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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 deductible of $550. Once you meet your deductible, you will pay the costs for your drugs. For preferred generic drugs, you will have no copay at a preferred pharmacy. For standard generic drugs, you will pay 21% coinsurance at either pharmacy. For preferred brand drugs, you will pay 25% coinsurance.
Additional Benefits
The Complete Blue PPO Merit (PPO) plan offers a range of benefits with varying cost-sharing. You can expect a $400 copay for inpatient hospital stays for the first 5 days, and no copay for days 6-90. The plan also covers outpatient services, emergency services, primary care, preventive services, hearing, vision, and dental services, each with its own copay or coinsurance structure. Other covered benefits include ambulance services, home health services with no copay, and skilled nursing facility care with a $0 copay for the first 20 days. The plan also covers home infusion services, medical equipment, and diagnostic and radiological services. There is a $40 benefit for over-the-counter items every three months.
Inpatient Hospital See details
Inpatient Hospital benefits are covered under the Complete Blue PPO Merit (PPO) plan. For Inpatient Hospital-Acute, you will pay a $400 copay for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient Services, including Outpatient Hospital Services and Observation Services, have a $325 copay. Ambulatory Surgical Center (ASC) Services have a $275 copay, and Individual and Group Sessions for Outpatient Substance Abuse have a copay between $45 and $45. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization benefits are covered by the Complete Blue PPO Merit (PPO) plan.
Ambulance and Transportation Services See details
Ambulance and Transportation Services include coverage for all ambulance services, with a $375 copay for both ground and air ambulance services. 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 under the Complete Blue PPO Merit (PPO) plan. Emergency Services have a $110 copay and no coinsurance, Urgently Needed Services have a $45 copay and no coinsurance, and Worldwide Emergency Coverage has a $110 copay, Worldwide Urgent Coverage has a $45 copay, and Worldwide Emergency Transportation has a $375 copay, with no coinsurance for all services.
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 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 Chiropractic Care is limited to 4 visits per year.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, annual physical exams, additional preventive services, kidney disease education services, and other preventive services. Fitness benefits include memory fitness, and remote access technologies have a copay between $0 and $40. Home and bathroom safety devices and modifications have a 20% coinsurance. However, health education, in-home safety assessments, personal emergency response systems, 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 benefits, 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 $40 copay, and Prescription Hearing Aids. The plan covers Routine Hearing Exams with a copay between $20 and $20, and covers Prescription Hearing Aids with a maximum benefit of $500 per year and a copay between $699 and $999. 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 include routine 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. Eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, contact lenses, and upgrades are also covered.
Dental Services See details
The Complete Blue PPO Merit (PPO) plan covers dental services, with a $40 copay for Medicare dental services. Other dental services have a maximum benefit of $1500 per year, and include Oral Exams, Dental X-Rays, Prophylaxis (Cleaning), and Fluoride Treatment. 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 and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay and between 0% and 20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Complete Blue PPO Merit (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits are covered under the Complete Blue PPO Merit (PPO) plan, including Durable Medical Equipment (DME) with 20% coinsurance and Prosthetics/Medical Supplies with 20% coinsurance. Diabetic Supplies have a coinsurance between 0-20%, and Diabetic Therapeutic Shoes/Inserts have 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by the Complete Blue PPO Merit (PPO) plan. Diagnostic services, including Diagnostic Procedures/Tests and Lab Services, are not covered, while 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 or coinsurance, but authorization is required. Additional Hours of Care and Personal Care Services are not covered.
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 and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other services include coverage for over-the-counter (OTC) items with a maximum benefit coverage amount of $40.00 every three months, while 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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