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Community Blue Medicare Plus PPO Signature (PPO)
The Centers for Medicare & Medicaid Services (CMS) publishes annual Star Ratings that reflect how each Medicare Advantage plan performs across a range of metrics, using a system of one to five stars.
$0.00
Monthly Premium
Community Blue Medicare Plus PPO Signature (PPO) is a PPO plan offered by Highmark Health
Plan ID: H3916-063
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.
Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.
Learn more about Medicare Advantage plans such as Community Blue Medicare Plus PPO Signature (PPO) - H3916-063 by Highmark Health as well as other Medicare Advantage plans available in your area.
$0.00
Monthly Premium
Pennsylvania Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $615 |
| Out of Pocket Max |
In-Network: $7950 Out-of-Network: 10000 |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $2100 |
| Primary Care Doctor Visit | Out-of-Network: Doctor Office Visit Services: Coinsurance for Medicare Covered Primary Care Office Visit $40% |
| Specialty Doctor Visit | Out-of-Network: Doctor Specialty Visit Services: Coinsurance for Medicare Covered Physician Specialist Office Visit $40% |
| Inpatient Hospital Care | Out-of-Network: Acute Hospital Services: $350 per day for days 1 to 10 $0 per day for days 11 to 90 Private accommodations will be covered when medically necessary. Inpatient rehabilitation is subject to the same cost sharing as Inpatient Acute Hospital Care. |
| Urgent Care | Urgent Care: Copayment for Urgent Care $40 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $40 |
| Emergency Room Visit | Emergency Care: Copayment for Emergency Care $115 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $115 Copayment for Worldwide Emergency Transportation $315 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $315 Non-emergent transport is only covered when Certified Medically Necessary. The copayment is applicable per one way trip. Air Ambulance: Copayment for Air Ambulance Services $315 Prior Authorization Required for Air Ambulance Non-emergent transport is only covered when Certified Medically Necessary. The copayment is applicable per one way trip. |
Health Care Services and Medical Supplies
Community Blue Medicare Plus PPO Signature (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Copayment for Routine Care $15
Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 40% |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: |
| Durable Medical Equipment (DME) | Out-of-Network: Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 40% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | Out-of-Network: Diagnostic Procedures/Tests Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40% Coinsurance for Medicare Covered Lab Services 40% Coinsurance for Medicare Covered Diagnostic Radiological Services 40% Coinsurance for Medicare Covered Therapeutic Radiological Services 40% Coinsurance for Medicare Covered Outpatient X-Ray Services 40% The minimum copayment applies for Medicare-covered diagnostic procedures/tests and lab services provided at free standing labs. The maximum copayment applies for Medicare-covered diagnostic procedures/tests and lab services at all other places of service. |
| Home Health Care | Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 30% |
| Mental Health Inpatient Care | Out-of-Network: Psychiatric Hospital Services: $500 per day for days 1 to 3 $0 per day for days 4 to 90 Private accommodations will be covered when medically necessary. Inpatient substance abuse is subject to the same cost sharing as Inpatient Psychiatric Hospital. |
| Mental Health Outpatient Care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 |
| Outpatient Services / Surgery | Out-of-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $525 Copayment for Medicare Covered Ambulatory Surgical Center Services $475 Copayment applies per visit/per day/per provider for outpatient surgical services. Same day visits to the same provider for the same procedure receives one copayment. |
| Outpatient Substance Abuse Care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $45 Copayment for Medicare-covered Group Sessions $45 Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
| Over-the-counter (OTC) Items | Out-of-Network: Over-The-Counter (OTC) Items Services: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0 Maximum Plan Benefit of $30 An OTC catalog of CMS-approved non-prescription over-the-counter medications and health-related items is available. Quantity limits and plan restrictions may apply. |
| Podiatry Services | Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 40% In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $50 Copayment for Routine Foot Care $50
|
| Skilled Nursing Facility Care | Coinsurance for Skilled Nursing Facility Services 30% |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | Out-of-Network: Preventive Dental Services: Coinsurance for Medicare Covered Preventive Dental 40% |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | Out-of-Network: Eye Exams Services: Coinsurance for Medicare Covered Eye Exams 40% Copayment for Medicare Covered Eyewear $0 |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | Out-of-Network: Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 40% |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The Community Blue Medicare Plus PPO Signature (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $615 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $615 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $615 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $615 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|