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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) prescription drug plan has 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 or through preferred mail order. Tier 2 generic drugs cost $3 for a 1-month supply at preferred pharmacies, whereas standard pharmacies charge a $20 copay. For higher-tier medications, the plan utilizes coinsurance instead of flat copays. Tier 3 preferred brand drugs require a 23% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance across all pharmacy and mail-order options. Choosing preferred pharmacies and mail-order services helps minimize your out-of-pocket prescription expenses.
Additional Benefits
The Complete Blue PPO Distinct (PPO) plan offers coverage with no copay and no coinsurance for primary care visits, preventive screenings, annual physicals, and home health services. For inpatient hospital stays, members pay a daily copay of $175 for the first five days of acute care and no copay for additional days, with no coinsurance required. Outpatient hospital services feature a $275 copay, while specialist visits require a $30 copay, both with no coinsurance. Additional benefits include preventive dental care and eyewear with no copay, alongside a $2,500 annual maximum for covered dental services. Members also benefit from a $55 quarterly over-the-counter allowance with no copay, routine hearing exams for a $15 copay, and emergency coverage with a $130 copay. Medical equipment is covered with no copays, though coinsurance ranges up to 50 percent depending on the item.
Inpatient Hospital See details
Complete Blue PPO Distinct (PPO) partially covers inpatient hospital services with no coinsurance, but prior authorization is required. For acute stays, there is a $175 daily copay for days 1-5 and no copay for additional days, while psychiatric stays require a $425 daily copay for days 1-3 and no copay for days 4-90; however, 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 $275 copay for outpatient hospital and observation services, and a $225 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $45 copay with no coinsurance, while outpatient blood services are fully covered with no copay or coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered under the Complete Blue PPO Distinct (PPO) plan with no copay and no coinsurance.
Ambulance and Transportation Services See details
Complete Blue PPO Distinct (PPO) covers ambulance services with a $305 copay and no coinsurance for both ground and air transportation. Transportation services are partially covered, offering unlimited one-way rides to plan-approved locations with no copay and no 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 (waived if admitted within 3 days) and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance and copays of $130, $40, and $305, respectively.
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 mental health services require a $30 copay and no coinsurance. Chiropractic care is partially covered, offering routine services for a $15 copay and no coinsurance, but other chiropractic services are not covered. Other services like telehealth, psychiatric care, and opioid treatment feature copays ranging from no copay up to $45 and no coinsurance.
Preventive Services See details
Complete Blue PPO Distinct (PPO) preventive services are partially covered, offering annual physicals, kidney disease education, and other preventive screenings with no copay and no coinsurance. Covered supplemental benefits include memory fitness and disease management with no copay and no coinsurance, remote access technologies with a $0 to $30 copay and no coinsurance, and safety devices with 20% coinsurance and no copay. Sub-services that are not covered include health education, personal emergency response systems, in-home safety assessments, 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, tobacco cessation, telemonitoring, and counseling.
Hearing Services See details
Complete Blue PPO Distinct (PPO) partially covers hearing services with no coinsurance, offering routine hearing exams for a $15 copay and prescription hearing aids with copays from $699 to $999 up to a $500 annual maximum. Fitting and evaluation services, over-the-counter hearing aids, and inner, outer, or over-the-ear prescription hearing aid types are not covered.
Vision Services See details
Vision services are partially covered by Complete Blue PPO Distinct (PPO), offering one routine eye exam per year for a $30 copay and no coinsurance, while other eye exam services are not covered. Covered eyewear, including contacts, frames, lenses, and upgrades, has no copay and no coinsurance up to a $400 annual limit.
Dental Services See details
Complete Blue PPO Distinct (PPO) dental services are partially covered, offering up to a $2,500 annual maximum benefit with a $30 copay and no coinsurance for Medicare-covered dental, and no copay and no coinsurance for preventive care. Covered comprehensive services require no copay and 0% to 25% coinsurance, while 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. Associated Medicare Part B drugs, including chemotherapy, radiation, and insulin, are subject to no coinsurance to 20% coinsurance, with insulin also requiring a $35 copay.
Dialysis Services See details
Dialysis services are covered by 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. Coinsurance ranges from no coinsurance up to 50% for durable medical equipment, 20% for prosthetics and medical supplies, and 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. Diagnostic lab services have no copay and diagnostic tests range from a $0 to $10 copay, while radiological copays are $20 for X-rays, at least $60 for therapeutic services, and at least $225 for diagnostic radiology.
Home Health Services See details
Complete Blue PPO Distinct (PPO) covers Home Health Services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Complete Blue PPO Distinct (PPO) plan, as all individual sub-services—including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation—are not covered.
Skilled Nursing Facility (SNF) See details
Complete Blue PPO Distinct (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not necessary, and additional days beyond the standard 100-day limit are not covered.
Other Services See details
Complete Blue PPO Distinct (PPO) partially covers other services, offering an over-the-counter (OTC) benefit of up to $55 every three months with no copay and no coinsurance. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone coverage are not covered.
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