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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 $99.00. 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) 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 preferred pharmacies or for a 3-month supply through preferred mail order. Tier 2 generic drugs cost as little as a $3 copay for a 1-month supply at a preferred pharmacy, compared to a $20 copay at standard pharmacies. For higher-tier medications, the plan utilizes coinsurance rather than flat copayments. Tier 3 preferred brand drugs require a 23% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs carry a 25% coinsurance across all pharmacy types. Utilizing preferred pharmacies and preferred mail order options generally provides the most cost-effective path for your prescription needs.
Additional Benefits
The Complete Blue Plus PPO Distinct (PPO) plan offers robust coverage with predictable costs, featuring no copay and no coinsurance for primary care visits, preventive services, and home health care. For specialist visits, patients pay a $40 copay with no coinsurance, while inpatient hospital stays require daily copays ranging from $250 to $425 for the first few days of a stay. Outpatient services and emergency care are also covered without coinsurance, requiring flat copays such as $350 for outpatient hospital services and $130 for emergency visits. Specialty benefits under this plan include partially covered dental care with up to a $1,500 annual limit, featuring no copay for preventive dental and a 50% coinsurance for comprehensive services. Vision care includes routine exams for a $40 copay and an annual eyewear allowance of up to $400 with no copay or coinsurance, while routine hearing exams require a $15 copay. Additionally, diagnostic labs and home infusion services feature no copays, though medical equipment and dialysis services require coinsurance ranging up to 50%.
Inpatient Hospital See details
Inpatient hospital services are covered by Complete Blue Plus PPO Distinct (PPO) with no coinsurance, requiring a $250 daily copay for days 1-7 of acute stays and a $425 daily copay for days 1-3 of psychiatric stays, with no copay for subsequent days. Prior authorization is required, and certain services like upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by Complete Blue Plus PPO Distinct (PPO) 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 sessions require a $45 copay with no coinsurance, while outpatient blood services are covered with no copay or coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by the Complete Blue Plus PPO Distinct (PPO) plan with no copay and no coinsurance.
Ambulance and Transportation Services See details
Complete Blue Plus PPO Distinct (PPO) covers ground and air ambulance services with a $375 copay and no coinsurance. Transportation services to plan-approved health-related locations are covered with no copay and no coinsurance, while transportation to any health-related location 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 3 days. Urgently needed services require a $40 copay and no coinsurance, while worldwide emergency services are covered with no coinsurance and copays of $130 for emergency care, $40 for urgent care, and $375 for emergency transportation.
Primary Care See details
Complete Blue Plus PPO Distinct (PPO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $40 copay and no coinsurance. Other services like therapy, mental health, and podiatry feature 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 Plus PPO Distinct (PPO) provides partially covered preventive services, offering annual physicals, kidney disease education, and routine screenings with no copay and no coinsurance. Covered supplemental benefits include remote access technologies ($0 to $40 copay, no coinsurance) and home safety devices (no copay, 20% coinsurance), while services like health education, personal emergency response systems, and in-home safety assessments are not covered.
Hearing Services See details
Hearing services are partially covered by Complete Blue Plus PPO Distinct (PPO), which features routine hearing exams for a $15 copay and prescription hearing aids with copays ranging from $699 to $999, both with no coinsurance. 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 Plus PPO Distinct (PPO) vision services are partially covered, featuring routine eye exams with a $40 copay and no coinsurance, while other eye exam services are not covered. Eyewear, including contact lenses and eyeglasses, is covered with no copay, no coinsurance, and no deductible up to a $400 combined annual maximum.
Dental Services See details
Dental services are partially covered by the Complete Blue Plus PPO Distinct (PPO) plan up to a $1,500 annual maximum, excluding implants, orthodontics, maxillofacial prosthetics, other diagnostic, and other preventive services. Medicare-covered dental services require a $40 copay and no coinsurance, while preventive services have no copay and no coinsurance. Most covered comprehensive services require no copay and a 50% coinsurance, with adjunctive services requiring no copay and 0% to 50% coinsurance.
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. Covered Medicare Part B chemotherapy, radiation, and other Part B drugs have no copay and a coinsurance ranging from no coinsurance to 20%, while Part B insulin drugs require a $35 copay and up to 20% coinsurance.
Dialysis Services See details
Complete Blue Plus PPO Distinct (PPO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by Complete Blue Plus PPO Distinct (PPO) with no copays, though prior authorization is required. Patients will pay a 0% to 50% coinsurance for durable medical equipment, a 20% coinsurance for prosthetics and medical supplies, and a 0% to 20% coinsurance for diabetic supplies and therapeutic shoes.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Complete Blue Plus PPO Distinct (PPO) with no coinsurance, though prior authorization is required. Diagnostic procedures and tests have a copay ranging from no copay to $10, lab services have no copay, outpatient X-rays have a $20 copay, and therapeutic and diagnostic radiological services have minimum copays of $60 and $300, respectively.
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) offers Cardiac Rehabilitation Services 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.
Skilled Nursing Facility (SNF) See details
Complete Blue Plus 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, a $218 daily copay for days 21 through 100, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Complete Blue Plus PPO Distinct (PPO) indicates that some services are covered under the other services benefit, but acupuncture, over-the-counter (OTC) items, and meal benefits are not covered. As these specific services are not covered, there are no associated copays or coinsurance costs.
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