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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, and 25% coinsurance for standard generic drugs at both preferred and standard pharmacies. You will also pay 50% coinsurance for preferred brand drugs and 33% coinsurance for non-preferred drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for Part D covered drugs. If you qualify for the low-income subsidy, your monthly premium will be reduced.
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 and emergency services have copays ranging from $15 to $200. Primary care, vision, and dental services are covered, and the plan also covers hearing services with a hearing aid benefit. This plan includes additional benefits like ambulance services, home health, and medical equipment, often with copays or coinsurance. Preventive services are covered, including some with no copay, while other services like diagnostic and radiological services have copays. The plan also has benefits for skilled nursing facilities and offers an over-the-counter item benefit.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with prior authorization required. For Inpatient Hospital-Acute, there is a $225 copay per admission or stay for Medicare-covered stays, and additional days are covered with no copay. Inpatient Hospital Psychiatric has a $300 copay per admission or stay for Medicare-covered stays, while additional days and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a $200 copay, and observation services with a $200 copay per day. Ambulatory Surgical Center (ASC) services have a $125 copay, and outpatient substance abuse services have 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 Complete Blue PPO Premier (PPO) plan. The plan covers the cost of this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including ground and air ambulance services, with a $270 copay for each service. Transportation Services to a Plan Approved Health-related Location are covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Complete Blue PPO Premier (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, Urgently Needed Services have a $15 copay, and Worldwide Emergency Transportation has a $270 copay, while all have no coinsurance.
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 for individual and group sessions, podiatry services, other health care professional 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
Preventive services are covered, including Medicare-covered zero-dollar preventive services, annual physical exams, and additional preventive services. Additional preventive services include a coinsurance, and Home and Bathroom Safety Devices and Modifications has a 20% coinsurance. Some services, such as Health Education, In-Home Safety Assessment, and Counseling Services, are not covered.
Hearing Services See details
Hearing Services includes coverage for routine hearing exams, with one exam allowed per year, and prescription hearing aids, with a maximum benefit of $500 per year and a copay between $699 and $999. Fitting/Evaluation for Hearing Aid, 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
The Complete Blue PPO Premier (PPO) plan covers vision services, including eye exams and eyewear, with no deductible. Routine eye exams are covered once per year, and eyewear has a combined maximum benefit of $400. 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, including oral exams, dental x-rays, cleaning, and fluoride treatment. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, coinsurance applies between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by 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 a 20% coinsurance and Prosthetics/Medical Supplies, with a 20% coinsurance for Medicare-covered devices and supplies. Diabetic Equipment is also covered, with a 0-20% coinsurance for Diabetic Supplies and a 20% coinsurance for Diabetic Therapeutic Shoes/Inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under 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 $150.00, Therapeutic Radiological Services have a copay of at most $50.00, and Outpatient X-Ray Services have a $10.00 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 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 the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Complete Blue PPO Premier (PPO) plan, with a $0 copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items, with a maximum plan benefit of $190.00 every three months, but 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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