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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 $35.00. 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 generic and Tier 2 generic drugs, members enjoy no copay for one-month and three-month supplies when using preferred pharmacies or preferred mail order services. If you choose standard pharmacies or standard mail order, Tier 1 copays range from $7 to $21, while Tier 2 copays range from $15 to $45 depending on the supply. For higher-tier medications, the plan transitions from flat copays to coinsurance across all pharmacy and mail order options. Tier 3 preferred brand drugs require a 20% coinsurance for both one-month and three-month supplies. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance, helping you plan for your out-of-pocket prescription costs.
Additional Benefits
The Community Blue Medicare HMO Distinct (HMO) plan offers robust medical coverage featuring no copayments or coinsurance for primary care visits, home health services, and annual preventive exams. Specialist visits require a low $30 copay, while inpatient hospital stays incur a $350 copay per stay with no coinsurance. Emergency room visits have a $130 copay, which is waived if you are admitted, and urgent care is available for a $40 copay. This plan also provides excellent supplemental benefits, including dental care with no copay up to a $3,000 annual maximum and eyewear covered up to a $400 annual limit with no copay. Routine vision and hearing exams are available for a $30 copay, and prescription hearing aids require a copay ranging from $699 to $999. Additionally, members benefit from a quarterly $75 over-the-counter allowance with no copay or coinsurance.
Inpatient Hospital See details
Community Blue Medicare HMO Distinct (HMO) covers inpatient acute hospital stays with no coinsurance and a $350 copayment per stay, while inpatient psychiatric stays require no coinsurance and a $425 copayment per day for days 1 through 3, followed by no copayment for days 4 through 90. Prior authorization is required, and upgrades, additional psychiatric days, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Community Blue Medicare HMO Distinct (HMO) covers outpatient services with no coinsurance, including outpatient hospital and observation services for a $275 copay and ambulatory surgical center services for a $225 copay. Additionally, outpatient substance abuse sessions 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
Community Blue Medicare HMO Distinct (HMO) covers partial hospitalization services 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, featuring a $345 copay and no coinsurance for both ground and air ambulance services. Transportation services to plan-approved health-related locations are covered 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 3 days) and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance, requiring 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, psychiatric, and mental health services carry a $30 copay and no coinsurance. Physical, occupational, and speech therapies require a $20 copay and no coinsurance, whereas chiropractic services are partially covered with a $10 copay and no coinsurance for routine care but other chiropractic services are not covered.
Preventive Services See details
Community Blue Medicare HMO Distinct (HMO) covers annual physical exams, kidney disease education, and other preventive screenings with no copay and no coinsurance. Additional preventive benefits are partially covered, including memory fitness, remote access technologies with a $0 to $30 copay, and home safety devices with 20% coinsurance. Several supplemental services are not covered, including health education, personal emergency response systems, nutritional/dietary benefits, and in-home support.
Hearing Services See details
Community Blue Medicare HMO Distinct (HMO) offers partially covered hearing services with no deductible, including one routine hearing exam per year for a $30 copay and no coinsurance, and up to two prescription hearing aids per year for a $699 to $999 copay and no coinsurance. Fitting or evaluation exams, 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
Vision services are partially covered by Community Blue Medicare HMO Distinct (HMO), which offers one routine eye exam per year for a $30 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $400 annual maximum for contacts, lenses, frames, and upgrades.
Dental Services See details
Community Blue Medicare HMO Distinct (HMO) covers dental services with a $30 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for other covered dental services up to a $3,000 annual maximum. These dental services are partially covered, as 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, though prior authorization is required. Covered Medicare Part B drugs, including chemotherapy, radiation, and other infusion drugs, require no coinsurance to 20% coinsurance, while Part B insulin has a $35 copay and no coinsurance 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, although prior authorization is required. Durable medical equipment carries coinsurance ranging from no coinsurance up to 50%, while prosthetics, medical supplies, and diabetic equipment incur up to 20% coinsurance.
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. Lab services have no copay, diagnostic tests have a $0 to $10 copay, outpatient X-rays cost $10, and therapeutic and diagnostic radiological services require minimum copays of $60 and $250, respectively.
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, though prior authorization is required.
Cardiac Rehabilitation Services See details
Community Blue Medicare HMO Distinct (HMO) covers some Cardiac Rehabilitation Services with no copay and no coinsurance, but specific services including Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Community Blue Medicare HMO Distinct (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, though prior authorization is required. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, with no coverage provided for additional days beyond the Medicare limit.
Other Services See details
Other services are partially covered by Community Blue Medicare HMO Distinct (HMO), which provides an over-the-counter (OTC) benefit of up to $75 every three months with no copay and no coinsurance. Acupuncture, meal benefits, nicotine replacement therapy, and Naloxone are not covered under this plan.
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