A non-government entity
Complete Blue PPO Choice Deluxe (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Complete Blue PPO Choice Deluxe (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 Deluxe (PPO) in 2025, please refer to our full plan details page.
Complete Blue PPO Choice Deluxe (PPO) is a PPO plan offered by Highmark Health available for enrollment in 2025 to people living in Southeast 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 Deluxe (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 Deluxe (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 Deluxe (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $9.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 $9550.00 (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 $9550.00 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 Deluxe (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Complete Blue PPO Choice Deluxe (PPO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have a $5 copay at preferred pharmacies and a $20 copay at standard pharmacies. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered Part D drugs. If you qualify for the low-income subsidy, you will pay $4.30 for Part D drugs.
Additional Benefits
The Complete Blue PPO Choice Deluxe (PPO) plan offers comprehensive coverage with a variety of benefits. The plan includes coverage for inpatient and outpatient hospital services, primary care, emergency services, and preventive services. Additional benefits include hearing, vision, and dental services, as well as coverage for medical equipment, home health, and skilled nursing facility care. The plan also covers ambulance, diagnostic, and radiological services. Copays and coinsurance amounts vary depending on the specific service.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, there is a $425 copay per admission for a Medicare-covered stay, and additional days are covered with no copay, while the Non-Medicare-covered Stay and Upgrades are not covered. For Inpatient Hospital Psychiatric, there is a $425 copay for days 1-3, and no copay for days 4-90.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services with a $300 copay, observation services with a $300 copay, and ambulatory surgical center (ASC) services with a $200 copay. Outpatient substance abuse services are covered with a copay of $45 for both individual and group sessions, and outpatient blood services are covered with a waived three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered by the Complete Blue PPO Choice Deluxe (PPO) plan.
Ambulance and Transportation Services See details
The Complete Blue PPO Choice Deluxe (PPO) plan covers ambulance and transportation services, with prior authorization required. Ground and air ambulance services have a copay of $290.00. 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, including urgently needed services and worldwide emergency services, are covered by the Complete Blue PPO Choice Deluxe (PPO) plan. Emergency Services have a $125 copay and no coinsurance, Urgently Needed Services have a $50 copay and no coinsurance, Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $50 copay, and Worldwide Emergency Transportation has a $290 copay.
Primary Care See details
The Complete Blue PPO Choice Deluxe (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 $25 copay, mental health specialty services with a $40 copay for individual and group sessions, podiatry services with a $25 copay, other health care professional services with a copay between $0 and $25, psychiatric services with a $40 copay for individual and group sessions, 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 and routine foot care are limited to 4 visits per year.
Preventive Services See details
The Complete Blue PPO Choice Deluxe (PPO) plan covers various preventive services, including Medicare-covered services and annual physical exams. Additional preventive services are covered, but some services like Health Education and Counseling Services are not covered. Remote Access Technologies have a copay between $0 and $25, and Home and Bathroom Safety Devices have a 20% coinsurance.
Hearing Services See details
Hearing Services include hearing exams and prescription hearing aids. Routine hearing exams have a $15 copay, and are limited to one per year. Prescription hearing aids have a maximum benefit of $500 per year, per ear, with 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 eye exams with a $25 copay, and coverage for eyewear including contact lenses, eyeglasses, eyeglass lenses, and eyeglass frames. Eyewear has a combined maximum benefit of $400 per year.
Dental Services See details
The Complete Blue PPO Choice Deluxe (PPO) plan covers dental services, including Medicare Dental Services with a $25 copay, and other dental services with a maximum benefit of $4,000 per year. The plan covers oral exams, dental x-rays, cleaning, and fluoride treatments with limitations on the number of visits and frequency, and restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery with a 50% coinsurance. 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. The plan covers Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Complete Blue PPO Choice Deluxe (PPO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered by the Complete Blue PPO Choice Deluxe (PPO) plan, including Durable Medical Equipment (DME) with 20% coinsurance and Prosthetic Devices and Medical Supplies with 20% coinsurance, but Durable Medical Equipment for use outside the home is not covered. Diabetic Equipment is covered, including Diabetic Supplies with 0-20% coinsurance and Diabetic Therapeutic Shoes/Inserts with 20% coinsurance.
Diagnostic and Radiological Services See details
The Complete Blue PPO Choice Deluxe (PPO) plan provides coverage for diagnostic and radiological services, but diagnostic procedures/tests and lab services are not covered. Diagnostic radiological services have a copay of at most $300, therapeutic radiological services have a copay of at most $75, and outpatient X-ray services have a $30 copay.
Home Health Services See details
Home Health Services are covered by the Complete Blue PPO Choice Deluxe (PPO) plan with no copay or 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
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.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Complete Blue PPO Choice Deluxe (PPO) plan, but require prior authorization. For days 1-20, there is no copay, but for days 21-100, there is a $214 copay. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services for the Complete Blue PPO Choice Deluxe (PPO) plan does not cover acupuncture, meal benefits, or dual eligible SNPs with highly integrated services. Over-the-Counter (OTC) Items are covered, but do not include Nicotine Replacement Therapy (NRT) or Naloxone coverage, and do not cover all drugs on the CMS OTC list. All other sub-services are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved