Community Blue Medicare PPO Distinct (PPO)

Community Blue Medicare PPO Distinct (PPO) H3916-034 Plan Details
4.5 out of 5 stars

Community Blue Medicare PPO Distinct (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H3916-034

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$27.00
Monthly Premium

Community Blue Medicare PPO Distinct (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H3916-034

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Community Blue Medicare PPO Distinct (PPO) H3916-034 Plan Details
4.5 out of 5 stars

Community Blue Medicare PPO Distinct (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H3916-034

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$27.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $5500
Out-of-Network: N/A
Initial Coverage Limit $5030
Catastrophic Coverage Limit $8,000
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Out-of-Network:

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $0.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $15.00
Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $15.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $200.00
Your plan covers an unlimited number of days for an inpatient stay.
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
Copayment for Acute Hospital Services per Stay $200.00
Urgent Care
Copayment for Urgent Care $30.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $30.00
Emergency Room Visit
Copayment for Emergency Care $100.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $100.00
Copayment for Worldwide Emergency Transportation $250.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $250.00

Air Ambulance:
Copayment for Air Ambulance Services $250.00

Non-emergent transport is only covered when Certified Medically Necessary. The copayment is applicable per one way trip.
Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $250.00
Coinsurance for Medicare Covered Ambulance Services - Ground 30%
Copayment for Medicare Covered Ambulance Services - Air $250.00
Coinsurance for Medicare Covered Ambulance Services - Air 30%

Health Care Services and Medical Supplies

Community Blue Medicare PPO Distinct (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:
Copayment for Medicare-covered Chiropractic Services $20.00
Copayment for Routine Care $20.00
  • Maximum 4 Routine Care every year
Prior Authorization Required for Chiropractic Services

Out-of-Network:
Copayment for Medicare Covered Chiropractic Services $20.00 Copayment for Non-Medicare Covered Chiropractic Services $20.00
Prior authorization required
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Diabetic Supplies and Services 30%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Durable Medical Equipment 30%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00
Copayment for Medicare-covered Lab Services $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $175.00
Copayment for Medicare-covered Therapeutic Radiological Services $60.00
Copayment for Medicare-covered X-Ray Services $20.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $0.00
Copayment for Medicare Covered Lab Services $0.00
Copayment for Medicare Covered Diagnostic Radiological Services $175.00
Copayment for Medicare Covered Therapeutic Radiological Services $60.00
Copayment for Medicare Covered Outpatient X-Ray Services $20.00
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Home Health 30%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$425.00 per day for days 1 to 3
$0.00 per day for days 4 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
$425.00 per day for days 1 to 3
$0.00 per day for days 4 to 90
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $30.00
Copayment for Medicare-covered Group Sessions $30.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Individual Sessions $30.00
Copayment for Medicare Covered Group Sessions $30.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $245.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per day $245.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $175.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Out-of-Network:

Outpatient Hospital and ASC Services:
Copayment for Medicare Covered Outpatient Hospital Services $245.00
Copayment for Medicare Covered Ambulatory Surgical Center Services $175.00
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $45.00
Copayment for Medicare-covered Group Sessions $45.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Individual or Group Sessions $50.00
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Maximum Plan Benefit of $190.00 every three months

Out-of-Network:

Over-The-Counter (OTC) Items:
Maximum Plan Benefit of $190.00 every three months
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $15.00
Copayment for Routine Foot Care $15.00
  • Maximum 4 visits every year
Out-of-Network:
Copayment for Medicare Covered Podiatry Services $15.00 Copayment for Non-Medicare Covered Podiatry Services $15.00
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$203.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 30%

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $15.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Standard Eyeglass lenses and frames or contact lenses are covered in full. A $150 benefit maximum applies to non-standard frames or specialty contact lenses.

Out-of-Network:

Medicare Covered Vision Services:
Copayment for Medicare Covered Eye Exams $15.00
Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eye Exams $50.00
Standard Eyeglass lenses and frames or contact lenses are covered in full. A $150 benefit maximum applies to non-standard frames or specialty contact lenses.

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $15.00
Copayment for Routine Hearing Exams $15.00
  • Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00
  • Maximum 2 Hearing Aids every year
Maximum Plan Benefit of $500.00 every year both ears combined for in and out of network services combined
You must see a TruHearing provider to use this benefit. Up to two TruHearing hearing aids every year (one per ear per year). Benefit is limited to the TruHearing Advanced ($699) and Premium ($999) hearing aids, which come in various styles and colors, and are available in rechargeable style options.
Hearing aid purchase includes:
- First year of follow-up provider visits
- 60-day trial period
- 3-year extended warranty
- 80 batteries per aid for non-rechargeable models

Members have a $500 maximum allowance towards hearing aids that are not the TruHearing Advanced or Premium models.

Out-of-Network:

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $15.00
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $15.00

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:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    Out-of-Network:

    Medicare-covered Zero Dollar Preventive Services:
    Copayment for Medicare Covered Medicare-covered Preventive Services $0.00