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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. Under this plan, you will pay no copay for Tier 1 preferred generic and Tier 2 generic drugs when using a preferred pharmacy or preferred mail-order service. If you choose a standard pharmacy or standard mail-order service, Tier 1 drugs require a $7 copay and Tier 2 drugs require a $15 copay for a one-month supply. For higher-tier medications, the plan transitions from flat copayments to coinsurance. Tier 3 preferred brand drugs require a 20% coinsurance across all pharmacy and mail-order options. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance for your prescriptions.
Additional Benefits
The Community Blue Medicare HMO Distinct (HMO) plan offers comprehensive medical coverage featuring no copay and no coinsurance for primary care visits, preventive services, and home health care. For specialized care, members pay copays ranging from $0 to $45 for specialist visits, while inpatient hospital acute stays require a $325 copay per admission with no coinsurance. Emergency care is covered with a $130 copay, and urgent care has a $40 copay, both with no coinsurance. This plan also includes supplemental benefits, such as routine dental care with no copay up to a $3,000 annual limit and routine vision exams for a $25 copay alongside a $400 eyewear allowance. Hearing exams require a $25 copay, and covered hearing aids carry copays between $699 and $999 with no coinsurance. Additionally, members benefit from a $75 over-the-counter quarterly allowance and no copay for the first 20 days of skilled nursing facility care.
Inpatient Hospital See details
Community Blue Medicare HMO Distinct (HMO) covers inpatient hospital care with no coinsurance, though prior authorization is required. Acute stays require a $325 copay per admission with no copay for unlimited additional days, while psychiatric stays require a $425 copay per stay for days 1 through 3 and no copay for days 4 through 90. Non-Medicare-covered stays, upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
Community Blue Medicare HMO Distinct (HMO) covers outpatient services with no coinsurance, including outpatient hospital and daily observation services for a $245 copay, and ambulatory surgical center services for a $195 copay. Outpatient substance abuse services require a $45 copay with no coinsurance, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
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
Community Blue Medicare HMO Distinct (HMO) covers ground and air ambulance services with a $345 copay and no coinsurance per trip. Transportation services are partially covered with no copay or coinsurance for unlimited one-way rides to plan-approved locations, but trips to any other health-related locations are not covered.
Emergency Services See details
Emergency services are covered by Community Blue Medicare HMO Distinct (HMO) with a $130 copay (waived if admitted to the hospital within 3 days) and no coinsurance, while urgently needed services require a $40 copay and no coinsurance. Worldwide emergency, urgent, and emergency 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) offers primary care physician services with no copay and no coinsurance, while specialist, therapy, and telehealth services feature copays ranging from $0 to $45 with no coinsurance. Chiropractic care is partially covered, as other chiropractic services are not covered.
Preventive Services See details
Preventive Services are partially covered by Community Blue Medicare HMO Distinct (HMO), offering annual physical exams, kidney disease education, and routine screenings with no copay and no coinsurance. Covered supplemental benefits include memory fitness, remote access technologies with a $0 to $25 copay, and home safety devices with 20% coinsurance, though services like health education, in-home safety assessments, and personal emergency response systems are not covered.
Hearing Services See details
Community Blue Medicare HMO Distinct (HMO) partially covers hearing services, offering one routine hearing exam annually for a $25 copay and no coinsurance, with no deductible. Up to two prescription hearing aids are covered per year with a copay ranging from $699.00 to $999.00 and no coinsurance, though fitting and evaluations, OTC hearing aids, and inner ear, outer ear, or over-the-ear prescription models are not covered.
Vision Services See details
Vision services are partially covered by Community Blue Medicare HMO Distinct (HMO) because other eye exam services are not covered. Routine eye exams cost a $25 copay with no coinsurance once per year, while eyewear is covered with no copay and no coinsurance up to a $400 annual maximum for contacts, eyeglasses, frames, and upgrades.
Dental Services See details
Dental services are partially covered by Community Blue Medicare HMO Distinct (HMO), featuring a $25 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for other covered services up to a $3,000 annual maximum. However, other diagnostic dental, other preventive dental, 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, although prior authorization is required. Associated Medicare Part B drugs, including chemotherapy and radiation, carry a coinsurance ranging from no coinsurance to 20%, while Medicare Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Community Blue Medicare HMO Distinct (HMO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Community Blue Medicare HMO Distinct (HMO) covers medical equipment with no copays, subject to prior authorization. Under this plan, durable medical equipment requires no coinsurance to 50% coinsurance, prosthetics and medical supplies carry a 20% coinsurance, and diabetic supplies from specified manufacturers require no coinsurance to 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. Lab services have no copay, outpatient X-rays have a $10 copay, and other diagnostic tests range from a $0 to $10 copay. Diagnostic radiological services carry a minimum $250 copay, while therapeutic radiological services have a minimum $60 copay.
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 the Community Blue Medicare HMO Distinct (HMO) plan, 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 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not needed, and additional days beyond the standard limit are not covered.
Other Services See details
Community Blue Medicare HMO Distinct (HMO) partially covers other services, providing a $75 allowance every three months for over-the-counter (OTC) items with no copay and no coinsurance. Acupuncture, meal benefits, and other miscellaneous services are not covered under this plan.
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