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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 different amounts depending on the drug tier and pharmacy. For preferred generic drugs, you will have no copay at a preferred pharmacy, and a $15 copay at a standard pharmacy. For other tiers, you will pay coinsurance amounts, with the non-preferred drug tier costing 33% coinsurance. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs.
Additional Benefits
The Complete Blue PPO Choice (PPO) plan offers a range of benefits, including coverage for inpatient and outpatient hospital services, with varying copays depending on the specific service. The plan also covers ambulance and emergency services, primary care, preventive services, hearing, vision, dental, and home infusion services. Additional benefits include coverage for dialysis services, medical equipment, diagnostic and radiological services, home health services, and skilled nursing facility (SNF) services. The plan also covers some services such as hearing exams, routine eye exams, and dental services with copays.
Inpatient Hospital See details
Inpatient Hospital services are covered, with a copay of $175 per day for days 1-5 and no copay for days 6-90 for Inpatient Hospital-Acute, and a copay of $425 per day for days 1-3 and no copay for days 4-90 for Inpatient Hospital Psychiatric. Additional days for Inpatient Hospital-Acute are covered with no copay, while non-Medicare covered stays and upgrades are not covered. Additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered, including all outpatient hospital services, observation services, and outpatient substance abuse services. Outpatient Hospital Services and Observation Services have a $300 copay, Ambulatory Surgical Center (ASC) Services have a $200 copay, and Individual and Group Sessions for Outpatient Substance Abuse have a copay between $45.00 and $45.00.
Partial Hospitalization See details
Partial Hospitalization is covered by the Complete Blue PPO Choice (PPO) plan. There is no information available about the cost of this service.
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 each have a copay of $375.00, and transportation services to a plan-approved health-related location 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 by the Complete Blue PPO Choice (PPO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $50 copay, Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $50 copay, and Worldwide Emergency Transportation has a $375 copay.
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, are covered by the Complete Blue PPO Choice (PPO) plan. Additional preventive services include coverage for Fitness Benefits, Enhanced Disease Management, Remote Access Technologies (with a copay between $0 and $30), and Home and Bathroom Safety Devices and Modifications (with 20% coinsurance). 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 with a $30 copay, and routine hearing exams with a $20 copay for up to one visit per year. Prescription hearing aids are covered with a maximum benefit of $500 per year, and a copay between $699 and $999 for up to two hearing aids per year. 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 include routine eye exams with a $30 copay, and eyewear with a combined maximum of $400 per year for both in-network and out-of-network services, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. You are limited to one routine eye exam every year.
Dental Services See details
Dental Services are covered, including Medicare Dental Services with a $30 copay, and other dental services with a $4,000 maximum benefit per year. Oral exams, dental X-rays, prophylaxis (cleaning), and fluoride treatment are covered, with limitations on the number of visits. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with 50% coinsurance. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. The plan has a $35 copay for Medicare Part B Insulin Drugs with 0-20% coinsurance, while other services have 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Complete Blue PPO Choice (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits are covered under the Complete Blue PPO Choice (PPO) plan. Durable Medical Equipment has a 20% coinsurance with no copay, and requires authorization, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies - Non-Medicare benefit is covered with a coinsurance, and no copay, while Diabetic Equipment is covered, with a coinsurance for Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Complete Blue PPO Choice (PPO) plan. Diagnostic services, including diagnostic procedures/tests and lab services, are not covered. For Diagnostic Radiological Services, the copay is at most $225, for Therapeutic Radiological Services, the copay is at most $75, and for Outpatient X-Ray Services, the copay is $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 additional hours of care and personal care services are not covered. This benefit requires authorization.
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 cost information available for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Complete Blue PPO Choice (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214.
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, and Self-Directed Personal Assistance Services. Over-the-Counter (OTC) Items are covered, and there is no maximum plan benefit coverage amount.
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