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Community Blue Medicare PPO Distinct (PPO)

H3916 - 034 - 1
4.5 out of 5 stars (4.5 / 5)

Community Blue Medicare PPO Distinct (PPO) 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 PPO Distinct (PPO) H3916 – 034 – 1 available in North Central PA.

Locations

Community Blue Medicare PPO Distinct (PPO) 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 PPO Distinct (PPO) offers the following coverage and cost-sharing.

Insurer:Highmark Blue Cross Blue Shield or Highmark Blue Shield
Health Plan Deductible:$0
MOOP:$8,950 In and Out-of-network
$5,500 In-network
Drugs Covered:Yes

Ready to sign up for Community Blue Medicare PPO Distinct (PPO) ?

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

Premium Breakdown

Community Blue Medicare PPO Distinct (PPO) has a monthly premium of $15.00. 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 $4.40 $10.60 $ $
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 PPO Distinct (PPO) 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
$10.60$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 PPO Distinct (PPO) 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: 0-10 Coins – No Co pay
  • Endodontics
    • In-Network: 10 Coins – No Co pay
  • Oral and Maxillofacial Surgery
    • In-Network: 10 Coins – No Co pay
  • Periodontics
    • In-Network: 10 Coins – No Co pay
  • Prosthodontics, fixed
    • In-Network: 10 Coins – No Co pay
  • Prosthodontics, removable
    • In-Network: 10 Coins – No Co pay
  • Restorative Services
    • In-Network: 10 Coins – No Co pay

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay
    • Out-of-Network: 30% Coins – No Copay
  • Fluoride Treatment
    • In-Network: No Coins – No Copay
    • Out-of-Network: 30% Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – No Copay
    • Out-of-Network: 30% Coins – No Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay
    • Out-of-Network: 30% Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: $175 copay (Authorization Required)
  • Diagnostic tests and procedures
    • Out-of-Network: $0 copay (Authorization Required)
  • Lab services
    • In-Network: $0 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $15 copay (Authorization Required)
    • In-Network: $20 copay (Authorization Required)
    • Out-of-Network: $20 copay (Authorization Required)
    • Out-of-Network: $15 copay (Authorization Required)
  • Lab services
    • Out-of-Network: $0 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $175 copay (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0 copay (Authorization Required)

Doctor visits

  • Primary
    • In-Network: $0 copay
  • Specialist
    • Out-of-Network: $5 copay per visit
    • In-Network: $15 copay per visit
    • Out-of-Network: $15 copay per visit
  • Primary
    • Out-of-Network: $0 copay
  • Specialist
    • In-Network: $5 copay per visit

Emergency care/Urgent care

  • Emergency
    • $125 copay per visit (always covered)
  • Urgent care
    • $30 copay per visit (always covered)
    • $10 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • In-Network: $5 copay
    • Out-of-Network: $5 copay
  • Routine foot care
    • In-Network: $15 copay (Limits Apply)
  • Foot exams and treatment
    • In-Network: $15 copay
    • Out-of-Network: $15 copay
  • Routine foot care
    • In-Network: $5 copay (Limits Apply)

Ground ambulance

    • In-Network: $250 copay
    • Out-of-Network: $275 copay or 30% coinsurance
    • In-Network: $275 copay
    • Out-of-Network: $250 copay or 30% coinsurance

Health plan deductible

    • $0

Hearing

  • Hearing aids
    • Out-of-Network: $0 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • In-Network: $5 copay
  • Hearing aids
    • In-Network: $699-999 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • Out-of-Network: $5 copay
    • Out-of-Network: $15 copay
  • Fitting/evaluation
    • Not covered
  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • In-Network: $15 copay

Inpatient hospital coverage

    • Out-of-Network: $250 per stay (Authorization Required)
    • In-Network: $250 per stay (Authorization Required)

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

    • $8,950 In and Out-of-network
      $5,500 In-network

Medical equipment/supplies

  • Diabetes supplies
    • In-Network: 0-20% coinsurance per item (Authorization Required)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 20% coinsurance per item (Authorization Required)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)
  • Chemotherapy
    • Out-of-Network: 30% coinsurance (Authorization Required)

Mental health services

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

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $245 copay per visit (Authorization Required)
    • Out-of-Network: $245 copay per visit (Authorization Required)

Preventive care

    • Out-of-Network: $0 copay
    • In-Network: $0 copay

Rehabilitation services

  • Occupational therapy visit
    • In-Network: $30 copay (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • In-Network: $15 copay (Authorization Required)
    • Out-of-Network: $15 copay (Authorization Required)
  • Occupational therapy visit
    • Out-of-Network: $30 copay (Authorization Required)

Skilled Nursing Facility

    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 100 (Authorization Required)
    • Out-of-Network: 30% per stay (Authorization Required)

Transportation

    • In-Network: $0 copay (Authorization Required)
    • Out-of-Network: 30% coinsurance (Authorization Required)

Vision

  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Other
    • Not covered
  • Eyeglasses (frames and lenses)
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • Out-of-Network: $50 copay (Limits Apply)
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
  • Upgrades
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • Out-of-Network: $0 copay (Limits Apply)

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

    • Covered

Ready to sign up for Community Blue Medicare PPO Distinct (PPO) ?

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

Need more information on Community Blue Medicare PPO Distinct (PPO)? See 2025 Community Blue Medicare PPO Distinct (PPO) at MedicareAdvantageRX.com.

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