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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 no copay for preferred generic drugs at a preferred pharmacy. For standard generic drugs, you will pay 25% coinsurance. For preferred brand drugs, you will pay 50% coinsurance, and for non-preferred drugs you will pay 33% coinsurance.
Additional Benefits
The Complete Blue PPO Distinct (PPO) plan offers a range of benefits including inpatient hospital stays with a $275 copay, outpatient services with varying copays, and ambulance services with a $260 copay. The plan also covers primary care, specialist visits, and mental health services with copays between $5 and $45, as well as preventive, vision, and dental services. Hearing exams have a $10 copay, with prescription hearing aids covered. This plan provides coverage for home infusion bundled services, dialysis, and medical equipment with coinsurance. Emergency services have a $125 copay, and skilled nursing facility stays have no copay for the first 20 days. The plan also covers over-the-counter items up to $105 every three months.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute with a $275 copay per admission, and Additional Days with no copay. Inpatient Hospital Psychiatric has a $425 copay for days 1-3, and no copay for days 4-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Additional Days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services includes coverage for all outpatient hospital services with a $200 copay, observation services with a $200 copay, ambulatory surgical center (ASC) services with a $175 copay, outpatient substance abuse services with a $45 copay for individual and group sessions, and outpatient blood services.
Partial Hospitalization See details
Partial Hospitalization benefits are covered by the Complete Blue PPO Distinct (PPO) plan. There is no additional information about the cost of this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Complete Blue PPO Distinct (PPO) plan, including ground and air ambulance services with a $260 copay. Transportation to a plan-approved health-related location is covered, but transportation to any other health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $125 copay, and Urgently Needed Services have a $30 copay, while 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, and mental health services with a $40 copay for individual and group sessions. This plan also covers podiatry services with a $10 copay, other health care professional services with a copay between $0 and $10, psychiatric services with a $40 copay for individual and group sessions, and physical therapy and speech-language pathology services with a $5 copay. Additional telehealth benefits are covered with a copay between $0 and $45, and opioid treatment program services have a $45 copay.
Preventive Services See details
Preventive services include coverage for Medicare-covered services, annual physical exams, additional preventive services, kidney disease education services, and other preventive services like glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. Home and bathroom safety devices and modifications have a 20% coinsurance, while Remote Access Technologies have a copay between $0 and $10. However, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, readmission 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, and prescription hearing aids with a copay between $699 and $999, 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 - 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 eye exams with a $10 copay, eyewear with a combined maximum of $400 per year for both in and out-of-network services, and unlimited 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. The plan covers oral exams with a $10 copay and one visit every six months, dental x-rays with a $10 copay and one visit per year, prophylaxis (cleaning) with a $10 copay and one visit every six months, and fluoride treatment with a $10 copay and one visit every six months. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed) and oral and maxillofacial surgery are covered with a 10% coinsurance, and other services are limited. 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. Medicare Part B Insulin Drugs have 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 by the Complete Blue PPO Distinct (PPO) plan. The coinsurance for Dialysis Services is 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment, Prosthetics/Medical Supplies, and Diabetic Equipment. Durable Medical Equipment has a 20% coinsurance and requires authorization, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a 20% coinsurance for Medicare-covered devices and supplies, and Diabetic Equipment has a coinsurance that varies. 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 under 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, 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 technically covered, but 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, but require prior authorization. There is no copay for days 1-20, and a $214 copay per day for days 21-100, while additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services include coverage for over-the-counter items, with a maximum benefit of $105 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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