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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.
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 $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:
Sign up for Complete Blue PPO Premier (PPO)
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Drug Coverage
The Complete Blue PPO Premier (PPO) plan has an enhanced alternative drug benefit with a $0 deductible. In the initial coverage phase, you will pay no copay for preferred generic drugs at a preferred pharmacy, while standard generic drugs have a 25% coinsurance. Preferred brand drugs have a 50% coinsurance, and 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 Medicare Part D covered drugs. The plan's premium is $29.30 per month, but may be reduced to $24.40 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 copays, while outpatient services have copays for services like outpatient hospital visits. Emergency and urgent care services have copays, and primary care, including chiropractic and mental health, is covered with copays. Preventive services have no copay, while hearing, vision, and dental services are included with annual maximums. Home health services and skilled nursing facility stays have no copay for a limited number of days. The plan also offers coverage for ambulance, home infusion, and dialysis services.
Inpatient Hospital See details
Inpatient Hospital benefits with the Complete Blue PPO Premier (PPO) plan include coverage for Inpatient Hospital-Acute with a $225 copay per admission or stay, and Inpatient Hospital Psychiatric with a $300 copay per admission or stay. Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a $200 copay, observation services with a $200 copay, ambulatory surgical center services with a $125 copay, and outpatient substance abuse services with a $30 copay for both individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the plan. There is no copay or coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Complete Blue PPO Premier (PPO) plan. Ground and Air Ambulance Services have a copay of $270, with no coinsurance. Transportation Services to plan-approved health-related locations are covered, while 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 under the Complete Blue PPO Premier (PPO) plan. Emergency Services have a $125 copay, while Urgently Needed Services have a $15 copay, and 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 services, physician specialist services, mental health specialty services with a $30 copay, podiatry services with 10 visits per year, other health care professional services, psychiatric services with a $30 copay, physical therapy and speech-language pathology services, additional telehealth benefits with a copay between $0 and $30, and opioid treatment program services with a $30 copay. Routine chiropractic care has a $20 copay for 8 visits per year.
Preventive Services See details
Preventive Services are covered, including Medicare-covered services with no copay. Additional preventive services are covered, but some services like Health Education, Counseling Services, and others are not covered. Home and Bathroom Safety Devices and Modifications have a 20% coinsurance.
Hearing Services See details
Hearing Services include routine hearing exams with 1 visit per year, and prescription hearing aids with a maximum benefit of $500 per year, with a copay between $699 and $999; 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 are covered, including eye exams, eyewear, and upgrades. Routine eye exams are covered once per year, while eyewear has a combined maximum benefit of $400 per year for both in-network and out-of-network services.
Dental Services See details
The Complete Blue PPO Premier (PPO) plan covers dental services with a maximum benefit of $3,500 per year, including oral exams, dental x-rays, cleaning, fluoride treatment, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics, fixed, and oral and maxillofacial surgery. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. The plan covers Medicare Part B insulin drugs with a $35 copay and 0-20% coinsurance, and other Medicare Part B drugs with 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Complete Blue PPO Premier (PPO) plan. You will pay 20% coinsurance for this benefit.
Medical Equipment See details
Medical equipment is covered by the Complete Blue PPO Premier (PPO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, and Durable Medical Equipment for use outside the home is not covered; Prosthetics/Medical Supplies have a 20% coinsurance, and Diabetic Equipment has a coinsurance that varies from 0% to 20% depending on the service.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by the Complete Blue PPO Premier (PPO) plan. Diagnostic Procedures/Tests and Lab Services are not covered, while 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 copay of $10.
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 prior authorization is required. 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 are covered, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Complete Blue PPO Premier (PPO) plan. There is no copay for days 1-20, and a $214 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items, with a maximum benefit of $195 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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