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Complete Blue PPO Premier (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Complete Blue PPO Premier (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 Premier (PPO) in 2025, please refer to our full plan details page.
Complete Blue PPO Premier (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 Premier (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 Premier (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 Premier (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $49.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $1.00. 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 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 $8950.00 (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 $8950.00 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 Premier (PPO) plan has an enhanced alternative drug benefit with no deductible. In the initial coverage phase, you will pay no copay for preferred generic drugs at a preferred pharmacy, 25% coinsurance for standard generic drugs, and 50% coinsurance for preferred brand drugs. Non-preferred drugs have a 33% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered drugs. Your monthly premium for Part D is $29.30, and may be reduced if you qualify for the low-income subsidy.
Additional Benefits
The Complete Blue PPO Premier (PPO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services like substance abuse treatment and primary care visits have copays ranging from $20-$200. Emergency services and ambulance services are covered, with copays for both. Preventive services and home health services are covered with no copay, and the plan includes coverage for hearing, vision, and dental services with annual maximums. Additional benefits include coverage for medical equipment, diagnostic and radiological services, and skilled nursing facility stays, which may include copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with prior authorization required. Inpatient Hospital-Acute has a $225 copay per admission or stay, while Inpatient Hospital Psychiatric has a $300 copay per admission or stay; additional days for Inpatient Hospital-Acute are covered with no copay, but non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services includes coverage for outpatient hospital services with a $200 copay, observation services with a $200 copay, ambulatory surgical center services with a $125 copay, outpatient substance abuse services with a $30 copay for both individual and group sessions, and outpatient blood services.
Partial Hospitalization See details
Partial Hospitalization is covered by the Complete Blue PPO Premier (PPO) plan. There is no additional cost information available for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required. Ground and air ambulance services have a $270 copay, and there is no coinsurance. 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. Emergency Services have a $125 copay, Urgently Needed Services have a $15 copay, Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $15 copay, and Worldwide Emergency Transportation has a $270 copay.
Primary Care See details
The Complete Blue PPO Premier (PPO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy, physician specialist services, mental health specialty services with a $30 copay for individual and group sessions, podiatry services, psychiatric services with a $30 copay for individual and group sessions, physical therapy and speech-language pathology services, additional telehealth benefits with a $0-$30 copay, and opioid treatment program services with a $30 copay. Routine Chiropractic Care is limited to 8 visits per year.
Preventive Services See details
The Complete Blue PPO Premier (PPO) plan covers preventive services, including Medicare-covered services with no copay and annual physical exams. Additional preventive services are covered, and some services are covered, including fitness benefits, enhanced disease management, remote access technologies, Home and Bathroom Safety Devices and Modifications with 20% coinsurance.
Hearing Services See details
Hearing services include routine hearing exams, covered once per year, and prescription hearing aids, covered up to $500 per year, with a copay between $699 and $999 depending on the type of aid. Fitting/evaluation for hearing aids, prescription hearing aids - inner ear, outer ear, and over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services for the Complete Blue PPO Premier (PPO) plan include routine eye exams once per year, and eyewear with a combined maximum benefit of $400 per year for in and out-of-network services. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
The Complete Blue PPO Premier (PPO) plan covers dental services, with a maximum benefit of $3,500 per year for both in-network and out-of-network services. Oral exams, dental x-rays, cleaning, fluoride treatment, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered, but 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 a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Complete Blue PPO Premier (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered by the Complete Blue PPO Premier (PPO) plan, including Durable Medical Equipment (DME) with 20% coinsurance and Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment with varying coinsurance costs. The plan does not cover Durable Medical Equipment for use outside the home.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, but Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of at most $150, Therapeutic Radiological Services have a copay of at most $50, and Outpatient X-Ray Services have a $10 copay.
Home Health Services See details
Home Health Services are covered by the Complete Blue PPO Premier (PPO) plan with no copay and no coinsurance, but authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are 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 by the Complete Blue PPO Premier (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 offered by the Complete Blue PPO Premier (PPO) plan include Over-the-Counter (OTC) Items with a maximum benefit of $185 every three months, while 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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