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
4.5out 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
Plan Details
$0
$0
$0
$0
$10,000 In and Out-of-network
$7,550 In-network
$7,550 In-network
No
Yes
Yes
Yes
Medical Benefits
Doctor Services
In-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
In-network: $35 copay per visit
Out-of-network: $35 copay per visit
Out-of-network: $35 copay per visit
Tests, labs, & imaging
In-network: $0-30 copay
Out-of-network: $35 copay
Out-of-network: $35 copay
In-network: $0-30 copay
Out-of-network: $35 copay
Out-of-network: $35 copay
In-network: $270 copay
Out-of-network: $370 copay
Out-of-network: $370 copay
In-network: $35 copay
Out-of-network: $50 copay
Out-of-network: $50 copay
$90 copay per visit (always covered)
$50 copay per visit (always covered)
Hospital Services
In-network: $395 per stay
Out-of-network: $275 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-network: $275 per day for days 1 through 5
$0 per day for days 6 through 90
In-network: $350 copay per visit
Out-of-network: $425 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
$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
Out-of-network: $0 copay
Ambulance
In-network: $295 copay
Out-of-network: $295 copay or 30% coinsurance
Out-of-network: $295 copay or 30% coinsurance
Therapy services
In-network: $40 copay
Out-of-network: $60 copay
Out-of-network: $60 copay
In-network: $40 copay
Out-of-network: $60 copay
Out-of-network: $60 copay
Mental health services
In-network: $40 copay
Out-of-network: $60 copay
Out-of-network: $60 copay
In-network: $40 copay
Out-of-network: $60 copay
Out-of-network: $60 copay
In-network: $40 copay
Out-of-network: $60 copay
Out-of-network: $60 copay
In-network: $40 copay
Out-of-network: $60 copay
Out-of-network: $60 copay
Opioid treatment services
Covered
Other services
In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item
Out-of-network: 30% coinsurance per item
In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item
Out-of-network: 30% coinsurance per item
In-network: 0-20% coinsurance per item
Out-of-network: 30% 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 |
Brand-name drugs :
|
Brand-name drugs :
|
Generic | $15.00 copay | ||
Preferred Brand | $47.00 copay | ||
Non-Preferred Drug | $100.00 copay | ||
Specialty Tier | 33% |
Part B Drugs
In-network: 20% coinsurance
Out-of-network: 30% coinsurance
Out-of-network: 30% coinsurance
In-network: 20% coinsurance
Out-of-network: 30% coinsurance
Out-of-network: 30% coinsurance
Extra Benefits
Hearing
In-network: $35 copay
Out-of-network: $35 copay
Out-of-network: $35 copay
Not covered
In-network: $699-999 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
Preventive Dental
Covered under office visit
Covered under office visit
Not covered
In-network: $15 copay
Out-of-network: 30% coinsurance
Out-of-network: 30% coinsurance
Comprehensive dental
Not covered
Not covered
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
Not covered
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Out-of-network: 50% coinsurance
Vision
In-network: $0 copay
Out-of-network: $50 copay
Out-of-network: $50 copay
In-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
Not covered
In-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
In-network: $0 copay
Out-of-network: $0 copay
Out-of-network: $0 copay
Other benefits
Limited coverage
Limited coverage
Not covered
Limited coverage
Not covered
Limited coverage
Limited coverage
Health Plan Star Ratings
(government star ratings are out of 5 stars)
Prescription Drug Plan Star Ratings
(government star ratings are out of 5 stars)
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