on the service. This plan also includes coverage for primary care, preventive, hearing, vision, and dental services, as well as medical equipment and home health services. There is no copay for partial hospitalization or home health services, and emergency services have a $125 copay. This plan includes additional benefits like ambulance and transportation services, with a $250 copay for ambulance services. It also covers skilled nursing facility services with a copay after the first 20 days, and offers an over-the-counter (OTC) items benefit, with a maximum benefit of $180 every three months. Diagnostic services have no copay, while diagnostic radiological services have a copay up to $95.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. The copay for a Medicare-covered stay is $200 for Inpatient Hospital-Acute and $225 for Inpatient Hospital Psychiatric. Non-Medicare-covered stays, additional days for Inpatient Hospital Psychiatric, and upgrades are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, outpatient substance abuse services, outpatient blood services, and ambulatory surgical center (ASC) services. Outpatient hospital and observation services have a $150 copay, ASC services have a $75 copay, and individual and group sessions for outpatient substance abuse have a copay between $30 and $30.
Partial Hospitalization See details
Partial Hospitalization benefits are covered with no copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Community Blue Medicare HMO Prestige (HMO), including both ground and air ambulance services with a $250 copay. 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 HMO Prestige (HMO) plan. Emergency Services has a $125 copay, and Urgently Needed Services has a $20 copay, and Worldwide Emergency Coverage has a $125 copay. Worldwide Urgent Coverage has a $20 copay, and Worldwide Emergency Transportation has a $250 copay; all services have no coinsurance.
Primary Care See details
The Community Blue Medicare HMO Prestige (HMO) plan covers primary care physician services, chiropractic services with a $10 copay, occupational therapy services with a $10 copay, physician specialist services, mental health specialty services with a $30 copay for individual and group sessions, podiatry services, other health care professional services, psychiatric services with a $30 copay for individual and group sessions, physical therapy and speech-language pathology services with a $10 copay, additional telehealth benefits with a copay between $0 and $30, and opioid treatment program services with a $30 copay. Routine chiropractic care is limited to 8 visits per year.
Preventive Services See details
Preventive services, including annual physical exams, are covered. Additional preventive services include coverage for Fitness Benefits, Enhanced Disease Management, Home and Bathroom Safety Devices and Modifications, Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, and may include a 20% coinsurance. Other services such as Health Education, In-Home Safety Assessment, and Counseling Services are not covered.
Hearing Services See details
The Community Blue Medicare HMO Prestige (HMO) plan covers hearing exams and routine hearing exams, with one routine exam allowed per year, and prescription hearing aids with a copay between $499 and $799 for two hearing aids 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
The Community Blue Medicare HMO Prestige (HMO) plan covers vision services, including routine eye exams once per year, and eyewear, with a combined maximum benefit of $400 per year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Dental services are covered with a maximum plan benefit of $3,500 per year. Oral exams, dental x-rays, prophylaxis (cleaning), and fluoride treatments are covered, with limitations on the number of visits and periodicity.
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% 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 with a coinsurance of 20%.
Medical Equipment See details
Medical equipment is covered, including durable medical equipment (DME) with 20% coinsurance, prosthetics and medical supplies with 20% coinsurance, and diabetic equipment. Diabetic supplies have a coinsurance between 0% and 20%, while diabetic therapeutic shoes/inserts have 20% coinsurance. Durable medical equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
The Community Blue Medicare HMO Prestige (HMO) plan covers diagnostic and radiological services. Diagnostic services have no copay, but diagnostic procedures/tests and lab services are not covered. Diagnostic radiological services have a copay of at most $95, therapeutic radiological services have a copay of at most $50, and outpatient X-ray services have a $20 copay.
Home Health Services See details
Home Health Services are covered by the Community Blue Medicare HMO Prestige (HMO) 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 the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Community Blue Medicare HMO Prestige (HMO) plan, but require prior authorization. There is 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 Over-the-Counter (OTC) Items, with a maximum benefit of $180 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.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved