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Complete Blue PPO Merit (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Complete Blue PPO Merit (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 Merit (PPO) in 2025, please refer to our full plan details page.
Complete Blue PPO Merit (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 Merit (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 Merit (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 Merit (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 $83.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $175.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $550.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
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 Merit (PPO) plan has an enhanced alternative drug benefit. The plan includes a $550 deductible for prescription drugs. Once you meet your deductible, you will pay a $0 copay for preferred generic drugs at a preferred pharmacy. For standard generic drugs, you will pay 21% coinsurance. For preferred brand drugs, non-preferred drugs, and specialty tier drugs, you will pay 25% coinsurance.
Additional Benefits
The Complete Blue PPO Merit (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $400 copay for the first five days, with no copay thereafter, while outpatient services have copays ranging from $45 to $325. Emergency services have copays from $45 to $375, and primary care services have copays between $15 and $45. The plan also covers preventive services with no copay for Medicare-covered services, along with vision and hearing services. Vision includes eye exams with a $40 copay and eyewear, while hearing includes hearing exams with a $40 copay and hearing aids. Dental services include a $40 copay for Medicare dental, and other dental services with a 50% coinsurance.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both requiring prior authorization. For Inpatient Hospital-Acute, you will pay a $400 copay for days 1-5, and no copay for days 6-90, while for Inpatient Hospital Psychiatric, you will pay a $400 copay for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital and observation services have a $325 copay, ambulatory surgical center services have a $275 copay, and individual and group outpatient substance abuse sessions have a $45 copay.
Partial Hospitalization See details
Partial Hospitalization benefits are covered. There is no copay or coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required. Ground and air ambulance services have a $375 copay, and 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 under the Complete Blue PPO Merit (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, Urgently Needed Services and Worldwide Urgent Coverage have a $45 copay, and Worldwide Emergency Transportation has a $375 copay; all have no coinsurance.
Primary Care See details
Complete Blue PPO Merit (PPO) covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $35 copay, physician specialist services with a $40 copay, and mental health specialty services with a $40 copay for individual and group sessions. The plan also covers podiatry services and other health care professionals, with copays ranging from $0 to $40, as well as psychiatric services with a $40 copay for individual and group sessions. Physical therapy and speech-language pathology services have a $35 copay, and additional telehealth benefits have a copay between $0 and $45, while opioid treatment program services have a $45 copay.
Preventive Services See details
The Complete Blue PPO Merit (PPO) plan covers preventive services, including Medicare-covered services with no copay. Additional preventive services include Fitness Benefits, Enhanced Disease Management, Remote Access Technologies (with a $0-$40 copay), and Home and Bathroom Safety Devices and Modifications (with 20% coinsurance). However, Health Education, In-Home Safety Assessment, Personal Emergency Response System, Medical Nutrition Therapy, and several other services are not covered.
Hearing Services See details
Hearing Services includes coverage for hearing exams with a $40 copay, and prescription hearing aids with a copay between $699 and $999, up to $500 per year for both in-network and out-of-network services. 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 with the Complete Blue PPO Merit (PPO) plan include eye exams with a $40 copay, and eyewear with a combined maximum benefit of $400 per 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 Merit (PPO) plan covers Medicare Dental Services with a $40 copay. Other Dental Services include oral exams, dental x-rays, cleaning, and fluoride treatment, which are subject to limitations and have a maximum benefit of $1500 per year. 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, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Complete Blue PPO Merit (PPO) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment is covered by the Complete Blue PPO Merit (PPO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, and Prosthetics/Medical Supplies have a 20% coinsurance, while Diabetic Supplies have between 0% and 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by the Complete Blue PPO Merit (PPO) plan, with Diagnostic Procedures/Tests and Lab Services not covered. Diagnostic Radiological Services have a maximum copay of $300, Therapeutic Radiological Services have a maximum copay of $60, and Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by the Complete Blue PPO Merit (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Complete Blue PPO Merit (PPO) 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 Merit (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services for the Complete Blue PPO Merit (PPO) plan include coverage for Over-the-Counter (OTC) Items, with a maximum plan benefit coverage amount of $40.00 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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