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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 a $0 copay for preferred generic drugs at preferred pharmacies, 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.
Additional Benefits
The Complete Blue PPO Choice (PPO) plan offers comprehensive coverage, including inpatient and outpatient hospital services with varying copays. Primary care visits have a $15 copay, and specialist visits have a $30 copay. The plan also covers preventive services, hearing, vision, dental, and home health services, as well as medical equipment, and diagnostic and radiological services with specific copays or coinsurance amounts. Additional benefits include coverage for emergency services, ambulance, and skilled nursing facility stays. However, there are some exclusions such as certain dental, and home health services, as well as additional hours of care and personal care services.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days for Inpatient Hospital Psychiatric and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered. For Inpatient Hospital-Acute, you pay a $175 copay for days 1-5, and no copay for days 6-90, while Inpatient Hospital Psychiatric has a $425 copay for days 1-3, and no copay for days 4-90.
Outpatient Services See details
Outpatient Services includes coverage for all outpatient hospital services, with a $300 copay, and observation services with a $300 copay. Ambulatory Surgical Center (ASC) Services have a $200 copay, while outpatient substance abuse services have a $45 copay per session. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Complete Blue PPO Choice (PPO) 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 Choice (PPO) plan. Ground and air ambulance services have a copay of $375.00, 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. Emergency Services have a $125 copay, Urgently Needed Services have a $50 copay, and Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $50 copay, and Worldwide Emergency Transportation has a $375 copay. There is no coinsurance for any of these services.
Primary Care See details
The Complete Blue PPO Choice (PPO) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $25 copay, physician specialist services with a $30 copay, mental health and psychiatric services with a $40 copay, podiatry services with a $30 copay, other health care professional services with a copay between $0 and $30, 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
The Complete Blue PPO Choice (PPO) plan covers preventive services, including Medicare-covered services, annual physical exams, and other preventive services. Additional preventive services have no coinsurance or copay, but Home and Bathroom Safety Devices and Modifications have 20% coinsurance, and Remote Access Technologies have a copay between $0 and $30. Some services like Health Education, Counseling Services, and several others are not covered.
Hearing Services See details
Hearing services with the Complete Blue PPO Choice (PPO) plan include hearing exams with a $30 copay, and prescription hearing aids with a $500 yearly maximum benefit with a copay between $699 and $999. Fitting/Evaluation for Hearing Aid, Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, Over the Ear, and OTC Hearing Aids are not covered.
Vision Services See details
Vision services include eye exams with a $30 copay, and eyewear with a combined maximum benefit of $400 every year for both in-network 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 Choice (PPO) plan covers dental services with a $30 copay for Medicare dental services. Other dental services are covered with a $4,000 maximum benefit per year. Some services, such as Maxillofacial Prosthetics, Implant Services, and Orthodontics, are not covered. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery have a 50% coinsurance, while adjunctive general services have a 0-50% coinsurance.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Complete Blue PPO Choice (PPO) plan. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Complete Blue PPO Choice (PPO) plan. You will pay 20% coinsurance for this benefit.
Medical Equipment See details
Medical Equipment benefits are covered by the Complete Blue PPO Choice (PPO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies also have a 20% coinsurance, while Diabetic Supplies have between 0% and 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by Complete Blue PPO Choice (PPO). Diagnostic services, including 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 the Complete Blue PPO Choice (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 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
The Complete Blue PPO Choice (PPO) plan covers Skilled Nursing Facility (SNF) services with a $0 copay for days 1-20 and a $214 copay for days 21-100; additional and non-Medicare-covered SNF stays are not covered. Prior authorization is required for this benefit.
Other Services See details
The Complete Blue PPO Choice (PPO) plan 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, or Self-Directed Personal Assistance Services. Over-the-counter (OTC) items are covered, but the plan does not offer Nicotine Replacement Therapy (NRT) or Naloxone coverage as a Part C OTC benefit, and does not cover all drugs on the CMS OTC list.
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