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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 $25.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $6.00. You must continue to pay paying your reduced 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) plan features an annual prescription drug deductible of $615. For Tier 1 preferred generics and Tier 2 generics, you will pay no copay for 1-month or 3-month supplies when using a preferred pharmacy or preferred mail-order service. Standard pharmacies and standard mail-order options are also available with copays ranging from $7 to $15 for a 1-month supply and $21 to $45 for a 3-month supply. For higher-tier medications, costs transition to a coinsurance model. You will pay a 20% coinsurance for Tier 3 preferred brands and a 30% coinsurance for Tier 4 non-preferred drugs at both preferred and standard pharmacies. Tier 5 specialty drugs carry a 25% coinsurance for a 1-month supply across all pharmacy and mail-order options.
Additional Benefits
The Complete Blue PPO Distinct (PPO) plan offers comprehensive medical coverage with no copays or coinsurance for primary care visits, preventive screenings, home health care, and partial hospitalization. For other essential services, members will pay predictable copays, such as $25 for specialist visits, $130 for emergency room care, and a $150 daily copay for the first three days of acute inpatient hospital stays. Outpatient hospital services and ambulatory surgical center visits are also covered with no coinsurance and fixed copays of $150 and $125 respectively. Additional benefits include dental, vision, and hearing services, featuring no copays for preventive dental care and up to $400 for eyewear, alongside routine eye exams for a $25 copay. While durable medical equipment and dialysis require no copays and carry coinsurance up to 50% and 20% respectively, members also receive a $75 quarterly over-the-counter allowance with no copay. Please note that cardiac rehabilitation, acupuncture, and meal benefits are excluded from this plan.
Inpatient Hospital See details
Inpatient hospital services are covered by Complete Blue PPO Distinct (PPO) with no coinsurance, requiring a $150 daily copay for days 1-3 of acute stays and a $425 daily copay for days 1-3 of psychiatric stays, with no copay for subsequent days. The benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Complete Blue PPO Distinct (PPO) covers outpatient services with no coinsurance, including outpatient hospital and observation services for a $150 copay, and ambulatory surgical center services for a $125 copay. Outpatient substance abuse sessions require a $45 copay with no coinsurance, and outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Complete Blue PPO Distinct (PPO) covers partial hospitalization services with no copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under Complete Blue PPO Distinct (PPO), featuring a $200 copay and no coinsurance for ground and air ambulance services. Transportation services are partially covered, offering unlimited one-way trips to plan-approved health-related locations with no copay and no coinsurance, while 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, which is waived if you are admitted to the hospital within three days. Urgently needed care has a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $130, $40, and $200 respectively.
Primary Care See details
Complete Blue PPO Distinct (PPO) offers primary care physician services with no copay and no coinsurance, while specialist visits have a $25 copay and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance, excluding other chiropractic services which are not covered. Other services like physical therapy, mental health, and podiatry are covered with copays ranging from $10 to $45 and no coinsurance.
Preventive Services See details
Complete Blue PPO Distinct (PPO) covers annual physical exams, kidney disease education, and other preventive screenings with no copay and no coinsurance. Additional preventive services are partially covered, offering memory fitness, remote access technologies for a $0 to $25 copay, and home safety devices with a 20% coinsurance, while excluding health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, smoking cessation, telemonitoring, and counseling.
Hearing Services See details
Complete Blue PPO Distinct (PPO) partially covers hearing services, excluding OTC hearing aids, hearing aid fitting and evaluations, and inner, outer, or over-the-ear prescription hearing aids. Covered routine hearing exams have a copay of up to $25 and no coinsurance, while covered prescription hearing aids have copays ranging from $699 to $999 and no coinsurance, up to a $500 annual maximum.
Vision Services See details
Complete Blue PPO Distinct (PPO) partially covers vision services with no deductible, offering one routine eye exam annually with a $25 copay and no coinsurance, while other eye exam services are not covered. Eyewear is also covered with no deductible, no copay, and no coinsurance, providing up to a $400 combined annual limit for contacts, frames, lenses, and upgrades.
Dental Services See details
Complete Blue PPO Distinct (PPO) partially covers dental services up to a $3,000 annual limit, excluding other diagnostic, other preventive, maxillofacial prosthetics, implants, and orthodontics. Covered Medicare dental services require a $25 copay and no coinsurance, preventive services have no copay and no coinsurance, and comprehensive services feature no copay and 10% coinsurance (0% to 10% for adjunctive services).
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Complete Blue PPO Distinct (PPO) with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs carry no copay and a coinsurance ranging from no coinsurance to 20%, while Part B insulin drugs require a $35 copay and a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis services are covered under 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. Durable medical equipment features no coinsurance to 50% coinsurance, diabetic supplies range from no coinsurance to 20% coinsurance, and prosthetics, medical supplies, and diabetic footwear require 20% coinsurance.
Diagnostic and Radiological Services See details
Complete Blue PPO Distinct (PPO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Lab services have no copay, diagnostic tests have a $0 to $10 copay, outpatient x-rays have a $20 copay, and therapeutic and diagnostic radiological services have minimum copays of $50 and $150, respectively.
Home Health Services See details
Home health services are covered under the Complete Blue PPO Distinct (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Complete Blue PPO Distinct (PPO) plan, as specific sub-services including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all excluded from coverage.
Skilled Nursing Facility (SNF) See details
Complete Blue PPO Distinct (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20, a $218 copay for days 21 through 100 per stay, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Complete Blue PPO Distinct (PPO) partially covers Other Services, excluding acupuncture and meal benefits. Over-the-counter (OTC) items are covered with no copay and no coinsurance, up to a maximum benefit of $75 every three months.
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