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Community Blue Medicare HMO Distinct (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Community Blue Medicare HMO Distinct (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 Distinct (HMO) in 2026, please refer to our full plan details page.
Community Blue Medicare HMO Distinct (HMO) is a HMO plan offered by Highmark Health available for enrollment in 2026 to people living in Central and Northeastern, PA. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Community Blue Medicare HMO Distinct (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 Distinct (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 Distinct (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $27.00. 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 a $615.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6250.00 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:
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Drug Coverage
The Community Blue Medicare HMO Distinct (HMO) plan features an annual prescription drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic drugs, you will pay no copay for one-month or three-month supplies at preferred pharmacies and preferred mail-order services. Standard pharmacies and mail-order options charge a $7 copay for Tier 1 and a $15 copay for Tier 2 for a one-month supply. Higher-tier medications require coinsurance rather than flat copays, regardless of the pharmacy you choose. Tier 3 preferred brand drugs cost 20% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require 25% coinsurance. These coinsurance rates apply to both one-month and three-month supplies, though Tier 5 specialty drugs are restricted to one-month fills.
Additional Benefits
The Community Blue Medicare HMO Distinct (HMO) plan offers robust medical coverage with no copay or coinsurance for primary care visits, preventive services, and home health care. For specialized care, members pay a low $20 copay for specialist visits, while emergency room visits carry a $130 copay that is waived upon admission. Inpatient hospital stays require a $295 copay per admission with no coinsurance, and outpatient hospital services feature a $245 copay. This plan also provides strong dental, vision, and hearing benefits, including a $3,000 annual limit on covered dental services with no copay and a $400 annual allowance for eyewear. Additionally, members can access up to $75 in over-the-counter items every three months with no copay or coinsurance. Skilled nursing facility stays feature no copay for the first 20 days, while durable medical equipment is available with no copay and coinsurance ranging up to 50 percent.
Inpatient Hospital See details
Community Blue Medicare HMO Distinct (HMO) covers inpatient acute hospital stays with a $295 copay per admission and no coinsurance, though upgrades and non-Medicare-covered stays are not covered. Inpatient psychiatric care is covered with no coinsurance, featuring a $425 daily copay for days 1 through 3 and no copay for days 4 through 90.
Outpatient Services See details
Community Blue Medicare HMO Distinct (HMO) covers outpatient services with no coinsurance, featuring a $245 copay for outpatient hospital and daily observation services, and a $195 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $45 copay, while outpatient blood services are fully covered with no copay or coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered under the Community Blue Medicare HMO Distinct (HMO) plan with no copay and no coinsurance.
Ambulance and Transportation Services See details
Community Blue Medicare HMO Distinct (HMO) covers ground and air ambulance services with a $345 copay and no coinsurance, requiring prior authorization. Transportation services are partially covered, offering unlimited one-way trips with no copay or coinsurance to plan-approved locations, while transportation to any other health-related location is not covered.
Emergency Services See details
Community Blue Medicare HMO Distinct (HMO) covers emergency services with a $130 copay, which is waived if admitted to the hospital within 3 days, and no coinsurance. Urgently needed services require a $40 copay with no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $130, $40, and $345, respectively.
Primary Care See details
Community Blue Medicare HMO Distinct (HMO) offers primary care physician services with no copay and no coinsurance, while specialist visits, physical therapy, and occupational therapy require a $20 copay and no coinsurance. Chiropractic care is partially covered with a $10 copay and no coinsurance, though other non-routine chiropractic services are not covered.
Preventive Services See details
Preventive Services are partially covered by Community Blue Medicare HMO Distinct (HMO), featuring no copay and no coinsurance for annual physicals, kidney disease education, and routine screenings. Remote access technologies require a $0 to $20 copay with no coinsurance, and home safety devices have a 20% coinsurance with no copay, while services such as health education, PERS, alternative therapies, and in-home support are not covered.
Hearing Services See details
Hearing services are partially covered by Community Blue Medicare HMO Distinct (HMO), featuring one routine hearing exam annually for a $20 copay and no coinsurance, while fitting and evaluation services are not covered. Up to two prescription hearing aids are covered per year with no coinsurance and copays between $699 and $999, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Community Blue Medicare HMO Distinct (HMO) vision services are partially covered, featuring one routine eye exam per year with a $20 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a combined maximum benefit of $400 annually for contacts, eyeglass lenses, frames, and upgrades.
Dental Services See details
Dental services are partially covered by Community Blue Medicare HMO Distinct (HMO), offering Medicare-covered dental with a $20 copay and no coinsurance, and other covered dental services with no copay or coinsurance up to a $3,000 annual maximum. While preventive and restorative care are included, other diagnostic services, other preventive services, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Community Blue Medicare HMO Distinct (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and insulin, require coinsurance ranging from no coinsurance to 20%, with insulin also having a $35 copay that does not apply to the plan deductible.
Dialysis Services See details
Dialysis Services are covered by Community Blue Medicare HMO Distinct (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Community Blue Medicare HMO Distinct (HMO) covers medical equipment with no copays, though prior authorization is required. Durable medical equipment has a coinsurance ranging from no coinsurance to 50%, diabetic supplies range from no coinsurance to 20% coinsurance, and prosthetic devices, medical supplies, and diabetic shoes or inserts require a 20% coinsurance.
Diagnostic and Radiological Services See details
Community Blue Medicare HMO Distinct (HMO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Diagnostic tests carry a $0 to $10 copay with no copay for lab services, while radiological services require a $10 copay for X-rays, a minimum $60 copay for therapeutic radiology, and a minimum $200 copay for diagnostic radiology.
Home Health Services See details
Home health services are covered under the Community Blue Medicare HMO Distinct (HMO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Community Blue Medicare HMO Distinct (HMO) plan. Although the category technically features no copay and no coinsurance, cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Community Blue Medicare HMO Distinct (HMO) with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Community Blue Medicare HMO Distinct (HMO) partially covers other services, offering over-the-counter (OTC) items with no copay and no coinsurance up to a maximum of $75 every three months. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone are not covered.
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