A non-government entity
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 $55.00. 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:
Sign up for Community Blue Medicare HMO Distinct (HMO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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. Standard pharmacies and standard mail order services charge a $7 copay for Tier 1 drugs and a $15 copay for Tier 2 drugs for a 1-month supply. For higher-tier medications, cost-sharing is based on coinsurance rather than flat copayments. Tier 3 preferred brand drugs require a 20% coinsurance, while Tier 4 non-preferred drugs carry a 25% coinsurance across all pharmacy options. Tier 5 specialty drugs also require a 25% coinsurance and are limited to a 1-month supply.
Additional Benefits
The Community Blue Medicare HMO Distinct (HMO) plan offers robust coverage for essential medical services, featuring no copay and no coinsurance for primary care visits, preventive screenings, and home health services. Specialist visits, routine dental, and eye exams are available with a low $35 copay and no coinsurance. For acute hospital care, members pay a $400 copay per inpatient stay and a $300 copay for outpatient services, both with no coinsurance. Additional benefits include no copay for preventive and comprehensive dental up to a $3,000 annual limit, alongside a $400 annual eyewear allowance with no copay or coinsurance. Over-the-counter items are covered with no copay up to $40 every three months, and prescription hearing aids require copays between $699 and $999. While medical equipment and dialysis require no copay, they carry coinsurance rates up to 50% and 20% respectively.
Inpatient Hospital See details
Community Blue Medicare HMO Distinct (HMO) partially covers inpatient hospital services, excluding upgrades, non-Medicare-covered stays, and additional psychiatric days. For covered acute stays, there is a $400 copay per stay and no coinsurance, while psychiatric stays require a $425 daily copay for days 1 through 3 and no copay for days 4 through 90, with no coinsurance for either service.
Outpatient Services See details
Community Blue Medicare HMO Distinct (HMO) covers outpatient hospital and observation services with a $300 copay (per day for observation) and no coinsurance, and ambulatory surgical center services with a $250 copay and no coinsurance. Outpatient substance abuse sessions require a $45 copay with no coinsurance, while outpatient blood services are covered with no copay and no 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
Ambulance and transportation services are covered by Community Blue Medicare HMO Distinct (HMO), though transportation is only partially covered because rides to any health-related location are not covered. Prior authorized ground and air ambulances require a $345 copay and no coinsurance, while unlimited one-way trips to plan-approved locations have no copay and no coinsurance.
Emergency Services See details
Community Blue Medicare HMO Distinct (HMO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within 3 days. Urgently needed services are covered with a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services require copays ranging from $40 to $345 with no coinsurance.
Primary Care See details
Community Blue Medicare HMO Distinct (HMO) features primary care physician visits with no copay and no coinsurance, and specialist visits with a $35 copay and no coinsurance. Other services like physical therapy, mental health, and podiatry require copays between $0 and $45 with no coinsurance, while chiropractic care is partially covered as other chiropractic services are not covered.
Preventive Services See details
Community Blue Medicare HMO Distinct (HMO) covers preventive services, annual physical exams, kidney disease education, and other screenings with no copay and no coinsurance. Some additional services are not covered, including health education, personal emergency response systems, and nutritional counseling, while covered remote access technologies require a $0 to $35 copay with no coinsurance, and home safety devices require a 20% coinsurance with no copay.
Hearing Services See details
Hearing services are partially covered by Community Blue Medicare HMO Distinct (HMO), which offers one routine hearing exam annually for a $35 copay and no coinsurance. Up to two prescription hearing aids are covered each year with no coinsurance and a copay ranging from $699 to $999, while fitting and evaluation services, OTC hearing aids, and inner, outer, or over-the-ear prescription models are not covered.
Vision Services See details
Community Blue Medicare HMO Distinct (HMO) offers partially covered vision services, featuring a $35 copay and no coinsurance or deductible for one routine annual eye exam, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, up to a $400 annual maximum for contact lenses, eyeglasses, frames, and upgrades.
Dental Services See details
Community Blue Medicare HMO Distinct (HMO) dental services are partially covered, offering Medicare-covered dental with a $35 copay and no coinsurance, and other covered preventive and comprehensive services with no copay and no coinsurance up to a $3,000 annual maximum. Non-covered services include other diagnostic, other preventive, maxillofacial prosthetics, implants, 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 and other drugs have no copay and coinsurance ranging from no coinsurance to 20%, while Part B insulin requires 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
Medical equipment is covered by Community Blue Medicare HMO Distinct (HMO) with no copays, although prior authorization is required. Patients will pay coinsurance ranging from no coinsurance to 50% for durable medical equipment, no coinsurance to 20% for diabetic supplies from specified manufacturers, and a flat 20% coinsurance for prosthetics, medical supplies, and diabetic 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. Lab services have no copay, diagnostic procedures range from a $0 to $10 copay, outpatient X-rays require a $10 copay, and therapeutic and diagnostic radiological services have 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 not covered under Community Blue Medicare HMO Distinct (HMO), as all related sub-services—including intensive cardiac, pulmonary, and SET for PAD services—are excluded from coverage.
Skilled Nursing Facility (SNF) See details
Skilled nursing facility (SNF) care is covered by Community Blue Medicare HMO Distinct (HMO) with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100 per stay. Prior authorization is required, a prior three-day hospital stay is not necessary, and additional days beyond the Medicare-covered 100 days are not covered.
Other Services See details
Community Blue Medicare HMO Distinct (HMO) partially covers other services, which includes over-the-counter (OTC) items with no copay and no coinsurance up to $40 every three months. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved