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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 $84.00. 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 has a $550 deductible. After the deductible, you will pay a $0 copay for preferred generic drugs at a preferred pharmacy. For standard generic drugs, you'll pay 21% coinsurance. For preferred brand drugs, you'll pay 25% coinsurance. Once your total drug costs reach $2000, you enter the next coverage phase.
Additional Benefits
The Complete Blue PPO Merit (PPO) plan provides coverage for a wide range of services, including inpatient and outpatient care, with varying copays depending on the service. Emergency, primary care, and preventive services are covered, with copays ranging from $0 to $110. The plan also offers additional benefits such as hearing, vision, and dental services, with specific copays and maximum benefit amounts for each. Additional benefits include ambulance services, home health, and medical equipment. The plan covers a range of other services, including home infusion, dialysis, and skilled nursing facility care. However, some services like cardiac rehabilitation, and certain other services are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a $400 copay for days 1-5 and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered with no copay, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, observation services, and outpatient substance abuse services, are covered with a $325 copay, and a $275 copay for Ambulatory Surgical Center (ASC) Services. Individual and group sessions for outpatient substance abuse have a copay of $45. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization benefits are covered by the Complete Blue PPO Merit (PPO) plan. There is no additional information about the cost of this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Complete Blue PPO Merit (PPO) plan. Ground and air ambulance services both have a copay of $375. 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. Emergency Services has a $110 copay, Urgently Needed Services has a $45 copay, and Worldwide Emergency Coverage has a $110 copay, Worldwide Urgent Coverage has a $45 copay, and Worldwide Emergency Transportation has a $375 copay; all services have no coinsurance.
Primary Care See details
The Complete Blue PPO Merit (PPO) plan 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, mental health specialty services with a $40 copay, podiatry services with a $40 copay, other health care professional services with a copay between $0 and $40, psychiatric services with a $40 copay, physical therapy and speech-language pathology services with a $35 copay, additional telehealth benefits with a copay between $0 and $45, and opioid treatment program services with a $45 copay. Routine foot care is also covered.
Preventive Services See details
The Complete Blue PPO Merit (PPO) plan covers a variety of preventive services, including Medicare-covered preventive services, annual physical exams, and additional preventive services. The plan offers no copay for Remote Access Technologies, but has a maximum copay of $40; it also has a 20% coinsurance for Home and Bathroom Safety Devices and Modifications.
Hearing Services See details
Hearing Services include hearing exams and prescription hearing aids. Hearing exams have a $40 copay, and routine hearing exams are limited to 1 per year with a copay between $20 and $20. Prescription hearing aids have a maximum benefit of $500 per year, and a copay between $699 and $999 per year for up to 2 hearing aids. 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
Vision services, including routine eye exams, are covered with a $40 copay. Eyewear is covered with a combined maximum benefit of $400 every year for both in-network and out-of-network services, and 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 dental services, including a $40 copay for Medicare Dental Services. Other dental services are covered with a $1,500 maximum benefit amount per year. Restorative Services, Endodontics, Periodontics, Prosthodontics (removable and fixed) and Oral and Maxillofacial Surgery have a 50% coinsurance. Oral exams, dental x-rays, cleaning, and fluoride treatments are also covered. 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 and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Complete Blue PPO Merit (PPO) plan with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment is covered under the Complete Blue PPO Merit (PPO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies has a 20% coinsurance, and Diabetic Supplies has between 0% and 20% coinsurance, but Diabetic Therapeutic Shoes/Inserts has a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by the Complete Blue PPO Merit (PPO) plan, with no copay for all diagnostic services, but Diagnostic Procedures/Tests and Lab Services are not covered. Radiological Services have a copay for Medicare-covered services; 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 copay of $20.
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. Prior 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, with a $0 copay for days 1-20 and a $214 copay for days 21-100. Additional days beyond Medicare-covered for SNF and Non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes Over-the-Counter (OTC) Items, with a maximum plan benefit coverage amount of $40 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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