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Complete Blue PPO Distinct (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Complete Blue PPO Distinct (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 Distinct (PPO) in 2026, please refer to our full plan details page.
Complete Blue PPO Distinct (PPO) is a PPO plan offered by Highmark Health available for enrollment in 2026 to people living in Western, PA. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Complete Blue PPO Distinct (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 Distinct (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 Distinct (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $30.00. 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 a $615.00 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 $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:
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Drug Coverage
The Complete Blue PPO Distinct (PPO) plan features an annual drug deductible of $615 before coverage begins for certain tiers. For Tier 1 preferred generic drugs, you will pay no copay for a one-month or three-month supply at a preferred pharmacy or through preferred mail order, while standard pharmacies charge a $7 copay per month. Tier 2 generic medications cost as little as a $3 copay for a one-month supply at a preferred pharmacy, compared to a $20 copay at a standard pharmacy. Higher-tier medications under this Medicare plan transition to coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 23% coinsurance across all pharmacy options, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance. Utilizing preferred pharmacies and preferred mail-order services with this plan will help minimize your out-of-pocket prescription costs.
Additional Benefits
The Complete Blue PPO Distinct (PPO) plan offers comprehensive medical coverage with no copay and no coinsurance for primary care doctor visits, home health services, and annual physicals. Specialist visits require a $25 copay, while emergency room services have a $130 copay and urgent care costs $40 with no coinsurance. For inpatient hospital stays, members pay a $155 daily copay for the first three days and no copay for subsequent days. For extra health needs, the plan features preventive dental care and eyewear with no copay or coinsurance, plus a $95 quarterly over-the-counter allowance. Comprehensive dental services are covered up to a $3,000 annual limit with a 10% coinsurance, while routine hearing exams require a $10 to $25 copay. Additionally, skilled nursing facility stays are covered with no copay for the first 20 days before a $218 daily copay applies.
Inpatient Hospital See details
Inpatient hospital services are covered by Complete Blue PPO Distinct (PPO) with no coinsurance, requiring a $155 copay per day for days 1-3 of acute stays and a $425 copay per day for days 1-3 of psychiatric stays, with no copays for subsequent days. Prior authorization is required, and some services such as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Complete Blue PPO Distinct (PPO) covers outpatient services with no coinsurance, featuring a $200 copay for outpatient hospital and daily observation services, and a $175 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $45 copay with no coinsurance, while outpatient blood services are covered with no copay, coinsurance, or deductible.
Partial Hospitalization See details
Complete Blue PPO Distinct (PPO) covers partial hospitalization services with no copay and no coinsurance.
Ambulance and Transportation Services See details
Complete Blue PPO Distinct (PPO) covers ground and air ambulance services with a $460 copay and no coinsurance, requiring prior authorization. Transportation services are partially covered under prior authorization, offering unlimited one-way trips to plan-approved locations with no copay or coinsurance, while transportation to any health-related location is not covered.
Emergency Services See details
Complete Blue PPO Distinct (PPO) covers emergency services with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within three days. Urgently needed services are covered with a $40 copay and no coinsurance, while worldwide emergency services are covered with no coinsurance and copays ranging from $40 to $460 depending on the service.
Primary Care See details
Complete Blue PPO Distinct (PPO) covers primary care physician services with no copay and no coinsurance, and specialist visits for a $25 copay and no coinsurance. Additional benefits include physical therapy, mental health, and partially covered chiropractic services (which excludes other chiropractic services), all featuring copays ranging from $0 to $45 and no coinsurance.
Preventive Services See details
Complete Blue PPO Distinct (PPO) partially covers preventive services, offering annual physicals, kidney disease education, and select screenings with no copay and no coinsurance. Covered supplemental benefits include remote access technologies with a $0 to $25 copay (no coinsurance), home safety devices with a 20% coinsurance (no copay), and memory fitness. Sub-services not covered under this benefit include health education, in-home safety assessments, PERS, medical nutrition therapy, medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, additional smoking cessation, telemonitoring, and counseling.
Hearing Services See details
Hearing services are partially covered by Complete Blue PPO Distinct (PPO), which features annual routine hearing exams with a $10 to $25 copay and no coinsurance. Prescription hearing aids are covered up to $500 per year with no coinsurance and copays between $699 and $999, but OTC hearing aids, fitting and evaluation services, and inner, outer, or over-the-ear device types are not covered.
Vision Services See details
Complete Blue PPO Distinct (PPO) covers vision services, including one routine eye exam per year for a $25 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance, offering a combined maximum benefit of $400 per year for contacts, glasses, frames, lenses, and upgrades.
Dental Services See details
Dental services are partially covered by Complete Blue PPO Distinct (PPO) up to a combined $3,000 annual limit, with Medicare-covered dental requiring a $25 copay and no coinsurance, covered preventive services having no copay and no coinsurance, and covered comprehensive services having no copay and 10% coinsurance (0% to 10% for adjunctive services). Other diagnostic dental, other preventive dental, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Complete Blue PPO Distinct (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other Part B drugs feature no copay and coinsurance ranging from no coinsurance to 20%, while Part B insulin is covered with a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis Services are covered under the Complete Blue PPO Distinct (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Complete Blue PPO Distinct (PPO) covers medical equipment with no copay, though prior authorization is required for services. Coinsurance ranges from no coinsurance up to 50% for durable medical equipment, is 20% for prosthetics and medical supplies, and ranges from no coinsurance up to 20% for diabetic equipment and supplies.
Diagnostic and Radiological Services See details
Complete Blue PPO Distinct (PPO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Lab services have no copay, diagnostic tests range from a $0 to $10 copay, outpatient X-rays require a $20 copay, and therapeutic and diagnostic radiology services have minimum copays of $50 and $175, respectively.
Home Health Services See details
Home Health Services are covered under the Complete Blue PPO Distinct (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Complete Blue PPO Distinct (PPO) does not cover Cardiac Rehabilitation Services, as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all excluded from coverage.
Skilled Nursing Facility (SNF) See details
Complete Blue PPO Distinct (PPO) partially covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, and additional days beyond the standard 100-day Medicare limit are not covered.
Other Services See details
Complete Blue PPO Distinct (PPO) partially covers other services, featuring an over-the-counter (OTC) benefit with no copay and no coinsurance up to a maximum of $95 every three months. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone are not covered.
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