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Complete Blue PPO Distinct (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Complete Blue PPO Distinct (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Complete Blue PPO Distinct (PPO) in 2026, please refer to our full plan details page.
Complete Blue PPO Distinct (PPO) is a PPO plan offered by Highmark Health available for enrollment in 2025 to people living in Western PA. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Complete Blue PPO Distinct (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Complete Blue PPO Distinct (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Complete Blue PPO Distinct (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $23.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $615.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $9550.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $9550.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Complete Blue PPO Distinct (PPO) Medicare plan features an annual drug deductible of $615. For Tier 1 (Preferred Generic) and Tier 2 (Generic) medications, you will pay no copay for a 1-month or 3-month supply when using a preferred pharmacy or preferred mail-order service. If you choose a standard pharmacy, copays start at $7 for Tier 1 and $15 for Tier 2 drugs. Higher-tier medications under this plan are subject to coinsurance rather than flat copays. Tier 3 (Preferred Brand) drugs require a 20% coinsurance, while Tier 4 (Non-Preferred) drugs carry a 30% coinsurance at both preferred and standard pharmacies. Specialty drugs in Tier 5 require a 25% coinsurance for a 1-month supply across all pharmacy networks.
Additional Benefits
The Complete Blue PPO Distinct (PPO) plan offers comprehensive coverage with no copay and no coinsurance for primary care visits, Medicare-covered preventive services, and home health care. Specialist visits require a $25 copay, while inpatient hospital stays feature no coinsurance and a $150 daily copay for the first three days of acute stays. Emergency room visits carry a $130 copay, which is waived if you are admitted within three days, and urgent care visits have a $40 copay. For ancillary care, members benefit from no copay or coinsurance for most dental services up to a $3,000 annual limit, as well as no copay for eyewear up to a $400 yearly maximum. Routine hearing exams carry a $10 copay, while up to two prescription hearing aids per year require a copay between $699 and $999. Additionally, the plan covers over-the-counter items with no copay or coinsurance up to $95 every three months, and provides unlimited one-way transportation to plan-approved locations with no copay.
Inpatient Hospital See details
Complete Blue PPO Distinct (PPO) partially covers inpatient hospital services with no coinsurance, requiring prior authorization and a copay of $150 per day for days 1 through 3 of acute stays and $425 per day for days 1 through 3 of psychiatric stays, with no copay for days 4 through 90. Upgrades, non-Medicare-covered stays, and additional psychiatric stay days are not covered under this plan.
Outpatient Services See details
Complete Blue PPO Distinct (PPO) covers outpatient services with no coinsurance, including outpatient hospital and daily observation services for a $200 copay, and ambulatory surgical center services for a $175 copay (prior authorization required for hospital and surgical services). Outpatient substance abuse sessions require a $45 copay, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Complete Blue PPO Distinct (PPO) offers coverage for partial hospitalization with no copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Complete Blue PPO Distinct (PPO), featuring a $260 copay and no coinsurance for both ground and air ambulance transport. Transportation services are partially covered, offering unlimited one-way rides to plan-approved health-related locations with no copay and no coinsurance, though transportation to any health-related location is not covered.
Emergency Services See details
Complete Blue PPO Distinct (PPO) covers emergency services with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within three days. Urgently needed services have a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $130, $40, and $260 respectively.
Primary Care See details
Complete Blue PPO Distinct (PPO) covers primary care physician visits with no copay and no coinsurance, while specialist visits require a $25 copay and no coinsurance. Other services like physical therapy ($10 copay) and mental health sessions ($40 copay) also feature no coinsurance, though chiropractic care is only partially covered with routine visits costing a $15 copay.
Preventive Services See details
Complete Blue PPO Distinct (PPO) offers Medicare-covered preventive services, annual physical exams, and kidney disease education with no copay and no coinsurance. Additional preventive services are partially covered, featuring memory fitness, remote access technologies with a $0 to $25 copay, and home safety devices with a 20% coinsurance, though several sub-services like health education, in-home safety assessments, and personal emergency response systems are not covered.
Hearing Services See details
Hearing services are partially covered by Complete Blue PPO Distinct (PPO) with no deductible and no coinsurance, offering annual routine hearing exams for a $10 copay and up to two prescription hearing aids per year for a $699 to $999 copay with a $500 annual limit. Fitting and evaluation, OTC hearing aids, and inner, outer, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Complete Blue PPO Distinct (PPO) partially covers vision services, as other eye exam services are not covered. Routine eye exams are covered once per year with a $25 copay and no coinsurance, and eyewear is covered with no copay and no coinsurance up to a $400 combined annual maximum.
Dental Services See details
Complete Blue PPO Distinct (PPO) offers partially covered dental services with an annual maximum of $3,000, featuring a $25 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for most preventive and comprehensive dental care. However, other diagnostic, other preventive, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Complete Blue PPO Distinct (PPO) covers Home Infusion bundled Services with no copay, though prior authorization and step therapy are required. Associated Medicare Part B drugs, including chemotherapy, radiation, and other drugs, carry a coinsurance ranging from no coinsurance up to 20%, while insulin is covered with a $35 copay and a coinsurance ranging from no coinsurance up to 20%.
Dialysis Services See details
Dialysis services are covered by the Complete Blue PPO Distinct (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Complete Blue PPO Distinct (PPO) covers medical equipment with no copays, though prior authorization is required for these services. Durable medical equipment incurs a coinsurance between 0% and 50%, diabetic supplies range from no coinsurance to 20% coinsurance, and medical supplies, prosthetics, and therapeutic shoes require a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Complete Blue PPO Distinct (PPO) with no coinsurance, though prior authorization is required. Members pay no copay for lab services, a $0 to $10 copay for diagnostic tests, a $20 copay for outpatient X-rays, and minimum copays of $50 for therapeutic radiology and $175 for diagnostic radiology.
Home Health Services See details
Home Health Services are covered under the Complete Blue PPO Distinct (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Complete Blue PPO Distinct (PPO) with no copay and no coinsurance, though only some services are covered in practice as standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled nursing facility (SNF) care is covered by Complete Blue PPO Distinct (PPO) with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and while a three-day prior hospital stay is not necessary for admission, additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Complete Blue PPO Distinct (PPO) partially covers other services, which includes over-the-counter (OTC) items with no copay and no coinsurance up to a maximum of $95 every three months. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone are not covered.
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