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Complete Blue Plus PPO Merit (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Complete Blue Plus PPO Merit (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 Merit (PPO) in 2026, please refer to our full plan details page.
Complete Blue Plus PPO Merit (PPO) is a PPO plan offered by Highmark Health available for enrollment in 2026 to people living in Clinton, Lycoming, Sullivan, 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 Merit (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 Merit (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 Merit (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $91.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $200.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
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 Merit (PPO) plan features an annual drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic medications, there is no copay for a 1-month or 3-month supply at preferred pharmacies, as well as for a 3-month supply via preferred mail order. Standard pharmacies and standard mail order options require a copay, ranging from $7 to $21 for Tier 1 and $15 to $45 for Tier 2 depending on the supply. For higher-tier medications, costs transition to coinsurance percentages across both preferred and standard networks. Tier 3 preferred brand drugs carry a 23% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance. These coinsurance rates apply consistently whether you use a preferred or standard pharmacy, or opt for mail-order delivery.
Additional Benefits
The Complete Blue Plus PPO Merit (PPO) plan offers comprehensive coverage for everyday healthcare needs, featuring no copay for primary care visits, preventive screenings, and home health care. For specialist visits, a $40 copay applies, while inpatient hospital stays require a $400 daily copay for the first five days and no copay for days six through ninety. Emergency room visits carry a $115 copay and urgent care is $40, with no coinsurance required for either service. This plan also includes valuable supplemental benefits, such as preventive dental care with no copay up to a $1,500 annual limit and a $400 annual allowance for eyewear with no copay. For medical equipment and dialysis, members will pay no copay and a 20% coinsurance. Routine diagnostic lab tests are also highly accessible with no copay, helping you manage your health with predictable out-of-pocket costs.
Inpatient Hospital See details
Complete Blue Plus PPO Merit (PPO) partially covers inpatient hospital services with no coinsurance, requiring a $400 daily copay for days 1 through 5 and no copay for days 6 through 90. Prior authorization is required, and specific services like upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Complete Blue Plus PPO Merit (PPO) covers outpatient hospital and observation services for a $375 copay and ambulatory surgical center services for a $325 copay, both with no coinsurance. Outpatient substance abuse services require a $45 copay with no coinsurance, while outpatient blood services are available with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Partial hospitalization services are covered by Complete Blue Plus PPO Merit (PPO) with no copay and no coinsurance.
Ambulance and Transportation Services See details
Complete Blue Plus PPO Merit (PPO) covers ambulance services with a $320 copay and no coinsurance for both ground and air transportation. Transportation services are partially covered with no copay or coinsurance for unlimited one-way trips to plan-approved locations, but transportation to any health-related location is not covered.
Emergency Services See details
Complete Blue Plus PPO Merit (PPO) covers emergency services with a $115 copay—waived if admitted to the hospital within three days—and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency care, urgent care, and emergency transportation are also covered with no coinsurance, requiring copays of $115, $40, and $320, respectively.
Primary Care See details
Complete Blue Plus PPO Merit (PPO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $40 copay and no coinsurance. Therapy services are available with a $35 copay and no coinsurance, while chiropractic services are partially covered, offering routine care for a $15 copay and no coinsurance but excluding other chiropractic services.
Preventive Services See details
Complete Blue Plus PPO Merit (PPO) covers preventive services, including annual physical exams, kidney disease education, and screenings with no copay and no coinsurance. Additional preventive benefits are partially covered, offering remote access technologies with a $0 to $40 copay and home safety modifications with 20% coinsurance, while services like health education, in-home support, and nutritional counseling are not covered.
Hearing Services See details
Hearing services are partially covered by Complete Blue Plus PPO Merit (PPO), which offers one routine hearing exam annually with a $20 copay and no coinsurance, while fitting and evaluation services are not covered. Prescription hearing aids are covered up to $500 annually with no coinsurance and copays ranging from $699 to $999, though OTC hearing aids and inner, outer, or over-the-ear prescription models are not covered.
Vision Services See details
Complete Blue Plus PPO Merit (PPO) partially covers vision services, offering one routine eye exam per year with a $40 copay, no coinsurance, and no deductible, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, up to a combined annual maximum benefit of $400 for contacts, frames, lenses, and upgrades.
Dental Services See details
Dental services are partially covered by Complete Blue Plus PPO Merit (PPO) up to a $1,500 annual maximum, with Medicare-covered dental requiring a $40 copay and no coinsurance. Preventive care has no copay and no coinsurance, while covered comprehensive services carry no copay and 0% to 50% coinsurance; however, other diagnostic, other preventive, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Complete Blue Plus PPO Merit (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 drugs require no coinsurance to 20% coinsurance, while Part B insulin requires a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the Complete Blue Plus PPO Merit (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Complete Blue Plus PPO Merit (PPO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic equipment, with no copays and a 20% coinsurance, though diabetic supplies range from no coinsurance to 20% coinsurance. Prior authorization is required for these covered benefits, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Complete Blue Plus PPO Merit (PPO) covers diagnostic and radiological services with no coinsurance, subject to prior authorization. Lab services have no copay, diagnostic tests have a $0 to $10 copay, outpatient X-rays have a $20 copay, and therapeutic and diagnostic radiological services carry minimum copays of $60 and $300, respectively.
Home Health Services See details
Home Health Services are covered by Complete Blue Plus PPO Merit (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Complete Blue Plus PPO Merit (PPO) plan. This means there is no coverage for cardiac, intensive cardiac, pulmonary, or SET for PAD rehabilitation services.
Skilled Nursing Facility (SNF) See details
Complete Blue Plus PPO Merit (PPO) covers skilled nursing facility (SNF) care with no coinsurance and requires no prior three-day inpatient hospital stay, though prior authorization is required. There is no copay for days 1 through 20, a $218 daily copay applies for days 21 through 100, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Complete Blue Plus PPO Merit (PPO) does not provide coverage for Other Services, meaning supplemental benefits such as acupuncture, over-the-counter (OTC) items, and meal benefits are not covered.
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