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Community Blue Medicare PPO Signature (PPO) - H3916-037-008
$0.00
Monthly Premium
Community Blue Medicare PPO Signature (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H3916-037-008
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Pennsylvania Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other additional benefits Original Medicare doesn’t cover.
Learn more about Pennsylvania Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Enrollment may be limited to certain times of the year. See why you may be able to enroll today.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $615.00 |
| Out-of-pocket maximum | $7,950.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,100.00 |
| 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: $250 per day for days 1 to 7 $0 per day for days 8 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 $260 |
| Ambulance transportation | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $260 Coinsurance for Medicare Covered Ambulance Services - Ground 30% Copayment for Medicare Covered Ambulance Services - Air $260 Coinsurance for Medicare Covered Ambulance Services - Air 30% 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 PPO Signature (PPO) covers a range of additional benefits. Learn more about Community Blue Medicare PPO Signature (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Copayment for Routine Care $15
|
| 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 | In-Network: Psychiatric Hospital Services: $425 per day for days 1 to 3 $0 per day for days 4 to 90 Prior Authorization Required for Psychiatric Hospital Services 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 $425 Copayment for Medicare Covered Ambulatory Surgical Center Services $400 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 | Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
| Over-the-counter 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 $40 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% |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $218 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Private accommodations will be covered when medically necessary. |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network: Medicare Covered Preventive Dental: Copayment for Office Visit $35 Non-Medicare Covered Preventive Dental: Copayment for Non-medicare preventive $0
Non-Medicare Covered Comprehensive Dental: Copayment for Non-medicare comprehensive $0 Coinsurance for Restorative services 20%
|
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $35 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0 Copayment for Eyeglasses (lenses and frames) $0 Copayment for Eyeglass Lenses $0 Copayment for Eyeglass Frames $0 Copayment for Upgrades $0 Maximum Plan Benefit of $350 every year A $200 benefit maximum applies to upgrades to post cataract surgery eyewear that are not medically necessary. Benefit maximum is available following cataract surgery once per operated eye. For non-post cataract eyewear, the Plan offers additional coverage for non-Medicare covered (routine) eyewear. Routine eyewear benefit is limited to one pair of eyeglass frames, including one pair of eyeglass lenses or contact lenses every calendar year. Standard eyeglass frames, standard plastic eyeglass lenses, or standard contact lenses are covered in full at participating network provider locations. A $150 benefit maximum is available towards the purchase of non-standard eyeglass frames or towards the purchase of non-standard contact lenses. Members must pay the difference between benefit maximums and provider charge. |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | 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, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | Out-of-Network: Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
Prescription Drug Costs and Coverage
The Community Blue Medicare PPO Signature (PPO) offers prescription drug coverage, with an annual drug deductible of $615.00 (excludes Tiers 1 and 2)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $615.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $615.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $615.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
When reviewing Pennsylvania Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Pennsylvania that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Pennsylvania Counties Served
We offer plans from Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Healthspring, Wellcare, or Kaiser Permanente.
Enrollment may be limited to certain times of the year. See why you may be able to enroll today.