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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 $39.00. 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 Tier 1 preferred generic drugs, members pay no copay for a one-month or three-month supply at preferred pharmacies, while standard pharmacies charge a $7 copay for a one-month supply. Tier 2 generic drugs cost a low $3 copay at preferred pharmacies and a $20 copay at standard pharmacies for a one-month supply. Higher-tier medications transition from flat copays to coinsurance percentages. Tier 3 preferred brand drugs require a 23% coinsurance across all pharmacy and mail-order options. Both Tier 4 non-preferred drugs and Tier 5 specialty drugs carry a 25% coinsurance at all preferred and standard pharmacies.
Additional Benefits
The Complete Blue PPO Distinct (PPO) plan offers robust medical coverage with no copays for primary care visits, home health services, and partial hospitalization. For specialized care, members pay predictable copays, such as $30 for specialist visits and a daily copay of $175 for the first five days of inpatient hospital stays. Emergency care is accessible with a $130 copay, which is waived if admitted, while urgent care visits require a $40 copay. Ancillary benefits include preventive dental and routine eyewear with no copays, alongside a $2,000 annual maximum for dental services and a $400 annual limit for vision hardware. Hearing aids are covered with copays ranging from $699 to $999, and diagnostic lab services require no copay. Additionally, the plan features an over-the-counter allowance of $65 every three months with no copay or coinsurance.
Inpatient Hospital See details
Complete Blue PPO Distinct (PPO) covers inpatient hospital services with no coinsurance, requiring a $175 daily copay for days 1 through 5 of acute stays (no copay thereafter) and a $425 daily copay for days 1 through 3 of psychiatric stays (no copay thereafter). Prior authorization is required, and the benefit is partially covered since upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Complete Blue PPO Distinct (PPO) offers outpatient services with no coinsurance, featuring a $300 copay for outpatient hospital and observation services and a $250 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $45 copay with no coinsurance, and outpatient blood services are covered with no copays, coinsurance, or deductibles.
Partial Hospitalization See details
Complete Blue PPO Distinct (PPO) provides coverage for partial hospitalization services with no copay and no coinsurance.
Ambulance and Transportation Services See details
Complete Blue PPO Distinct (PPO) covers ambulance services with a $465 copay and no coinsurance for both ground and air transport. Transportation services are partially covered, offering unlimited one-way trips to plan-approved locations with no copay and no coinsurance, but trips to any health-related location are not covered.
Emergency Services See details
Complete Blue PPO Distinct (PPO) covers emergency services with a $130 copay and no coinsurance, which is waived if you are admitted to the hospital within three days. Urgently needed services require a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with copays of $130, $40, and $465 respectively, all with no coinsurance.
Primary Care See details
Complete Blue PPO Distinct (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits, physical therapy, and podiatry require a $30 copay and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance for routine care, but other chiropractic services are not covered; mental health, psychiatric, and telehealth services are also covered with copays up to $45 and no coinsurance.
Preventive Services See details
Complete Blue PPO Distinct (PPO) offers preventive services with no copay and no coinsurance for annual physical exams, kidney disease education, and routine screenings. Additional benefits are partially covered, featuring remote access technologies with a $0 to $30 copay and no coinsurance, alongside home safety devices with a 20% coinsurance and no copay. However, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, smoking cessation, telemonitoring, and counseling services are not covered.
Hearing Services See details
Hearing services under the Complete Blue PPO Distinct (PPO) are partially covered, offering routine hearing exams with a $10 to $30 copay and no coinsurance, while fitting and evaluation exams are not covered. Prescription hearing aids are covered with a $699 to $999 copay and no coinsurance up to a $500 annual maximum, but OTC hearing aids and inner ear, outer ear, and over the ear prescription aids are not covered.
Vision Services See details
Complete Blue PPO Distinct (PPO) provides partially covered vision services, as other eye exam services are not covered. Routine eye exams are covered with a $30 copay and no coinsurance, while eyewear is covered with no copay, no coinsurance, and a $400 combined annual maximum benefit.
Dental Services See details
Dental services are partially covered by Complete Blue PPO Distinct (PPO), which features a $2,000 annual maximum benefit for combined in- and out-of-network care. Medicare-covered dental has a $30 copay and no coinsurance, while covered preventive care has no copay and no coinsurance. Covered comprehensive services have no copay and 20% coinsurance (0% to 20% for adjunctive), but implants, orthodontics, maxillofacial prosthetics, other diagnostic, and other preventive services 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. Associated Medicare Part B drugs, including chemotherapy, radiation, and other drugs, are covered with coinsurance ranging from no coinsurance up to 20%, while Part B insulin has a $35 copay and up to 20% coinsurance.
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 copays, though prior authorization is required. Durable medical equipment features 0% to 50% coinsurance, while prosthetics, medical supplies, and diabetic equipment and supplies range from 0% to 20% coinsurance.
Diagnostic and Radiological Services See details
Complete Blue PPO Distinct (PPO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Members pay no copay for lab services, a $0 to $10 copay for diagnostic procedures and tests, a $20 copay for outpatient X-rays, and minimum copays of $50 for therapeutic and $275 for diagnostic radiological services.
Home Health Services See details
Home Health Services are covered under the Complete Blue PPO Distinct (PPO) plan with no copay and no coinsurance. Prior authorization is required to access these fully covered services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Complete Blue PPO Distinct (PPO) plan, as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all not covered.
Skilled Nursing Facility (SNF) See details
Complete Blue PPO Distinct (PPO) covers skilled nursing facility stays with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the standard Medicare limit are not covered.
Other Services See details
Complete Blue PPO Distinct (PPO) partially covers other services, providing an over-the-counter (OTC) benefit with no copay and no coinsurance up to $65 every three months. Acupuncture, meal benefits, and other supplemental services under this category are not covered.
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