Medicare Plan Lookup Official CMS data · Contract Year 2026
CMS 2026 data

2026 Medicare plan code

H3957-042

Medicare Plan

Community Blue Medicare HMO Signature (HMO) · Highmark Blue Cross Blue Shield or Highmark Blue Shield · HMO · Berks, Lehigh, Williamsport Metro

Full CMS plan ID: H3957-042-004

H3957-042-004 is the full CMS identifier for the H3957-042 Medicare plan. Common searches include H3957 042 and H3957042.

Historical 2026 record. Benefits and service areas shown apply to that year.

2026

Spaces or dashes work: H5216-435-002 · S2135 802

● CMS 2026 plan record

Community Blue Medicare HMO Signature (HMO)

H3957-042-004 Berks, Lehigh, Williamsport Metro HMO

At-a-glance

Quick view

01

In-network

Inpatient hospital

Per admission $325 per stay
Plan-listed inpatient copay $325
02

Emergency transport

Ambulance

Ground · in-network$175 copay
Air · in-network$175 copay
03

Emergency services

Emergency room

$130 copay

Waived if admitted

04

Medical maximum

Maximum out-of-pocket

In-network$6,750
Combined in + outNot reported
05

Skilled care at home

Home health

In-networkCost share not reported
Out-of-networkNot separately reported
06

Monthly cost

Premium & giveback

Part C premium$0 / month
Consolidated C + D$0 / month

Plan details

All plan benefits

Medical care3 benefits

Primary care physician

In-networkCost share not reported
Out-of-networkNot separately reported

Specialist

In-network$20 copay
Out-of-networkNot separately reported

Preventive care

In-networkCost share not reported
Out-of-networkNot separately reported
Diagnostics & imaging4 benefits

Diagnostic procedures & tests

In-network$0–$10 copay
Out-of-networkNot separately reported

Laboratory services

In-network$0–$10 copay
Out-of-networkNot separately reported

X-rays & standard imaging

In-network$150 copay
Out-of-networkNot separately reported

MRI, CT & PET imaging

In-network$60 copay
Out-of-networkNot separately reported
Urgent & hospital care6 benefits

Urgent care

In-networkCost share not reported
Out-of-networkNot separately reported

Emergency room

In-network$130 copay
Out-of-networkNot separately reported

Ground ambulance

In-network$175 copay
Out-of-networkNot separately reported

Air ambulance

In-network$175 copay
Out-of-networkNot separately reported

Outpatient hospital

In-network$200 copay
Out-of-networkNot separately reported

Outpatient surgery / ASC

In-network$150 copay
Out-of-networkNot separately reported
Recovery & therapy5 benefits

Home health

In-networkCost share not reported
Out-of-networkNot separately reported

Skilled nursing facility

In-networkCost share not reported
Out-of-networkNot separately reported

Cardiac & pulmonary rehabilitation

In-networkCost share not reported
Out-of-networkNot separately reported

Occupational therapy

In-network$20 copay
Out-of-networkNot separately reported

Physical & speech therapy

In-network$20 copay
Out-of-networkNot separately reported
Behavioral health2 benefits

Mental health services

In-networkCost share not reported
Out-of-networkNot separately reported

Substance use treatment

In-network$45 copay
Out-of-networkNot separately reported
Specialty care2 benefits

Podiatry

In-network$20 copay
Out-of-networkNot separately reported

Chiropractic

In-network$10 copay
Out-of-networkNot separately reported
Supplemental benefits7 benefits

Dental

In-network$20 copay
Out-of-networkNot separately reported

Vision

In-networkCost share not reported
Out-of-networkNot separately reported

Hearing

In-network$699–$999 copay
Out-of-networkNot separately reported

Transportation

In-networkCost share not reported
Out-of-networkNot separately reported

Fitness & wellness

In-networkCost share not reported
Out-of-networkNot separately reported

Over-the-counter allowance

Not reported in this CMS export

Not reported in this CMS export

Meals

In-networkCost share not reported
Out-of-networkNot separately reported
Plan costs & rulesCoverage overview

Premium & Part B giveback

$0 Part C premium / month · Part B giveback not separately reported

Maximum out-of-pocket (MOOP)

In-network$6,750
Combined in + outNot reported

Medical deductibles

In-networkNot reported
Out-of-networkNot reported

Network & referrals

HMO · Referrals: Not required · Out-of-network coverage: No

Prescription drugs5 tiers

Part D deductible

Not reported

Drug tier 1

$7 retail copay · 31-day supply

Drug tier 2

$15 retail copay · 31-day supply

Drug tier 3

20% retail coinsurance · 31-day supply

Drug tier 4

25% retail coinsurance · 31-day supply

Drug tier 5

25% retail coinsurance · 31-day supply

Using this plan

Understand H3957-042-004

Plain-language context built from this plan’s 2026 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.

