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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 2025, 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 2025.
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 $12.00. 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 no drug deductible. Your prescription medication coverage will start immediately.
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) plan has an enhanced alternative drug benefit. There is no deductible for prescription drugs. During the initial coverage phase, you will pay either a copay or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs have no copay at preferred pharmacies, while standard generic drugs have 25% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Complete Blue PPO Distinct (PPO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a $275 copay, while outpatient services have copays ranging from $45 to $200. Emergency services have a $125 copay, and primary care visits have copays between $5 and $40, depending on the service. Preventive services are covered with no copay, while hearing and vision services have copays for exams and coverage for eyewear. Dental services offer a $3,000 maximum benefit, and other services include coverage for home infusion, medical equipment, and skilled nursing facilities.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, you will pay a $275 copay, and additional days have no copay. For Inpatient Hospital Psychiatric, there is a $425 copay for days 1-3, and no copay for days 4-90.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital and observation services have a $200 copay, ambulatory surgical center services have a $175 copay, and individual and group sessions for outpatient substance abuse have a copay between $45 and $45.
Partial Hospitalization See details
Partial Hospitalization benefits are covered by the Complete Blue PPO Distinct (PPO) plan. There is no additional cost information available for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Complete Blue PPO Distinct (PPO) plan. Ground and Air Ambulance Services have a $260 copay. Transportation Services to a plan-approved health-related location are covered, but transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Complete Blue PPO Distinct (PPO) plan. Emergency Services has a $125 copay, Urgently Needed Services has a $30 copay, and Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $30 copay, and Worldwide Emergency Transportation has a $260 copay.
Primary Care See details
The Complete Blue PPO Distinct (PPO) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $30 copay, specialist services with a $10 copay, mental health specialty services with a $40 copay for individual and group sessions, podiatry services with a $10 copay for routine foot care, other health care professional services with a copay between $0 and $10, psychiatric services with a $40 copay for individual and group sessions, physical therapy and speech-language pathology services with a $5 copay, additional telehealth benefits with a copay between $0 and $45, and opioid treatment program services with a $45 copay. Routine chiropractic care is limited to 4 visits per year.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, annual physical exams, and additional services, including fitness benefits and remote access technologies with a copay between $0 and $10 and Home and Bathroom Safety Devices and Modifications with 20% coinsurance. Health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, telemonitoring services, and counseling services are not covered.
Hearing Services See details
Hearing Services includes coverage for routine hearing exams with a $10 copay, with a limit of one exam per year, and prescription hearing aids with a copay between $699 and $999, up to $500 per year. Fitting/Evaluation for Hearing Aid, Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, Prescription Hearing Aids - Over the Ear, and OTC Hearing Aids are not covered.
Vision Services See details
Vision services include coverage for eye exams with a $10 copay, and eyewear including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Eyewear has a combined maximum benefit of $400.00 per year.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a $10 copay, and other dental services with a $3,000 maximum benefit per year. Oral exams, dental x-rays, cleaning, and fluoride treatments are covered, each limited to one visit per specified period. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with a 10% coinsurance, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay, and the coinsurance ranges from 0% to 20%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance that ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the Complete Blue PPO Distinct (PPO) plan. The plan has a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment are covered. DME has a 20% coinsurance, with no copay, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices have a coinsurance of 20%, with no copay. Medical Supplies have a 20% coinsurance, with no copay. Diabetic Supplies have a coinsurance between 0% and 20%, and Diabetic Therapeutic Shoes/Inserts have a coinsurance of 20%.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Complete Blue PPO Distinct (PPO) plan. Diagnostic Procedures/Tests and Lab Services are not covered, while Diagnostic Radiological Services have a copay of at most $175, Therapeutic Radiological Services have a copay of at most $50, and Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by the Complete Blue PPO Distinct (PPO) plan. There is no copay or coinsurance for this benefit, but authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, however, none of the sub-services, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services, are covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Complete Blue PPO Distinct (PPO) plan, with prior authorization required. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) items, with a maximum benefit coverage amount of $105.00 every three months. However, acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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