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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 drug deductible of $615. For Tier 1 preferred generics and Tier 2 generics, you will pay no copay for 1-month or 3-month supplies when using preferred pharmacies or preferred mail-order services. If you choose standard pharmacies or standard mail order, Tier 1 drugs have a $7 copay and Tier 2 drugs have a $15 copay for a 1-month supply. For higher-tier medications, costs transition from flat copays to coinsurance percentages. Tier 3 preferred brand drugs require a 20% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance. These coinsurance rates apply equally across all preferred and standard pharmacy and mail-order options.
Additional Benefits
The Community Blue Medicare HMO Distinct (HMO) plan offers comprehensive coverage with predictable costs, featuring no copay for primary care visits, preventive screenings, and home health services. Specialist visits, routine eye exams, and routine hearing exams require a low $20 copay, while preventive dental care and eyewear are covered with no copay. Inpatient acute hospital stays carry a $295 copay per stay with no coinsurance, and outpatient hospital services have a $245 copay. For urgent and emergency needs, members pay a $40 copay for urgent care and a $130 copay for emergency room visits. Skilled nursing facility stays feature no copay for the first 20 days, and diagnostic lab services are also provided with no copay. Additionally, the plan includes an over-the-counter allowance of up to $75 every three months with no copay to help cover everyday wellness items.
Inpatient Hospital See details
Community Blue Medicare HMO Distinct (HMO) covers inpatient acute hospital stays with a $295 copay per stay and no coinsurance, though upgrades and non-Medicare-covered stays are not covered. Inpatient psychiatric hospital stays are covered with no coinsurance, requiring a $425 copay per stay for days 1 through 3 and no copay for days 4 through 90. Prior authorization is required for both services, and additional psychiatric days or non-Medicare-covered psychiatric stays are not covered.
Outpatient Services See details
Community Blue Medicare HMO Distinct (HMO) covers outpatient services with no coinsurance, featuring a $245 copay for outpatient hospital and observation services and a $195 copay for ambulatory surgical center services. Outpatient substance abuse sessions have a $45 copay and no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered by Community Blue Medicare HMO Distinct (HMO) with no copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered under the Community Blue Medicare HMO Distinct (HMO) plan, with prior authorization required for both. Ground and air ambulance services require a $345 copay and no coinsurance, while unlimited one-way transportation to plan-approved locations is provided with no copay and no coinsurance, though transportation to any health-related location is not covered.
Emergency Services See details
Community Blue Medicare HMO Distinct (HMO) covers emergency services with a $130 copay (waived if admitted to the hospital within three days) and no coinsurance, and urgently needed services with a $40 copay and no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance and copays of $130, $40, and $345, respectively.
Primary Care See details
Community Blue Medicare HMO Distinct (HMO) provides primary care physician services with no copay and no coinsurance, while specialist visits and therapy services require a $20 copay and no coinsurance. Chiropractic benefits are partially covered, offering routine care for a $10 copay and no coinsurance but excluding other chiropractic services, while mental health, podiatry, and telehealth are covered with copays up to $45 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 physicals, kidney disease education, and standard screenings. Covered supplemental benefits include memory fitness, remote access technologies (with a $0 to $20 copay), and home safety devices (with a 20% coinsurance), but health education, PERS, nutritional/dietary services, in-home support, and therapeutic massages 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, and up to two prescription hearing aids per year with copays ranging from $699 to $999 and no coinsurance. Hearing aid fittings and evaluations, over-the-counter (OTC) hearing aids, and inner ear, outer ear, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Community Blue Medicare HMO Distinct (HMO) partially covers vision services, offering 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, no coinsurance, and no deductible, providing up to a $400 annual maximum benefit for contacts, glasses, frames, lenses, and upgrades.
Dental Services See details
Community Blue Medicare HMO Distinct (HMO) provides partially covered dental services with a $3,000 annual maximum, requiring a $20 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for covered preventive and comprehensive services. Specific sub-services that are not covered under this plan include other diagnostic dental, other preventive dental, maxillofacial prosthetics, implant services, and orthodontics.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Community Blue Medicare HMO Distinct (HMO) with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs carry no copay and 0% to 20% coinsurance, while Part B insulin drugs are covered with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Community Blue Medicare HMO Distinct (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical Equipment benefits under Community Blue Medicare HMO Distinct (HMO) are covered with no copay, subject to prior authorization. Durable medical equipment ranges from no coinsurance to 50% coinsurance, while diabetic supplies range from no coinsurance to 20% coinsurance. Prosthetics, medical supplies, and diabetic therapeutic shoes carry a 20% coinsurance, with diabetic items limited to specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Community Blue Medicare HMO Distinct (HMO) with no coinsurance, though prior authorization is required. Members will pay no copay for lab services, a $0 to $10 copay for diagnostic procedures, a $10 copay for outpatient X-rays, and minimum copays of $60 for therapeutic radiology and $200 for diagnostic radiology.
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
Cardiac Rehabilitation Services are not covered under Community Blue Medicare HMO Distinct (HMO), as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all excluded from coverage.
Skilled Nursing Facility (SNF) See details
Community Blue Medicare HMO Distinct (HMO) covers skilled nursing facility (SNF) services with no coinsurance, requiring no copay for days 1 to 20 and a $218 copay for days 21 to 100. Prior authorization is required, and while a three-day prior hospital stay is not required, additional days beyond the 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 $75 maximum benefit every three months. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone are not covered under this benefit.
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