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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 as little as a $3 copay for a 1-month supply at preferred pharmacies, compared to a $20 copay at standard pharmacies. Higher-tier medications require coinsurance rather than flat copays, 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 incur a 25% coinsurance for a 1-month supply at both preferred and standard pharmacies. This prescription drug structure helps you maximize your savings when utilizing preferred network pharmacies and generic medications.
Additional Benefits
The Complete Blue PPO Distinct (PPO) plan offers comprehensive medical coverage featuring no copays and no coinsurance for primary care visits, annual physicals, and routine preventive screenings. For more specialized care, members can expect a $30 copay for specialist visits and a $175 daily copay for days one through five of inpatient hospital stays. Outpatient hospital services require a $275 copay, while emergency care carries a $130 copay that is waived upon hospital admission. In addition to medical care, this plan provides valuable coverage for dental, vision, and hearing services to reduce out-of-pocket expenses. Preventive dental services carry no copay and no coinsurance, while comprehensive dental care requires a 25% coinsurance up to a $2,500 annual limit. Members also receive a $400 annual eyewear allowance and a $55 quarterly over-the-counter benefit with no copays or coinsurance.
Inpatient Hospital See details
Complete Blue PPO Distinct (PPO) covers inpatient acute hospital stays with no coinsurance and a $175 daily copay for days 1 through 5, and inpatient psychiatric stays with a $425 daily copay for days 1 through 3, with no copay for subsequent days. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Complete Blue PPO Distinct (PPO) covers outpatient hospital and observation services with a $275 copay and no coinsurance, and ambulatory surgical center services with a $225 copay and no coinsurance. Outpatient substance abuse sessions require a $45 copay and no coinsurance, while outpatient blood services are covered with no copay, no deductible, 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
Ambulance and transportation services are covered by Complete Blue PPO Distinct (PPO), with ground and air ambulance services requiring a $370 copay and no coinsurance. Plan-approved transportation is partially covered, offering unlimited one-way trips with no copay and no coinsurance, while 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 admitted to the hospital within three days, and urgent care with a $40 copay and no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance and copays of $130, $40, and $370, respectively.
Primary Care See details
Complete Blue PPO Distinct (PPO) covers primary care physician services with no copay and no coinsurance, while specialist, therapy, psychiatric, and podiatry visits require a $30 copay and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance, as other chiropractic services are not covered.
Preventive Services See details
Preventive Services are partially covered by Complete Blue PPO Distinct (PPO), offering no copay and no coinsurance for annual physicals, kidney disease education, and routine screenings. Covered remote access technologies require a $0 to $30 copay and no coinsurance, while home safety devices require a 20% coinsurance and no copay. Several supplemental services are not covered, including health education, personal emergency response systems, weight management, and nutritional/dietary benefits.
Hearing Services See details
Complete Blue PPO Distinct (PPO) provides partial coverage for hearing services with no deductible. Hearing exams are covered with a $30 copay and no coinsurance (routine exams are $5, limited to one per year), but fitting evaluations and OTC hearing aids are not covered. Prescription hearing aids are covered with no coinsurance and copays from $699 to $999 up to a $500 annual limit, though inner, outer, and over-the-ear types are excluded.
Vision Services See details
Complete Blue PPO Distinct (PPO) provides partially covered vision services with no deductibles, featuring one annual routine eye exam for a $30 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and a $400 combined annual maximum for contacts, frames, lenses, and upgrades.
Dental Services See details
Dental services are partially covered by Complete Blue PPO Distinct (PPO), with Medicare-covered services requiring a $30 copay and no coinsurance, and other covered dental services capped at a $2,500 annual limit. Preventive care like cleanings and exams has no copay and no coinsurance, while covered comprehensive services require no copay and a 25% coinsurance (0% to 25% for adjunctive services). Other diagnostic, other preventive, 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, although prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs have no copay and a coinsurance ranging from no coinsurance to 20%, while Part B insulin is covered with a $35 copay and a 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
Medical equipment is covered by Complete Blue PPO Distinct (PPO) with no copays and coinsurance ranging from 0% to 50% for durable medical equipment, 20% for prosthetics and medical supplies, and 0% to 20% for diabetic supplies and therapeutic shoes. Prior authorization is required for these benefits, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Complete Blue PPO Distinct (PPO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. There is no copay for lab services, a $0 to $10 copay for diagnostic tests, a $15 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
Cardiac Rehabilitation Services are covered under the Complete Blue PPO Distinct (PPO) plan with no copay and no coinsurance. While some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered in practice.
Skilled Nursing Facility (SNF) See details
Complete Blue PPO Distinct (PPO) covers skilled nursing facility (SNF) care 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 three-day prior hospital stay is not required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Complete Blue PPO Distinct (PPO) partially covers other services, offering an over-the-counter (OTC) benefit with no copay and no coinsurance up to $55 every three months. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone coverage are not covered under this plan.
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