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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 $98.00. 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 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 $3 copay for a one-month supply at preferred pharmacies compared to a $20 copay at standard pharmacies. For higher-tier medications, the plan transitions from flat copays to coinsurance percentages. 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. Utilizing preferred pharmacies and preferred mail-order services offers the most cost-effective savings under this prescription drug coverage.
Additional Benefits
The Complete Blue PPO Distinct (PPO) plan offers robust medical coverage featuring no copay and no coinsurance for primary care visits, preventive services, and home health care. Specialist visits require a $40 copay, while inpatient hospital stays cost a $250 daily copay for the first seven days with no copay thereafter. Emergency care is accessible with a $130 copay, which is waived if you are admitted, and urgent care visits require a $40 copay. For supplemental care, members enjoy preventive dental services with no copay or coinsurance up to a $1,500 annual limit, alongside a $400 annual allowance for eyewear with no copay. Diagnostic lab work and home infusion services also feature no copay, while durable medical equipment and dialysis require coinsurance ranging from 0% to 50% with no copayments. Standard prescription hearing aids are covered with copays ranging from $699 to $999, helping you manage out-of-pocket healthcare costs.
Inpatient Hospital See details
Complete Blue PPO Distinct (PPO) covers inpatient acute hospital stays with no coinsurance, requiring a $250 daily copay for days 1 through 7 and no copay for days 8 and beyond. Inpatient psychiatric stays are also covered with no coinsurance, requiring a $425 daily copay for days 1 through 3 and no copay for days 4 through 90, though non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Complete Blue PPO Distinct (PPO) outpatient services are covered with no coinsurance, featuring a $350 copay for outpatient hospital and daily observation services, and a $300 copay for ambulatory surgical center services. Outpatient substance abuse individual and group sessions require a $45 copay with no coinsurance, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Complete Blue PPO Distinct (PPO) covers partial hospitalization services with no copay and no coinsurance.
Ambulance and Transportation Services See details
Complete Blue PPO Distinct (PPO) covers ground and air ambulance services with a $380 copay and no coinsurance per service. Transportation services are partially covered, offering unlimited one-way trips to plan-approved health-related locations with no copay and no 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, with the copay waived if you are admitted to the hospital within three days. Urgently needed services require a $40 copay with no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $130, $40, and $380, respectively.
Primary Care See details
Complete Blue PPO Distinct (PPO) provides primary care physician services with no copay and no coinsurance, while specialist visits require a $40 copay and no coinsurance. Other covered services such as physical therapy, mental health, and podiatry have copays ranging from $0 to $45 with no coinsurance, though chiropractic care is only partially covered because other chiropractic services are not covered.
Preventive Services See details
Complete Blue PPO Distinct (PPO) covers preventive services, annual exams, and kidney disease education with no copay and no coinsurance, while remote access technologies have a $0 to $40 copay (no coinsurance) and safety devices require 20% coinsurance (no copay). Additional preventive benefits are partially covered, excluding health education, in-home safety assessments, PERS, MNT, post-discharge medication reconciliation, readmission prevention, wigs for chemotherapy-related hair loss, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, additional smoking cessation, telemonitoring, and counseling.
Hearing Services See details
Complete Blue PPO Distinct (PPO) partially covers hearing services, offering exams with a $15 to $40 copay and no coinsurance, and prescription hearing aids with a $699 to $999 copay, no coinsurance, and a $500 annual maximum. Fitting and evaluation exams, OTC hearing aids, and inner ear, outer ear, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Complete Blue PPO Distinct (PPO) partially covers vision services, offering one routine eye exam per year for a $40 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance, providing up to a $400 combined annual maximum benefit for contacts, lenses, frames, and upgrades.
Dental Services See details
Complete Blue PPO Distinct (PPO) offers partially covered dental services with a combined $1,500 annual limit, featuring no copay or coinsurance for preventive care like cleanings and exams. Medicare-covered dental has a $40 copay and no coinsurance, and covered comprehensive services have no copay and up to 50% coinsurance, while implants, orthodontics, maxillofacial prosthetics, and other diagnostic services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Complete Blue PPO Distinct (PPO) with no copay and no coinsurance, subject to prior authorization. Under this benefit, Medicare Part B chemotherapy and other drugs have no copay and a 0% to 20% coinsurance, while Part B insulin has a $35 copay and a 0% 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
Medical equipment is covered by Complete Blue PPO Distinct (PPO) with no copays, though prior authorization is required. Members pay no coinsurance to 50% coinsurance for durable medical equipment, 20% coinsurance for prosthetics and medical supplies, and no coinsurance to 20% coinsurance for diabetic supplies and services.
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, members pay no copay for lab services, $0 to $10 for diagnostic tests, $20 for X-rays, and a minimum copay of $60 for therapeutic radiation and $300 for diagnostic radiology.
Home Health Services See details
Home Health Services are covered under the Complete Blue PPO Distinct (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Complete Blue PPO Distinct (PPO) covers some cardiac rehabilitation services with no copay and no coinsurance, but standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Complete Blue PPO Distinct (PPO) with no coinsurance, requiring no copay for days 1 through 20 and a $218 copay per day for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not required, and additional days beyond the standard Medicare-covered days are not covered.
Other Services See details
Complete Blue PPO Distinct (PPO) does not cover other services, meaning there is no coverage for acupuncture, over-the-counter (OTC) items, or meal benefits under this plan.
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