2022 Community Blue Medicare PPO Distinct (PPO)

Community Blue Medicare PPO Distinct (PPO) H3916-034 is a 2022 Medicare Advantage Plan or Part-C by Highmark Inc available to residents in Pennsylvania. This plan includes additional prescription drug (Part-D) coverage. The Community Blue Medicare PPO Distinct (PPO) has a monthly premium of $25.00 and has an in-network maximum out-of-pocket limit of $6,500 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,500 out-of-pocket. This can be a extremely nice safety net.

Community Blue Medicare PPO Distinct (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Highmark Inc works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Community Blue Medicare PPO Distinct (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Highmark Inc and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Highmark Inc except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 Highmark Inc Medicare Advantage Plan Costs

Community Blue Medicare PPO Distinct (PPO) Part-C Premium

Highmark Inc charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H3916-034 Part-D Deductible and Premium

Community Blue Medicare PPO Distinct (PPO) has a monthly drug premium of $25.00 and a $0.00 drug deductible. This Highmark Inc plan offers a $25.00 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Highmark Inc above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $25.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Highmark Inc Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Highmark Inc plan does not offer additional coverage through the gap.

Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Community Blue Medicare PPO Distinct (PPO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $6.20 for 75% low income subsidy $12.50 for 50% and $18.70 for 25%.

H3916-034 Formulary or Drug Coverage

Community Blue Medicare PPO Distinct (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Community Blue Medicare PPO Distinct (PPO) H3916-034 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$7
Tier 2	$5	$15
Tier 3	$47	$47
Tier 4	$100	$100
Tier 5	33%	33%

*Initial Coverage Phase and 30 day supply

2021 Community Blue Medicare PPO Distinct (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	50% coinsurance
Endodontics	50% coinsurance (Out-of-Network)
Extractions	50% coinsurance
Extractions	50% coinsurance (Out-of-Network)
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	50% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services	50% coinsurance (Out-of-Network)
Restorative services	50% coinsurance
Restorative services	50% coinsurance (Out-of-Network)

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$285 copay
Diagnostic radiology services (e.g., MRI)	$300 copay (Out-of-Network)
Diagnostic tests and procedures	$0-30 copay
Diagnostic tests and procedures	$40 copay (Out-of-Network)
Lab services	$40 copay (Out-of-Network)
Lab services	$0-30 copay
Outpatient x-rays	$25 copay
Outpatient x-rays	$40 copay (Out-of-Network)

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Doctor Visits

Primary	$0 copay (Out-of-Network)
Primary	$0 copay
Specialist	$30 copay per visit
Specialist	$30 copay per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$50 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$30 copay (Out-of-Network)
Foot exams and treatment	$30 copay
Routine foot care	$30 copay (Out-of-Network)
Routine foot care	$30 copay

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Ground Ambulance

$295 copay
$295 copay or 30% coinsurance (Out-of-Network)

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Hearing

Fitting/evaluation	Not covered
Hearing aids	$0 copay (Out-of-Network)
Hearing aids	$699-999 copay
Hearing exam	$30 copay
Hearing exam	$30 copay (Out-of-Network)

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Inpatient Hospital Coverage

$325 per stay
$375 per stay (Out-of-Network)

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Medical Equipment/Supplies

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

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Medicare Part B Drugs

Chemotherapy	30% coinsurance (Out-of-Network)
Chemotherapy	20% coinsurance
Other Part B drugs	30% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	$425 per day for days 1 through 3 $0 per day for days 4 through 90
Inpatient hospital - psychiatric	$475 per day for days 1 through 3 $0 per day for days 4 through 90 (Out-of-Network)
Outpatient group therapy visit	$50 copay (Out-of-Network)
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient group therapy visit with a psychiatrist	$50 copay (Out-of-Network)
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit	$50 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit with a psychiatrist	$50 copay (Out-of-Network)

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MOOP

$10,000 In and Out-of-network $6,500 In-network

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Option

No

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

$325 copay per visit (Out-of-Network)
$275 copay per visit

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Preventive Care

$0 copay (Out-of-Network)
$0 copay

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Preventive Dental

Cleaning	Covered under office visit
Dental x-ray(s)	$15 copay
Dental x-ray(s)	30% coinsurance (Out-of-Network)
Fluoride treatment	Not covered
Office visit	$15.00
Office visit	30% coinsurance (Out-of-Network)
Oral exam	Covered under office visit

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Rehabilitation Services

Occupational therapy visit	$50 copay (Out-of-Network)
Occupational therapy visit	$40 copay
Physical therapy and speech and language therapy visit	$40 copay (Out-of-Network)
Physical therapy and speech and language therapy visit	$25 copay

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Skilled Nursing Facility

30% per stay (Out-of-Network)
$0 per day for days 1 through 20 $184 per day for days 21 through 100

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Transportation

$0 copay
30% coinsurance (Out-of-Network)

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Vision

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

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Community Blue Medicare PPO Distinct (PPO) H3916

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Community Blue Medicare PPO Distinct (PPO) Plans Performance

Health Plan Customer Service Rating for Community Blue Medicare PPO Distinct (PPO)

Community Blue Medicare PPO Distinct (PPO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Community Blue Medicare PPO Distinct (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.