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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 Bucks, Chester, Montgomery, Philadelphia. 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 $109.00. 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 $9550.00 (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 $9550.00 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 prescription drug deductible of $615. For Tier 1 preferred generic drugs, you will pay no copay for a 1-month or 3-month supply when using preferred pharmacies or preferred mail-order services. Tier 2 generic drugs are also highly affordable, costing just a $3 copay for a 1-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 across all pharmacy and mail-order channels. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance for your prescription needs.
Additional Benefits
The Complete Blue PPO Distinct (PPO) plan offers robust medical coverage featuring no copay for primary care visits, preventive services, and home health care. For specialist visits, members pay a predictable $40 copay, while emergency care carries a $130 copay that is waived upon hospital admission. Inpatient hospital stays require a $275 daily copay for the first seven days, after which there is no copay for the remainder of the stay. Ancillary benefits include dental coverage up to a $1,500 annual limit with no copay for preventive care, alongside a $400 yearly allowance for eyewear with no copay. Diagnostic lab tests and home infusion services also feature no copay, while durable medical equipment and dialysis require coinsurance up to 50% and 20% respectively. Routine hearing exams are available with low copays, and prescription hearing aids are covered with copays up to a $500 annual maximum.
Inpatient Hospital See details
Complete Blue PPO Distinct (PPO) covers inpatient acute hospital stays with no coinsurance, requiring a $275 daily copay for days 1 through 7 and no copay for days 8 and beyond, though upgrades and non-Medicare-covered stays are not covered. Inpatient psychiatric hospital stays are also covered with no coinsurance, featuring a $425 daily copay for days 1 through 3 and no copay for days 4 through 90, but additional days and non-Medicare-covered stays are excluded.
Outpatient Services See details
Outpatient services are covered by Complete Blue PPO Distinct (PPO) with no coinsurance, including a $350 copay for outpatient hospital and observation services, and a $300 copay for ambulatory surgical center services. Outpatient substance abuse sessions have a $45 copay with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Complete Blue PPO Distinct (PPO) covers partial hospitalization services with no copay and no coinsurance. Members can access this covered benefit with zero out-of-pocket costs.
Ambulance and Transportation Services See details
Complete Blue PPO Distinct (PPO) covers ground and air ambulance services with a $375 copay and no coinsurance. Transportation services are partially covered with no copay or coinsurance for unlimited trips to plan-approved locations, while 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, which is waived if admitted to the hospital within three days, and urgently needed services with a $50 copay, both with no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance and copays of $130, $50, and $375, respectively.
Primary Care See details
Complete Blue 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 medical services like mental health, physical therapy, and telehealth require copays ranging from $0 to $50 with no coinsurance, while chiropractic care is partially covered as other chiropractic services are not covered.
Preventive Services See details
Complete Blue PPO Distinct (PPO) offers Medicare-covered preventive services, annual physical exams, and kidney disease education with no copay and no coinsurance. Additional benefits are partially covered, featuring remote access technologies with a $0 to $40 copay and home safety modifications with 20% coinsurance, though services like health education, in-home safety assessments, and personal emergency response systems are not covered.
Hearing Services See details
Complete Blue PPO Distinct (PPO) partially covers hearing services with no coinsurance, offering routine hearing exams for a $15 to $40 copay and prescription hearing aids with a $699 to $999 copay up to a $500 annual maximum. Fitting and evaluation exams, over-the-counter (OTC) hearing aids, and specific inner, outer, or over-the-ear prescription aid types are not covered.
Vision Services See details
Complete Blue PPO Distinct (PPO) provides partially covered vision services with no deductibles, featuring one routine eye exam per year for a $40 copay and no coinsurance, while other eye exam services are not covered. Eyewear, including contacts, frames, lenses, and upgrades, is covered with no copay and no coinsurance up to a combined annual limit of $400.
Dental Services See details
Dental services are partially covered by Complete Blue PPO Distinct (PPO) up to a $1,500 annual limit, featuring no copay and no coinsurance for covered preventive care, and a $40 copay with no coinsurance for Medicare-covered dental. Covered comprehensive services require no copay and a 50% coinsurance (0% to 50% for adjunctive services), while other diagnostic services, other preventive services, maxillofacial prosthetics, implants, and orthodontics 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. Medicare Part B chemotherapy, radiation, and other drugs have no copay and coinsurance ranging from no coinsurance to 20%, while Part B insulin is covered with a $35 copay and coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis services are covered by Complete Blue PPO Distinct (PPO) with no copay and a 20% coinsurance.
Medical Equipment See details
Complete Blue PPO Distinct (PPO) covers medical equipment with no copays, though prior authorization is required. Durable medical equipment carries a 0% to 50% coinsurance, diabetic supplies have a 0% to 20% coinsurance from specified manufacturers, and prosthetic devices, medical supplies, and diabetic shoes or inserts require a 20% coinsurance.
Diagnostic and Radiological Services See details
Complete Blue PPO Distinct (PPO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Lab services have no copay, diagnostic procedures carry a $0 to $10 copay, outpatient X-rays cost $30, and therapeutic and diagnostic radiological services require minimum copays of $75 and $300, respectively.
Home Health Services See details
Home Health Services are covered by Complete Blue PPO Distinct (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the Complete Blue PPO Distinct (PPO) with no copay and no coinsurance. However, some services are covered but cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, 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, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day hospital stay is not required for admission, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Complete Blue PPO Distinct (PPO) does not cover Other Services, meaning supplemental benefits such as acupuncture, over-the-counter (OTC) items, and meal benefits are not covered.
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