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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 $72.00. 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
Complete Blue PPO Distinct (PPO) has an annual prescription drug deductible of $615. For Tier 1 preferred generic drugs, members 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 are available for a $3 copay for a 1-month supply at preferred pharmacies, compared to a $20 copay at standard pharmacies. For higher-tier medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 23% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both require a 25% coinsurance at all pharmacy types. Utilizing preferred mail-order services can also help reduce costs, offering no copay for a 3-month supply of Tier 1 preferred generic drugs.
Additional Benefits
Complete Blue PPO Distinct (PPO) provides strong foundational coverage with no copay and no coinsurance for primary care doctor visits, preventive care, and home health services. When hospital care is needed, inpatient stays require a $175 daily copay for the first five days, while outpatient hospital services carry a $300 copay. Emergency room visits have a $130 copay, and specialist visits require a $40 copay, both with no coinsurance. For additional wellness needs, the plan features a $2,000 annual dental limit with no copay for select preventive services, alongside a $400 yearly allowance for eyewear with no copay or coinsurance. Routine hearing exams are covered with a $15 copay, and members receive a $50 quarterly allowance for over-the-counter products. Durable medical equipment is available with no copay, though coinsurance ranges from 0% to 50% depending on the item.
Inpatient Hospital See details
Complete Blue PPO Distinct (PPO) covers inpatient hospital services with no coinsurance, requiring a daily copay of $175 for days 1 through 5 of acute stays and $425 for days 1 through 3 of psychiatric stays, with no copay for additional days. Prior authorization is required, and non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient services covered by Complete Blue PPO Distinct (PPO) feature no coinsurance, with a $300 copay for outpatient hospital and daily observation services and a $250 copay for ambulatory surgical center services. Outpatient substance abuse individual and group sessions require a $45 copay, while outpatient blood services are covered with no copay or 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 services with a $400 copay and no coinsurance for both ground and air transport. 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 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 require a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $130, $40, and $400 respectively.
Primary Care See details
Complete Blue PPO Distinct (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $40 copay and no coinsurance. Most other primary care benefits, including physical therapy, mental health services, and telehealth, have copays ranging from $30 to $45 and no coinsurance, though chiropractic services are only partially covered.
Preventive Services See details
Preventive Services are partially covered by Complete Blue PPO Distinct (PPO), featuring annual physical exams, kidney disease education, and screenings with no copay and no coinsurance. Covered supplemental benefits include remote access technologies with a $0 to $40 copay and home safety devices with a 20% coinsurance, while services such as health education, personal emergency response systems, and nutritional counseling are not covered.
Hearing Services See details
Complete Blue PPO Distinct (PPO) partially covers hearing services, excluding OTC hearing aids, fitting and evaluations, and inner, outer, or over-the-ear hearing aid types. Routine hearing exams are covered with a $15 copay and no coinsurance, while covered prescription hearing aids require a copay between $699 and $999 and no coinsurance, up to a $500 annual maximum.
Vision Services See details
Complete Blue PPO Distinct (PPO) offers partially covered vision services, which include one routine eye exam per year for a $40 copay and no coinsurance, with no deductible, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, up to a $400 combined maximum benefit limit every year for contacts, lenses, frames, and upgrades.
Dental Services See details
Complete Blue PPO Distinct (PPO) offers partially covered dental services with a $2,000 annual maximum for both in-network and out-of-network care, requiring a $40 copay and no coinsurance for Medicare-covered dental, and no copay with 0% to 25% coinsurance for other covered services. However, 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, carry a coinsurance ranging from no coinsurance to 20%, with insulin also requiring a $35 copay.
Dialysis Services See details
Dialysis Services are covered by Complete Blue PPO Distinct (PPO) with no copay and a 20% coinsurance. This coverage ensures affordable access to necessary dialysis treatments with clear, predictable out-of-pocket costs.
Medical Equipment See details
Complete Blue PPO Distinct (PPO) covers medical equipment with no copay, though prior authorization is required. Durable medical equipment carries a 0% to 50% coinsurance, diabetic supplies have a 0% to 20% coinsurance, and medical supplies, prosthetics, and diabetic shoes require a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the Complete Blue PPO Distinct (PPO) with no coinsurance, though prior authorization is required. Members pay no copay for lab services, $0 to $10 for diagnostic procedures, a $20 copay for outpatient X-rays, and minimum copays of $195 for diagnostic radiology and $60 for therapeutic radiology.
Home Health Services See details
Home health services are covered by Complete Blue PPO Distinct (PPO) with no copay and no coinsurance. Prior authorization is required to receive this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered by Complete Blue PPO Distinct (PPO) with no copay and no coinsurance, though only some services are covered. Under this plan, cardiac rehabilitation services, intensive cardiac rehabilitation services, pulmonary rehabilitation services, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Complete Blue PPO Distinct (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no 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 limit are not covered.
Other Services See details
Complete Blue PPO Distinct (PPO) partially covers Other Services, offering a $50 allowance every three months for over-the-counter (OTC) items with no copay and no coinsurance. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone are not covered under this plan.
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