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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 $50.00. 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 medications, you will pay no copay when using a preferred pharmacy or preferred mail-order services. If you utilize standard pharmacies or standard mail order, Tier 1 drugs require a $7 copay and Tier 2 drugs require a $15 copay for a one-month supply. Brand-name and specialty drugs under this plan are subject to coinsurance rather than flat copayments. Tier 3 preferred brand drugs require a 20% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance. These cost-sharing rates apply to both preferred and standard pharmacies, as well as mail-order options.
Additional Benefits
The Community Blue Medicare HMO Distinct (HMO) plan offers robust coverage with no copay or coinsurance for primary care visits, preventive services, and home health care. Specialist visits require a $35 copay, while inpatient hospital stays have a $400 copay per stay with no coinsurance. Emergency care is available with a $130 copay, and outpatient hospital services carry a $300 copay. For supplemental care, the plan features routine vision and dental services with no copay up to specified annual limits, alongside a $35 copay for routine hearing exams. Skilled nursing facility stays have no copay for the first 20 days, and select over-the-counter items are covered with no copay up to $75 every three months. Diagnostic lab work and partial hospitalization are also covered with no copay, helping to keep out-of-pocket costs predictable.
Inpatient Hospital See details
Community Blue Medicare HMO Distinct (HMO) covers inpatient acute hospital stays with a $400 copay per stay and no coinsurance, though upgrades and non-Medicare-covered stays are not covered. Inpatient psychiatric care is covered with no coinsurance and a $425 daily copay for days 1 through 3 and no copay for days 4 through 90, but additional 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 $300 copay, and ambulatory surgical center services for a $250 copay. Outpatient substance abuse services carry a $45 copay per session with no coinsurance, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
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, subject to prior authorization. Transportation services are partially covered, offering unlimited one-way trips to plan-approved health-related locations with no copay and no coinsurance, though 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 (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 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) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $35 copay and no coinsurance. Other primary care benefits—including physical therapy, mental health, and podiatry—have copays ranging from $0 to $45 and no coinsurance, though chiropractic care is only partially covered because other chiropractic services are not covered.
Preventive Services See details
Community Blue Medicare HMO Distinct (HMO) covers preventive services, annual physical exams, and kidney disease education with no copay and no coinsurance. Supplemental benefits are partially covered, including remote access technologies with a $0 to $35 copay and home safety devices with a 20% coinsurance, while services like health education, nutritional benefits, 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 with no deductible, a $35 copay, and no coinsurance, plus up to two prescription hearing aids per year with a $699 to $999 copay and no coinsurance. Fitting and evaluation exams, 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) covers vision services, offering one routine eye exam per year with a $35 copay and no coinsurance, though other eye exam services are not covered. Eyewear, including contacts and glasses, is covered with no copay or coinsurance up to a $400 annual maximum limit.
Dental Services See details
Community Blue Medicare HMO Distinct (HMO) partially covers dental services up to a $3,000 annual maximum, offering Medicare-covered dental with a $35 copay and no coinsurance, and other covered dental services with no copay and no coinsurance. However, other diagnostic dental services, other preventive dental services, maxillofacial prosthetics, implant services, and orthodontics are not covered under this plan.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Community Blue Medicare HMO Distinct (HMO) with no copay and no coinsurance, although prior authorization is required. Covered Part B insulin drugs have a $35 copay and no coinsurance to 20% coinsurance, while chemotherapy, radiation, and other Part B drugs require no 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 copay, although prior authorization is required. Durable medical equipment has coinsurance ranging from no coinsurance up to 50%, diabetic supplies range from no coinsurance to 20% coinsurance, and prosthetic devices, medical supplies, and diabetic shoes carry a 20% coinsurance.
Diagnostic and Radiological Services See details
Community Blue Medicare HMO Distinct (HMO) covers diagnostic and radiological services with no coinsurance, subject to prior authorization. Lab services have no copay, diagnostic tests range from a $0 to $10 copay, outpatient X-rays carry a $10 copay, and therapeutic and diagnostic radiological services require minimum copays of $60 and $250, respectively.
Home Health Services See details
Home Health Services are covered by Community Blue Medicare HMO Distinct (HMO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Community Blue Medicare HMO Distinct (HMO) with no copay and no coinsurance. Although some services are covered, standard 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, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required and no prior three-day hospital stay is needed, though additional 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 select over-the-counter (OTC) items with no copay and no coinsurance up to a maximum benefit of $75 every three months. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone are not covered under this plan.
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