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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 generic medications, the plan offers savings with no copay for Tier 1 preferred generics and Tier 2 generics when filled at a preferred pharmacy or through preferred mail order. Standard pharmacies and standard mail order options charge a copay ranging from $7 to $15 for a one-month supply of these generic drugs. Higher-tier medications are subject to coinsurance rather than flat copayments. You will pay a 20% coinsurance for Tier 3 preferred brand drugs at all pharmacy types. Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance for both preferred and standard pharmacy fills.
Additional Benefits
The Community Blue Medicare HMO Distinct (HMO) plan offers comprehensive medical coverage with predictable costs, including no copay and no coinsurance for primary care visits and annual preventive exams. Specialist visits, physical therapy, and routine vision and hearing exams are highly affordable with a low $20 copay and no coinsurance. For more intensive care, inpatient hospital admissions require a $295 copay per stay with no coinsurance, while emergency room visits carry a $130 copay that is waived if you are admitted. This plan also features robust supplemental benefits, including a $3,000 annual maximum for covered dental services and a $400 yearly allowance for eyewear with no copay or coinsurance. Members also benefit from no copays on lab services, home health visits, and partial hospitalization, alongside a quarterly $75 over-the-counter allowance. Prescription hearing aids are covered with copays ranging from $699 to $999, ensuring your essential health and wellness needs are met with minimal out-of-pocket expenses.
Inpatient Hospital See details
Community Blue Medicare HMO Distinct (HMO) covers inpatient hospital services with no coinsurance, though prior authorization is required. Acute stays require a $295.00 copay per admission with unlimited additional days at no copay, whereas psychiatric stays require a $425.00 copay for days 1 to 3 and no copay for days 4 to 90. This benefit is partially covered as upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Community Blue Medicare HMO Distinct (HMO) covers outpatient hospital and observation services with a $245 copay per day and no coinsurance, and ambulatory surgical center services with a $195 copay and no coinsurance. Outpatient substance abuse services require a $45 copay per individual or group session with no coinsurance, while outpatient blood services are covered with no copay, deductible, or coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Community Blue Medicare HMO Distinct (HMO) 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. Transportation services are partially covered, offering unlimited one-way trips to plan-approved locations with no copay and no coinsurance, while transportation to any health-related location is not covered.
Emergency Services See details
Community Blue Medicare HMO Distinct (HMO) covers emergency services for a $130 copay (waived if admitted to the hospital within 3 days) and urgently needed services for a $40 copay, with no coinsurance required for either. Worldwide emergency, urgent, and emergency transportation services are also covered with no coinsurance, featuring copays of $130, $40, and $345, respectively.
Primary Care See details
Community Blue Medicare HMO Distinct (HMO) covers primary care physician services with no copay and no coinsurance, and specialist, physical therapy, and occupational therapy visits with a $20 copay and no coinsurance. Chiropractic services are partially covered with a $10 copay and no coinsurance, excluding other chiropractic services, while mental health, psychiatric, and podiatry services feature copays of $20 to $30 and no coinsurance.
Preventive Services See details
Preventive Services are partially covered by Community Blue Medicare HMO Distinct (HMO), featuring no copay and no coinsurance for annual physical exams, kidney disease education, and standard screenings. While remote access technologies require a $0 to $20 copay and home safety devices have a 20% coinsurance, several supplemental benefits such as health education, nutritional counseling, and personal emergency response systems are not covered.
Hearing Services See details
Hearing services are partially covered by Community Blue Medicare HMO Distinct (HMO), offering one annual routine hearing exam for a $20 copay and no coinsurance, and up to two prescription hearing aids per year with a copay ranging from $699 to $999 and no coinsurance. Hearing aid fittings and evaluations, over-the-counter (OTC) hearing aids, and inner, outer, or over-the-ear prescription hearing aid types are not covered.
Vision Services See details
Vision Services are partially covered by Community Blue Medicare HMO Distinct (HMO), offering one routine eye exam per year for a $20 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay or coinsurance up to a $400 annual maximum for contacts, lenses, frames, and upgrades.
Dental Services See details
Community Blue Medicare HMO Distinct (HMO) partially covers dental services with a $20 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for other covered services up to a $3,000 annual maximum. While preventive and comprehensive care like exams and cleanings are included, other diagnostic, other preventive, maxillofacial prosthetics, implant services, 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 and no coinsurance, although prior authorization and step therapy are required. Associated Medicare Part B chemotherapy, radiation, and other drugs have no copay and 0% to 20% coinsurance, while Medicare Part B insulin drugs require a $35 copay and 0% to 20% coinsurance.
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 for these services. Coinsurance ranges from no coinsurance up to 50% for durable medical equipment, 20% for prosthetics and medical supplies, and no coinsurance up to 20% for diabetic supplies and therapeutic shoes.
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. Members pay no copay for lab services, $0 to $10 for diagnostic procedures and tests, $10 for outpatient X-rays, $60 for therapeutic radiological services, and a $200 copay for diagnostic radiological services.
Home Health Services See details
Home health services are covered by Community Blue Medicare HMO Distinct (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Community Blue Medicare HMO Distinct (HMO) covers cardiac rehabilitation services with no copay and no coinsurance, but only some services are covered because cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are partially covered by Community Blue Medicare HMO Distinct (HMO) with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by Community Blue Medicare HMO Distinct (HMO), featuring an over-the-counter (OTC) benefit with no copay and no coinsurance up to $75 every three months. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone are not covered under this plan.
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