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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 Central and Northeastern, 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 $55.00. 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 $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 Distinct (PPO) plan features an annual drug deductible of $615. For Tier 1 preferred generic drugs, you will pay no copay for a 1-month or 3-month supply at preferred pharmacies, while standard pharmacies charge a $7 copay for a 1-month supply. Tier 2 generic drugs cost a low $3 copay for a 1-month supply at preferred pharmacies compared to a $20 copay at standard pharmacies. Higher-tier medications transition to coinsurance, with Tier 3 preferred brand drugs requiring 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 regardless of whether you use preferred or standard pharmacies. Utilizing preferred pharmacies and mail-order services under this plan is the most effective way to minimize your out-of-pocket prescription expenses.
Additional Benefits
The Complete Blue PPO Distinct (PPO) plan offers comprehensive medical coverage with no copay and no coinsurance for primary care visits, preventive screenings, and home health care. For specialized care, members pay predictable copays with no coinsurance, including a $175 daily copay for the first five days of an inpatient hospital stay and $15 to $45 copays for specialist visits. Emergency room visits carry a $130 copay, while urgent care visits require a $40 copay. Additionally, the plan provides valuable dental, vision, and hearing benefits, featuring no copay for preventive dental services and a $400 annual allowance for eyewear. Routine hearing exams require a low copay, and prescription hearing aids are covered with copays between $699 and $999. While medical equipment and dialysis services require no copays, they are subject to coinsurance ranging from 20 to 50 percent.
Inpatient Hospital See details
Inpatient hospital care is partially covered by Complete Blue PPO Distinct (PPO) with no coinsurance, though prior authorization is required. Acute stays require a $175 daily copay for days 1-5 and no copay for days 6 and beyond, while psychiatric stays require a $425 daily copay for days 1-3 and no copay for days 4-90. Non-Medicare-covered stays, hospital upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by Complete Blue PPO Distinct (PPO) with no coinsurance, featuring a $275 copay for outpatient hospital and daily observation services, and a $225 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $45 copay, while outpatient blood services are provided with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Complete Blue PPO Distinct (PPO) with no copay and no coinsurance.
Ambulance and Transportation Services See details
Complete Blue PPO Distinct (PPO) covers ambulance and transportation services with prior authorization, requiring a $400 copay and no coinsurance for ground and air ambulance services. Transportation services are partially covered, offering unlimited one-way rides to plan-approved health-related locations with no copay or coinsurance, though transportation to any other 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, which is waived if you are admitted to the hospital within three days. Urgently needed services have a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays ranging from $40 to $400.
Primary Care See details
Complete Blue PPO Distinct (PPO) offers primary care physician services with no copay and no coinsurance, while specialists, therapies, and mental health services have copays ranging from $15 to $45 and no coinsurance. Chiropractic services are partially covered, with routine care covered at a $15 copay and no coinsurance, while other chiropractic services are not covered.
Preventive Services See details
Complete Blue PPO Distinct (PPO) offers partially covered preventive services, featuring annual physical exams, kidney disease education, and screenings with no copay and no coinsurance. Covered supplemental services include remote access technologies (with a $0 to $30 copay and no coinsurance) and home safety devices (with a 20% coinsurance and no copay), while health education, PERS, in-home safety assessments, and weight management are not covered.
Hearing Services See details
Complete Blue PPO Distinct (PPO) partially covers hearing services, offering routine hearing exams with a $15 to $30 copay and no coinsurance, and prescription hearing aids with a $699 to $999 copay and no coinsurance up to a $500 annual maximum. Fitting and evaluation exams, OTC hearing aids, and inner, outer, or over-the-ear prescription hearing aid types are not covered.
Vision Services See details
Complete Blue PPO Distinct (PPO) provides partially covered vision services, featuring one routine eye exam per year for a $30 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay or coinsurance up to a combined maximum of $400 per year for contacts, eyeglasses, lenses, frames, and upgrades.
Dental Services See details
Complete Blue PPO Distinct (PPO) covers Medicare dental services for a $30 copay and no coinsurance, and preventive dental services with no copay and no coinsurance up to a $2,500 annual limit. Many comprehensive services are covered with no copay and 25% coinsurance, though implants, orthodontics, maxillofacial prosthetics, and other diagnostic or preventive services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under Complete Blue PPO Distinct (PPO) with no copay, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs have no coinsurance to 20% coinsurance, while covered Part B insulin carries a $35 copay and no coinsurance 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 ranges from no coinsurance to 50% coinsurance, diabetic supplies range from no coinsurance to 20% coinsurance, and prosthetics, medical supplies, and therapeutic shoes carry a 20% coinsurance.
Diagnostic and Radiological Services See details
Complete Blue PPO Distinct (PPO) covers diagnostic and radiological services with no coinsurance, subject to prior authorization. Under this plan, there is no copay for lab services, a $0 to $10 copay for diagnostic tests, a $20 copay for X-rays, and minimum copays of $60 for therapeutic radiology and $225 for diagnostic radiology.
Home Health Services See details
Complete Blue PPO Distinct (PPO) covers Home Health Services 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
Skilled Nursing Facility (SNF) care is covered by Complete Blue PPO Distinct (PPO) with no coinsurance and requires prior authorization, but does not require a prior three-day inpatient hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Complete Blue PPO Distinct (PPO) partially covers other services, offering over-the-counter (OTC) items with no copay and no coinsurance up to a maximum of $55 every three months. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone are not covered under this benefit.
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