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Complete Blue Plus PPO Distinct (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Complete Blue Plus 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 Plus PPO Distinct (PPO) in 2026, please refer to our full plan details page.
Complete Blue Plus PPO Distinct (PPO) is a PPO plan offered by Highmark Health available for enrollment in 2026 to people living in 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 Plus 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 Plus 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 Plus 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
The Complete Blue Plus PPO Distinct (PPO) Medicare prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generic drugs, you pay no copay for a 1-month or 3-month supply at a preferred pharmacy, while standard pharmacies charge a $7 copay for a 1-month supply. Tier 2 generic drugs cost a $3 copay for a 1-month supply at preferred pharmacies compared to a $20 copay at standard pharmacies. For higher-tier medications, this plan utilizes coinsurance rather than flat copays during the initial coverage phase. 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 preferred and standard pharmacy and mail-order options.
Additional Benefits
The Complete Blue Plus PPO Distinct (PPO) plan offers affordable access to essential medical care, featuring no copay and no coinsurance for primary care doctor visits, annual physicals, and home health services. Specialist visits require a $40 copay, while emergency room visits carry a $130 copay, both with no coinsurance. For hospital stays, there is no coinsurance, though acute inpatient care requires a $175 daily copay for the first five days before transitioning to no copay for subsequent days. This plan also includes valuable supplemental benefits, such as preventive dental care and routine eyewear coverage up to a $400 annual limit with no copay or coinsurance. Routine hearing exams are available for a $15 copay, and members receive a $50 allowance every three months for over-the-counter items with no copay. Comprehensive dental services are covered up to a $2,000 annual limit with coinsurance ranging from 0% to 25% and no copay.
Inpatient Hospital See details
Complete Blue Plus PPO Distinct (PPO) covers inpatient hospital services with no coinsurance, though prior authorization is required. For acute care, there is a $175 daily copay for days 1 to 5 and no copay for subsequent unlimited days, while psychiatric care requires a $425 daily copay for days 1 to 3 and no copay for days 4 to 90. Upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Complete Blue Plus PPO Distinct (PPO) covers outpatient services with no coinsurance, requiring a $300 copay for outpatient hospital and daily observation services, and a $250 copay for ambulatory surgical center services. Outpatient substance abuse services have a $45 copay per individual or group session with no coinsurance, while outpatient blood services are covered with no copay or coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Complete Blue Plus PPO Distinct (PPO) with no copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered under the Complete Blue Plus PPO Distinct (PPO) plan, with ground and air ambulance services requiring a $370 copay and no coinsurance. Transportation services are partially covered, offering unlimited one-way trips to plan-approved health-related locations with no copay and no coinsurance, while transportation to non-approved health-related locations is not covered.
Emergency Services See details
Complete Blue Plus 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 with no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $130, $40, and $370 respectively.
Primary Care See details
Complete Blue Plus PPO Distinct (PPO) offers primary care doctor visits with no copay and no coinsurance, while specialist visits require a $40 copay and no coinsurance. Other outpatient services, such as physical therapy, mental health, and podiatry, carry copays ranging from $30 to $45 with no coinsurance, though chiropractic care is only partially covered because non-routine services are excluded.
Preventive Services See details
Complete Blue Plus PPO Distinct (PPO) covers annual physical exams, kidney disease education, and other preventive screenings with no copay and no coinsurance. Additional preventive benefits are partially covered, featuring memory fitness and disease management with no copay and no coinsurance, remote access technologies with a $0 to $40 copay and no coinsurance, and safety devices with 20% coinsurance and no copay. However, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, medication reconciliation, readmission prevention, wigs, 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 are not covered.
Hearing Services See details
Complete Blue Plus PPO Distinct (PPO) provides partially covered hearing services with no coinsurance, featuring a $15 copay for one routine hearing exam annually and copays ranging from $699 to $999 for prescription hearing aids (up to a $500 annual benefit). Hearing aid fittings, OTC hearing aids, and inner ear, outer ear, or over-the-ear prescription aid types are not covered.
Vision Services See details
Complete Blue Plus PPO Distinct (PPO) provides partially covered vision services with no deductibles, featuring routine eye exams for a $40 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance, offering up to a $400 combined annual maximum for contacts, frames, lenses, and upgrades.
Dental Services See details
Complete Blue Plus PPO Distinct (PPO) partially covers dental services up to a $2,000 annual limit, with no copay and no coinsurance for preventive care, a $40 copay and no coinsurance for Medicare-covered dental, and no copay with 0% to 25% coinsurance for comprehensive services. Other diagnostic dental, other preventive dental, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Complete Blue Plus PPO Distinct (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Medicare Part B chemotherapy, radiation, and other drugs carry no coinsurance to 20% coinsurance, while Part B insulin is covered with a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the Complete Blue Plus PPO Distinct (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Complete Blue Plus PPO Distinct (PPO) covers medical equipment with no copay, though prior authorization is required. Durable medical equipment has a 0% to 50% coinsurance, diabetic supplies have a 0% to 20% coinsurance, and prosthetics, medical supplies, and therapeutic shoes carry a 20% coinsurance.
Diagnostic and Radiological Services See details
Complete Blue Plus PPO Distinct (PPO) covers diagnostic and radiological services with no coinsurance, although prior authorization is required. Diagnostic tests have a $0 to $10 copay and lab services have no copay, while radiological services require copays of $20 for X-rays, a minimum of $60 for therapeutic services, and a minimum of $195 for diagnostic radiology.
Home Health Services See details
Home Health Services are covered under the Complete Blue Plus PPO Distinct (PPO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Complete Blue Plus PPO Distinct (PPO) indicates some services are covered under Cardiac Rehabilitation Services with no copay and no coinsurance, though 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) care is covered by Complete Blue Plus PPO Distinct (PPO) with no coinsurance and requires prior authorization, but does not require a prior three-day hospital stay. There is no copay for days 1 through 20, a $218 daily copay for days 21 through 100, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Complete Blue Plus PPO Distinct (PPO) partially covers other services, providing over-the-counter (OTC) items with no copay and no coinsurance up to a maximum benefit of $50 every three months. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone are not covered.
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