Community Blue Medicare Plus PPO Signature (PPO)

Medicare Plan Details

2021 Plan

Monthly Premium

(select county for price)

by Highmark Inc.

Additional Coverage

Hearing Vision Dental

Overall Government Star Rating

4.5

out of 5 stars

State: Pennsylvania

Select your county to view the price for this plan

Plan Type

Medicare Advantage (Part C) with Prescription Drug (Part D)

Medicare Advantage combines Part A and Part B. This plan = Part A + Part B + Part D

Monthly Premium

Health Portion of Premium

Drug Portion of Premium

Health Plan Deductible

Health Plan Max Out-of-Pocket

$10,000 In and Out-of-network
$7,550 In-network

Nationwide Coverage included

Hearing Coverage included

Yes

Vision Coverage included

Yes

Dental Coverage included

Yes

Doctor Lookup Link

http://medicare.highmark.com

Plan Link

http://medicare.highmark.com

Medical Benefits

Doctor Services

Primary doctor visit

In-network: $0 copay
Out-of-network: $0 copay

Specialist visit

In-network: $35 copay per visit
Out-of-network: $35 copay per visit

Tests, labs, & imaging

Diagnostic tests & procedures

In-network: $0-30 copay
Out-of-network: $35 copay

Lab services

In-network: $0-30 copay
Out-of-network: $35 copay

Diagnostic radiology services (like MRI)

In-network: $270 copay
Out-of-network: $370 copay

Outpatient x-rays

In-network: $35 copay
Out-of-network: $50 copay

Emergency care

$90 copay per visit (always covered)

Urgent care

$50 copay per visit (always covered)

Hospital Services

Inpatient hospital coverage

In-network: $395 per stay
Out-of-network: $275 per day for days 1 through 5
$0 per day for days 6 through 90

Outpatient hospital coverage

In-network: $350 copay per visit
Out-of-network: $425 copay per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$184 per day for days 21 through 100
Out-of-network: 30% per stay

Preventive services

In-network: $0 copay
Out-of-network: $0 copay

Ambulance

Ground ambulance

In-network: $295 copay
Out-of-network: $295 copay or 30% coinsurance

Therapy services

Occupational therapy visit

In-network: $40 copay
Out-of-network: $60 copay

Physical therapy & speech & language therapy visit

In-network: $40 copay
Out-of-network: $60 copay

Mental health services

Outpatient group therapy with a psychiatrist

In-network: $40 copay
Out-of-network: $60 copay

Outpatient individual therapy with a psychiatrist

In-network: $40 copay
Out-of-network: $60 copay

Outpatient group therapy visit

In-network: $40 copay
Out-of-network: $60 copay

Outpatient individual therapy visit

In-network: $40 copay
Out-of-network: $60 copay

Opioid treatment services

Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)

In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item

Prosthetics (like braces, artificial limbs)

In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item

Diabetes supplies

In-network: 0-20% coinsurance per item
Out-of-network: 30% coinsurance per item

Prescription Drug Benefits

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

Tiers	Initial coverage phase	Gap coverage phase	Catastrophic coverage phase
Preferred Generic	$7.00 copay	Generic drugs : 25% Brand-name drugs : 25%	Generic drugs : $3.70 copay or 5% (whichever costs more) Brand-name drugs : $9.20 copay or 5% (whichever costs more)
Generic	$15.00 copay
Preferred Brand	$47.00 copay
Non-Preferred Drug	$100.00 copay
Specialty Tier	33%

Part B Drugs

Chemotherapy drugs

In-network: 20% coinsurance
Out-of-network: 30% coinsurance

Other Part B drugs

In-network: 20% coinsurance
Out-of-network: 30% coinsurance

Extra Benefits

Hearing

Hearing exam

In-network: $35 copay
Out-of-network: $35 copay

Fitting/evaluation

Not covered

Hearing aids - All types

In-network: $699-999 copay
Out-of-network: $0 copay

Preventive Dental

Oral exam

Covered under office visit

Cleaning

Covered under office visit

Fluoride treatment

Not covered

Dental x-rays

In-network: $15 copay
Out-of-network: 30% coinsurance

Comprehensive dental

Non-routine services

Not covered

Diagnostic services

Not covered

Restorative services

In-network: 50% coinsurance
Out-of-network: 50% coinsurance

Endodontics

In-network: 50% coinsurance
Out-of-network: 50% coinsurance

Periodontics

Not covered

Extractions

In-network: 50% coinsurance
Out-of-network: 50% coinsurance

Prosthodontics, other oral/maxillofacial surgery, other services

In-network: 50% coinsurance
Out-of-network: 50% coinsurance

Vision

Routine eye exam

In-network: $0 copay
Out-of-network: $50 copay

Contact lenses

In-network: $0 copay
Out-of-network: $0 copay

Eyeglasses (frames & lenses)

Not covered

Eyeglass frames (only)

In-network: $0 copay
Out-of-network: $0 copay

Eyeglass lenses (only)

In-network: $0 copay
Out-of-network: $0 copay

Upgrades

In-network: $0 copay
Out-of-network: $0 copay

Other benefits

Fitness benefit

Limited coverage

Over the counter drug benefits

Limited coverage

In-home support services

Not covered

Home and bathroom safety devices

Limited coverage

Meals for short duration

Not covered

Annual physical exams

Limited coverage

Telehealth

Limited coverage

Summary rating of health plan quality

4.5

Staying healthy: screenings, tests, & vaccines

Managing chronic (long term) conditions

Member experience with health plan

Member complaints & changes in the health plan's performance

Health plan customer service

Summary rating of drug plan quality

4.5

Drug plan customer service

Member complaints & changes in the drug plan's performance

Member experience with the drug plan

Drug safety & accuracy of drug pricing

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