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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 with a $0 deductible. During the initial coverage phase, you'll pay either a copay or coinsurance based 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 Part D covered drugs. If you qualify for the low-income subsidy, you'll pay $6.70 for Part D drugs.
Additional Benefits
The Complete Blue PPO Distinct (PPO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services with copays, and ambulance services with a copay. Primary care, preventive, hearing, vision, and dental services are also covered, each with its own copay or coinsurance structure. Additional benefits include home health services with no copay, and skilled nursing facility stays with no copay for the first 20 days, and a copay for days 21-100. The plan also covers home infusion, dialysis, and medical equipment with varying coinsurance, as well as diagnostic and radiological services with copays. Over-the-counter items are covered up to a maximum benefit amount every three months.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, there is a $275 copay per admission, and for days 1-3 of Inpatient Hospital Psychiatric, there is a $425 copay, but there is 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, while ambulatory surgical center services have a $175 copay. Individual and group sessions for outpatient substance abuse services have a copay between $45 and $45.
Partial Hospitalization See details
Partial Hospitalization is covered by the Complete Blue PPO Distinct (PPO) plan. There is no information about the cost of services.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Complete Blue PPO Distinct (PPO) plan, including both ground and air ambulance services, each with a $260 copay. Transportation Services to a plan-approved health-related location are also covered. Transportation to any health-related location is 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 have a $125 copay, Urgently Needed Services have a $30 copay, 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, physician specialist services with a $10 copay, mental health specialty services with a $40 copay, podiatry services with a $10 copay, other health care professional services with a copay between $0 and $10, psychiatric services with a $40 copay, 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 other preventive services; services such as health education, in-home safety assessments, and counseling services are not covered. The plan also covers Remote Access Technologies with a copay between $0 and $10, and Home and Bathroom Safety Devices and Modifications with 20% coinsurance.
Hearing Services See details
Hearing services include hearing exams with a $10 copay, and prescription hearing aids with a copay between $699 and $999 per year, up to a maximum of $500 per year for both in-network and out-of-network services; however, fitting/evaluation for hearing aids, prescription hearing aids for the inner ear, outer ear, and over the ear, and OTC hearing aids are not covered. Routine hearing exams are covered, up to 1 per year.
Vision Services See details
Vision services include eye exams with a $10 copay, eyewear with a combined maximum benefit of $400 per year, and coverage for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Routine eye exams are covered once per year.
Dental Services See details
Dental Services include 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. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery have a 10% coinsurance. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, requiring prior authorization, with coinsurance costs that vary. Insulin has a $35 copay, with coinsurance between 0% and 20%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Complete Blue PPO Distinct (PPO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance and Prosthetic Devices, Medical Supplies and Diabetic Equipment, each with a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered, while Diabetic Supplies have a 0-20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, but Diagnostic Procedures/Tests and Lab Services are not covered. For Diagnostic Radiological Services, the copay is at most $175, for Therapeutic Radiological Services the copay is at most $50, and for Outpatient X-Ray Services the copay is $20.
Home Health Services See details
Home Health Services are covered by Complete Blue PPO Distinct (PPO), with no copay or coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Complete Blue PPO Distinct (PPO) plan. Specifically, Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
Other Services See details
Other services include Over-the-Counter (OTC) Items, but acupuncture, meal benefits, and several other services are not covered. Over-the-counter items have a maximum benefit coverage amount of $105 every three months.
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