Plan at a glance

A quick read on this plan

Community Blue Medicare HMO Signature (HMO) is a 2026 HMO offered by Highmark Blue Cross Blue Shield or Highmark Blue Shield in Berks, Lehigh, Williamsport Metro. The CMS record does not indicate routine out-of-network coverage. The plan record does not require referrals. Its listed inpatient copay stages total $325 across null charged days.

Common benefit costs

What you may pay

These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.

Routine care

Primary care physician
Cost share not reported
Specialist
$20 copay
Laboratory services
$0–$10 copay

Separate visits or services; costs are not added together.

Tests & outpatient care

Diagnostic procedures & tests
$0–$10 copay
MRI, CT & PET imaging
$60 copay
Outpatient hospital
$200 copay

The service setting and billing details can change what you pay.

Emergency & hospital care

Emergency room
$130 copay
Listed inpatient stages
$325 total

null charged inpatient days are included in the calculated total. Actual costs depend on the care received and plan rules.

Helpful context

Terms worth knowing

Maximum out-of-pocket (MOOP)

This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.

Availability

Who can enroll

Service area
Berks, Lehigh, Williamsport Metro (PA)
Plan type
HMO
Contract / plan
H3957-042
Coverage year
2026

Enrollment generally requires Medicare eligibility and residence in the plan's service area. Confirm eligibility and the exact service area with the plan before enrolling.

Supplemental coverage

Extra benefits reported

Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.

Dental$20 copay
VisionCost share not reported
Hearing$699–$999 copay
Fitness & wellnessCost share not reported
TransportationCost share not reported
MealsCost share not reported

Plan-specific answers

Frequently asked questions

Where is H3957-042-004 available?

Community Blue Medicare HMO Signature (HMO) is listed for Berks, Lehigh, Williamsport Metro (PA). Enrollment generally requires Medicare eligibility and residence in the plan's service area.

What is the in-network maximum out-of-pocket limit for H3957-042-004?

The 2026 CMS record lists an in-network medical maximum out-of-pocket limit of $6,750. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H3957-042-004?

The listed consolidated Part C and Part D premium is $0 per month. This does not replace the standard Medicare Part B premium.

What does an emergency room visit cost on H3957-042-004?

The plan record lists $130 copay, waived when an admission meets the plan's stated timing rule.

Does H3957-042-004 report extra benefits?

Yes. CMS reports dental, vision, hearing, fitness & wellness, transportation, and other supplemental benefits. See the detailed benefit rows and official plan documents for limits and conditions.

Source trail

Official CMS, Contract Year 2026

Plan identity and benefits come from CMS PBP data. Premium and MOOP figures are cross-checked against the August 2026 Landscape release; county identity is sourced from segment-level Landscape rows and stable codes are enriched from the aligned MA contract service-area release where matched. Quick-reference values should be confirmed in 2026 official plan documents.

PBP benefits ↗ Landscape data ↗ County service area ↗

Plan context

Where H3957-042-004 fits

Full CMS plan ID
H3957-042-004
Contract
H3957
Base plan code
H3957-042
Segment
004
Carrier
Highmark Blue Cross Blue Shield or Highmark Blue Shield
Plan type
HMO
Service area
Berks, Lehigh, Williamsport Metro (PA)

County/service-area foundation

CMS service-area entries

Named county entries are tied to this exact contract, plan, and segment in CMS Landscape data. County codes are enriched from the aligned CMS contract service-area release where a match exists.

  • Berks, PA
  • Lehigh, PA
  • Lycoming, PA
  • Mifflin, PA
  • Snyder, PA
  • Sullivan, PA
  • Union, PA

Same CMS contract

H3957-042-001 Community Blue Medicare HMO Signature (HMO) Lackawanna, Luzerne, Wyoming · HMO H3957-042-002 Community Blue Medicare HMO Signature (HMO) Lancaster, Lebanon · HMO H3957-042-005 Community Blue Medicare HMO Signature (HMO) Eastern PA Rural Counties Group 1 · HMO H3957-042-006 Community Blue Medicare HMO Signature (HMO) Eastern PA Rural Counties Group 2 · HMO H3957-042-007 Community Blue Medicare HMO Signature (HMO) Cumberland, Dauphin, Perry, York · HMO H3957-047-001 Community Blue Medicare HMO Signature (HMO) Allegheny, Armstrong, Beaver, Butler, Washington · HMO H3957-047-002 Community Blue Medicare HMO Signature (HMO) Erie, Fayette, Indiana, Lawrence, Mercer, Westmore · HMO H3957-047-003 Community Blue Medicare HMO Signature (HMO) Blair, Cambria, Clarion, Greene, Jefferson, Somer · HMO

About this code

What H3957-042-004 identifies

H3957-042-004 is a Contract Year 2026 Medicare plan segment code. Searches written as H3957-042, H3957 042, or the compact full CMS ID H3957042004 refer to this plan or its base plan code.

Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.