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Complete Blue PPO Merit (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Complete Blue 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 PPO Merit (PPO) in 2026, please refer to our full plan details page.
Complete Blue PPO Merit (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 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 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 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 PPO Merit (PPO) prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generics and Tier 2 generics, members pay no copay for 1-month and 3-month supplies when using preferred pharmacies or preferred mail order. If you choose a standard pharmacy or standard mail order, Tier 1 copays range from $7 to $21, while Tier 2 copays range from $15 to $45. Higher tier medications require coinsurance rather than flat copayments under this plan. Tier 3 preferred brand drugs have a 23% coinsurance across all pharmacy and mail-order options. Tier 4 non-preferred drugs and Tier 5 specialty medications both require a 25% coinsurance at all preferred and standard retail or mail-order pharmacies.
Additional Benefits
The Complete Blue PPO Merit (PPO) plan offers robust medical coverage with no copay for primary care visits, preventive services, and home health care. For specialized care, members pay a $40 copay for specialist visits, while inpatient hospital stays require a $400 daily copay for the first five days and no copay thereafter. Outpatient hospital services carry a $375 copay, and emergency room visits feature a $115 copay, which is waived if admitted. Supplemental benefits under this plan include preventive dental care with no copay, alongside comprehensive dental coverage up to a $1,500 annual limit with a 50% coinsurance. Vision benefits include a $40 routine exam copay and up to $400 annually for eyewear with no copay, while routine hearing exams require a $20 to $40 copay. Additionally, members can access unlimited one-way transportation to plan-approved locations with no copay or coinsurance.
Inpatient Hospital See details
Inpatient hospital care is covered by Complete Blue PPO Merit (PPO) with no coinsurance, requiring a $400 daily copay for days 1 to 5 and no copay for days 6 to 90 per stay for acute and psychiatric admissions. Prior authorization is required, and certain services such as non-Medicare-covered stays, hospital upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
Complete Blue PPO Merit (PPO) covers outpatient services with no coinsurance, including outpatient hospital and observation services for a $375 copay, and ambulatory surgical center services for a $325 copay. Outpatient substance abuse 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
Partial hospitalization services are covered by the Complete Blue PPO Merit (PPO) plan with no copay and no coinsurance.
Ambulance and Transportation Services See details
Complete Blue PPO Merit (PPO) covers ambulance services with a $320 copay and no coinsurance, subject to prior authorization. Transportation services are partially covered, offering unlimited one-way trips to plan-approved locations with no copay and no coinsurance, though transportation to any health-related location is not covered.
Emergency Services See details
Emergency services are covered by Complete Blue PPO Merit (PPO) with a $115 copay and no coinsurance, with the copay waived if admitted to the hospital within three days. Urgently needed services require a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services feature no coinsurance and copays of $115, $40, and $320 respectively.
Primary Care See details
Complete Blue PPO Merit (PPO) offers primary care physician services with no copay and no coinsurance, and specialist visits with a $40 copay and no coinsurance. Chiropractic services are partially covered with a $15 copay and no coinsurance for routine care, though other chiropractic services are not covered, while therapy, mental health, and podiatry services are covered with copays ranging from $35 to $40 and no coinsurance.
Preventive Services See details
Complete Blue PPO Merit (PPO) partially covers preventive services, offering annual physicals, kidney disease education, and screenings with no copay and no coinsurance. Supplemental benefits include remote access technologies with a $0 to $40 copay and no coinsurance, and home safety devices with a 20% coinsurance and no copay, while health education, personal emergency response systems (PERS), and weight management programs are not covered.
Hearing Services See details
Hearing services are partially covered by Complete Blue PPO Merit (PPO), with no coverage for fitting or evaluation exams, OTC hearing aids, and inner, outer, or over-the-ear prescription hearing aid types. Covered routine hearing exams require a $20 to $40 copay and no coinsurance, while covered prescription hearing aids have a $699 to $999 copay, no coinsurance, and a $500 annual maximum benefit.
Vision Services See details
Vision Services are partially covered by Complete Blue PPO Merit (PPO), featuring one routine eye exam per year with a $40 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $400 annual maximum limit for contacts, eyeglasses, frames, lenses, and upgrades.
Dental Services See details
Dental services are partially covered by Complete Blue PPO Merit (PPO) up to a $1,500 combined annual limit, with Medicare-covered dental requiring a $40 copay and no coinsurance, and preventive care offering no copay and no coinsurance. Comprehensive services like restorative, endodontics, periodontics, prosthodontics, and oral surgery are covered with no copay and 50% coinsurance (0% to 50% for adjunctive), while other diagnostic, other preventive, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Complete Blue PPO Merit (PPO) covers home infusion bundled services with no copay, although prior authorization is required. Associated Medicare Part B drugs, such as chemotherapy and radiation, carry a coinsurance ranging from no coinsurance to 20%, while Part B insulin has a $35 copay and a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Dialysis services are covered under the Complete Blue PPO Merit (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Complete Blue PPO Merit (PPO) covers durable medical equipment, prosthetics, and diabetic supplies with no copay, though prior authorization is required. These covered services generally carry a 20% coinsurance, with diabetic supplies ranging from no coinsurance up to 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Complete Blue PPO Merit (PPO) with no coinsurance, though prior authorization is required. Members pay no copay for lab services, a $0 to $10 copay for diagnostic tests, a $20 copay for outpatient X-rays, and minimum copays of $60 for therapeutic and $300 for diagnostic radiological services.
Home Health Services See details
Home health services are covered by Complete Blue PPO Merit (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Complete Blue PPO Merit (PPO) offers Cardiac Rehabilitation Services with no copay and no coinsurance, meaning some services are covered, though Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Complete Blue PPO Merit (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 copay for days 21 through 100, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Complete Blue PPO Merit (PPO) indicates some services are covered under other services, but acupuncture, over-the-counter (OTC) items, and meal benefits are not covered.
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