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Community Blue Medicare HMO Signature (HMO)

H3957 - 042 - 1
5 out of 5 stars (5 / 5)

Community Blue Medicare HMO Signature (HMO) is a Medicare Advantage Plan by Highmark Blue Cross Blue Shield or Highmark Blue Shield.

This page features plan details for 2025 Community Blue Medicare HMO Signature (HMO) H3957 – 042 – 1 available in North Central PA.

Locations

Community Blue Medicare HMO Signature (HMO) is offered in the following locations.

Carbon County, Pennsylvania
Lehigh County, Pennsylvania
Monroe County, Pennsylvania

Click to see more locations

Plan Overview

Community Blue Medicare HMO Signature (HMO) offers the following coverage and cost-sharing.

Insurer:Highmark Blue Cross Blue Shield or Highmark Blue Shield
Health Plan Deductible:$0
MOOP:$6,500 In-network
Drugs Covered:Yes

Ready to sign up for Community Blue Medicare HMO Signature (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Medicare Part B Give Back Benefit

The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans. 

Community Blue Medicare HMO Signature (HMO) qualifies for a monthly Medicare Give Back Benefit of $33.00.

Premium Reduction:$33.00

Premium Breakdown

Community Blue Medicare HMO Signature (HMO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $0.00 $33.00 $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Community Blue Medicare HMO Signature (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $0.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$0.00$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Community Blue Medicare HMO Signature (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: No Coins – No Co pay
  • Endodontics
    • In-Network: No Coins – No Co pay
  • Oral and Maxillofacial Surgery
    • In-Network: No Coins – No Co pay
  • Periodontics
    • In-Network: No Coins – No Co pay
  • Prosthodontics, fixed
    • In-Network: No Coins – No Co pay
  • Prosthodontics, removable
    • In-Network: No Coins – No Co pay
  • Restorative Services
    • In-Network: No Coins – No Co pay

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay
  • Fluoride Treatment
    • In-Network: No Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – No Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Outpatient x-rays
    • $10 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • $200 copay (Authorization Required)
  • Diagnostic tests and procedures
    • $0 copay (Authorization Required)
  • Lab services
    • $0 copay (Authorization Required)

Doctor visits

  • Specialist
    • $0 copay
  • Primary
    • $0 copay

Emergency care/Urgent care

  • Emergency
    • $125 copay per visit (always covered)
  • Urgent care
    • $0 copay

Foot care (podiatry services)

  • Routine foot care
    • $0 copay (Limits Apply)
  • Foot exams and treatment
    • $0 copay

Ground ambulance

    • $250 copay
    • $275 copay

Health plan deductible

    • $0

Hearing

  • Hearing aids
    • $699-999 copay (Limits Apply)
  • Fitting/evaluation
    • Not covered
  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • $0 copay

Inpatient hospital coverage

    • $295 per stay (Authorization Required)
    • $250 per stay (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $6,500 In-network

Medical equipment/supplies

  • Diabetes supplies
    • 0-20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Other Part B drugs
    • 0-20% coinsurance (Authorization Required)
  • Chemotherapy
    • 0-20% coinsurance (Authorization Required)

Mental health services

  • Inpatient hospital – psychiatric
    • $425 per day for days 1 through 3
      $0 per day for days 4 through 90 (Authorization Required)
  • Outpatient individual therapy visit
    • $30 copay
  • Outpatient individual therapy visit with a psychiatrist
    • $30 copay
  • Outpatient group therapy visit with a psychiatrist
    • $30 copay
  • Outpatient group therapy visit
    • $30 copay

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • $325 copay per visit (Authorization Required)
    • $175 copay per visit (Authorization Required)

Preventive care

    • $0 copay

Rehabilitation services

  • Occupational therapy visit
    • $10 copay (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • $0 copay (Authorization Required)
    • $20 copay (Authorization Required)
  • Occupational therapy visit
    • $20 copay (Authorization Required)

Skilled Nursing Facility

    • $0 per day for days 1 through 20
      $214 per day for days 21 through 100 (Authorization Required)

Transportation

    • $0 copay (Authorization Required)

Vision

  • Eyeglass frames
    • $0 copay (Limits Apply)
  • Routine eye exam
    • $0 copay (Limits Apply)
  • Upgrades
    • $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • $0 copay (Limits Apply)
  • Other
    • Not covered
  • Contact lenses
    • $0 copay (Limits Apply)
  • Eyeglass lenses
    • $0 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for Community Blue Medicare HMO Signature (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Table of Contents

Get Help Enrolling

Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint

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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.

All plan-related information on this site is from CMS.gov and Medicare.gov. We only use data released publicly each year. While our goal is always to provide fact-based, accurate information, information is subject to change, and some data may be inaccurate. Contact a plan for a Summary of Benefits.

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.

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