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

2026 Medicare plan code

H3957-050

Medicare Plan

Complete Blue HMO Distinct (HMO) · Highmark Blue Cross Blue Shield or Highmark Blue Shield · HMO · Bedford, Warren, PA

Full CMS plan ID: H3957-050-005

H3957-050-005 is the full CMS identifier for the H3957-050 Medicare plan. Common searches include H3957 050 and H3957050.

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

Complete Blue HMO Distinct (HMO)

H3957-050-005 Bedford, Warren, PA HMO

At-a-glance

Quick view

01

In-network

Inpatient hospital

Days 1–5 $175 / day
Days 6–90 $0 / day
Total of listed copays · 5 charged days $875
02

Emergency transport

Ambulance

Ground · in-network$355 copay
Air · in-network$355 copay
03

Emergency services

Emergency room

$130 copay

Waived if admitted

04

Medical maximum

Maximum out-of-pocket

In-network$5,900
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$25 / month
Consolidated C + D$25 / 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$25 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$195 copay
Out-of-networkNot separately reported

MRI, CT & PET imaging

In-network$50 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$355 copay
Out-of-networkNot separately reported

Air ambulance

In-network$355 copay
Out-of-networkNot separately reported

Outpatient hospital

In-network$245 copay
Out-of-networkNot separately reported

Outpatient surgery / ASC

In-network$175 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$30 copay
Out-of-networkNot separately reported
Specialty care2 benefits

Podiatry

In-network$25 copay
Out-of-networkNot separately reported

Chiropractic

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

Dental

In-network$25 copay
Out-of-networkNot separately reported

Vision

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

Hearing

In-network$10 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

$25 Part C premium / month · Part B giveback not separately reported

Maximum out-of-pocket (MOOP)

In-network$5,900
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

23% 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 H3957-050-005

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

Complete Blue HMO Distinct (HMO) is a 2026 HMO offered by Highmark Blue Cross Blue Shield or Highmark Blue Shield in Bedford, Warren, PA. The CMS record does not indicate routine out-of-network coverage. The plan record does not require referrals. Its listed inpatient copay stages total $875 across 5 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
$25 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
$50 copay
Outpatient hospital
$245 copay

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

Emergency & hospital care

Emergency room
$130 copay
Listed inpatient stages
$875 total

5 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
Bedford, Warren, PA (PA)
Plan type
HMO
Contract / plan
H3957-050
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$25 copay
VisionCost share not reported
Hearing$10 copay
Fitness & wellnessCost share not reported
TransportationCost share not reported
MealsCost share not reported

Plan-specific answers

Frequently asked questions

Where is H3957-050-005 available?

Complete Blue HMO Distinct (HMO) is listed for Bedford, Warren, PA (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 H3957-050-005?

The 2026 CMS record lists an in-network medical maximum out-of-pocket limit of $5,900. Prescription drug spending generally does not count toward this medical limit.

What is the monthly plan premium for H3957-050-005?

The listed consolidated Part C and Part D premium is $25 per month. This does not replace the standard Medicare Part B premium.

What does an emergency room visit cost on H3957-050-005?

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

Does H3957-050-005 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 H3957-050-005 fits

Full CMS plan ID
H3957-050-005
Contract
H3957
Base plan code
H3957-050
Segment
005
Carrier
Highmark Blue Cross Blue Shield or Highmark Blue Shield
Plan type
HMO
Service area
Bedford, Warren, PA (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.

  • Bedford, PA
  • Warren, PA

Same CMS contract

H3957-050-001 Complete Blue HMO Distinct (HMO) Allegheny, Armstrong, Beaver, Butler, Washington · HMO H3957-050-002 Complete Blue HMO Distinct (HMO) Erie, Fayette, Indiana, Lawrence, Mercer, Westmore · HMO H3957-050-003 Complete Blue HMO Distinct (HMO) Blair, Cambria, Clarion, Greene, Jefferson, Somers · HMO H3957-050-004 Complete Blue HMO Distinct (HMO) Western PA Rural Counties · HMO 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 H3957-042-004 Community Blue Medicare HMO Signature (HMO) Berks, Lehigh, Williamsport Metro · HMO H3957-042-005 Community Blue Medicare HMO Signature (HMO) Eastern PA Rural Counties Group 1 · HMO

About this code

What H3957-050-005 identifies

H3957-050-005 is a Contract Year 2026 Medicare plan segment code. Searches written as H3957-050, H3957 050, or the compact full CMS ID H3957050005 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.