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Complete Blue PPO Choice (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Complete Blue PPO Choice (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 Choice (PPO) in 2025, please refer to our full plan details page.
Complete Blue PPO Choice (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 Choice (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 Choice (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 Choice (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $19.00. 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:
Sign up for Complete Blue PPO Choice (PPO)
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Drug Coverage
The Complete Blue PPO Choice (PPO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay varying costs depending on the drug tier and pharmacy. For example, in the preferred pharmacy, you will pay no copay for preferred generic drugs, 25% coinsurance for standard generic drugs, and 50% coinsurance for preferred brand drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Complete Blue PPO Choice (PPO) plan offers a range of benefits, including inpatient and outpatient hospital services, ambulance and emergency services, and various primary care services. You will pay a copay for many of these services, such as $175 for inpatient hospital stays (days 1-5), $300 for outpatient services, and $125 for emergency services. Additional benefits include coverage for preventive, hearing, vision, and dental services, as well as home infusion and dialysis services. The plan also covers medical equipment, diagnostic and radiological services, and home health services. However, some services such as certain dental and vision services, and some home health services, may have coinsurance or maximum benefit limits.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you pay a $175 copay for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, you pay a $425 copay for days 1-3, and no copay for days 4-90. 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 and observation services, both with a $300 copay, and ambulatory surgical center services with a $200 copay. Outpatient substance abuse services are covered with a copay between $45 and $45 for individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Complete Blue PPO Choice (PPO) plan.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Complete Blue PPO Choice (PPO) plan. Ground and air ambulance services have a copay of $375, with no coinsurance, while transportation services to any 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 Choice (PPO) plan. Emergency Services have a $125 copay, and Urgently Needed Services have a $50 copay, while Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $50 copay, and Worldwide Emergency Transportation has a $375 copay; all services have no coinsurance.
Primary Care See details
The Complete Blue PPO Choice (PPO) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy with a $25 copay, physician specialist services with a $30 copay, mental health specialty services with a $40 copay, podiatry services with a $30 copay, other health care professional services with a copay between $0 and $30, psychiatric services with a $40 copay, physical therapy and speech-language pathology services with a $25 copay, additional telehealth benefits with a copay between $0 and $50, 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, including Medicare-covered services and annual physical exams, are covered. Additional Preventive Services, Fitness Benefit, Enhanced Disease Management, Remote Access Technologies, and Home and Bathroom Safety Devices and Modifications are covered. Home and Bathroom Safety Devices and Modifications have a 20% coinsurance, while Remote Access Technologies have a copay between $0 and $30. Health Education, In-Home Safety Assessment, Personal Emergency Response System, Medical Nutrition Therapy, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, 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 include hearing exams and prescription hearing aids. Hearing exams have a $30 copay, and routine hearing exams are limited to one per year with a copay between $20 and $20. Prescription hearing aids have a maximum benefit of $500 per year, and all types of prescription hearing aids have a copay between $699 and $999 for two visits per year. Fitting/Evaluation for Hearing Aid, Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear are not covered, as well as OTC hearing aids.
Vision Services See details
Vision services include coverage for eye exams with a $30 copay, and for eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames; there is a combined maximum of $400 per year for eyewear. Routine eye exams are covered once per year.
Dental Services See details
The Complete Blue PPO Choice (PPO) plan covers dental services, including Medicare dental services with a $30 copay. Other dental services are covered, with a $4,000 maximum benefit per year, including oral exams with 1 visit every six months, dental x-rays with 1 visit per year, and prophylaxis (cleaning) with 1 visit every six months, and fluoride treatment with 1 visit every six months. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with a 50% coinsurance, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Complete Blue PPO Choice (PPO) plan, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Complete Blue PPO Choice (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetic Devices with 20% coinsurance, Medical Supplies with 20% coinsurance, and Diabetic Supplies with 0-20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
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 $225, Therapeutic Radiological Services have a copay of at most $75, and Outpatient X-Ray Services have a copay of $25.
Home Health Services See details
Home Health Services are covered by Complete Blue PPO Choice (PPO) with no copay and no coinsurance, but Additional Hours of Care and Personal Care Services are not covered. Prior authorization is required for this benefit.
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. There is no copay or coinsurance for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the Complete Blue PPO Choice (PPO) plan, with a $0 copay for days 1-20 and a $214 copay per day for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered. Prior authorization is required.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items, but does not cover 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.
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