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Complete Blue HMO Distinct (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Complete Blue HMO Distinct (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Complete Blue HMO Distinct (HMO) in 2026, please refer to our full plan details page.
Complete Blue HMO Distinct (HMO) is a HMO plan offered by Highmark Health available for enrollment in 2026 to people living in Western, PA. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Complete Blue HMO Distinct (HMO) 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 HMO Distinct (HMO).
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 HMO Distinct (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $20.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $5.00. You must continue to pay paying your reduced 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 Maximum Out-Of-Pocket cost of $5900.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
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 HMO Distinct (HMO) prescription drug plan has an annual drug deductible of $615. Under this plan, you will pay no copay for Tier 1 preferred generic and Tier 2 generic drugs when using a preferred pharmacy or preferred mail-order service. If you use standard pharmacies, Tier 1 drugs have a $7 copay and Tier 2 drugs have a $15 copay for a one-month supply. For brand-name and specialty drugs, you will pay a percentage of the drug cost rather than a flat copay. 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 and mail-order options. This plan offers a balance of cost-saving generics with shared costs for higher-tier medications.
Additional Benefits
The Complete Blue HMO Distinct (HMO) plan offers robust medical coverage with no copay and no coinsurance for primary care doctor visits, while specialist visits require a 20 dollar copay. Inpatient hospital stays carry a copay of 275 dollars per stay for acute care and 225 dollars per stay for psychiatric care with no coinsurance. Emergency room visits require a 130 dollar copay, which is waived if you are admitted to the hospital within three days. This plan also features valuable supplemental benefits, including a 3,000 dollar annual dental limit with no copay for most covered services, and up to a 400 dollar annual allowance for eyewear with no copay. Additionally, members receive an 80 dollar over-the-counter allowance every three months and unlimited one-way transportation to plan-approved locations with no copays. Routine preventive services and annual physical exams are also fully covered with no copay and no coinsurance.
Inpatient Hospital See details
Inpatient hospital services are covered by Complete Blue HMO Distinct (HMO) with no coinsurance, requiring prior authorization and a copayment of $275 per stay for acute care and $225 per stay for psychiatric care. The benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Complete Blue HMO Distinct (HMO) covers outpatient services with no coinsurance, featuring a $245 copay for outpatient hospital and daily observation services, and a $175 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $30 copay, while outpatient blood services are covered with no copay and no deductible.
Partial Hospitalization See details
Partial hospitalization is covered under the Complete Blue HMO Distinct (HMO) plan with no copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Complete Blue HMO Distinct (HMO), with ground and air ambulance services requiring prior authorization and a $200 copay with no coinsurance. Transportation services are partially covered, offering unlimited one-way rides to plan-approved locations with no copay and no coinsurance, but transportation to any health-related location is not covered.
Emergency Services See details
Complete Blue HMO Distinct (HMO) covers emergency services with a $130 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 are covered with no coinsurance and copays of $130, $40, and $200, respectively.
Primary Care See details
Primary care benefits under the Complete Blue HMO Distinct (HMO) plan are covered, featuring no copay and no coinsurance for primary care physician visits, and a $20 copay and no coinsurance for specialists. The benefit is partially covered because other chiropractic services are not covered, though routine chiropractic care is covered with a $10 copay and no coinsurance.
Preventive Services See details
Complete Blue HMO Distinct (HMO) covers preventive services, offering annual physical exams, kidney disease education, and other routine screenings with no copay and no coinsurance. Additional preventive benefits are partially covered, featuring memory fitness, remote access technologies with a $0 to $20 copay and no coinsurance, and home safety devices with a 20% coinsurance and no copay, while services like health education and in-home support are not covered.
Hearing Services See details
Complete Blue HMO Distinct (HMO) partially covers hearing services, offering routine hearing exams with a $10 to $20 copay and no coinsurance, and prescription hearing aids with a $699 to $999 copay and 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
Vision services are partially covered by Complete Blue HMO Distinct (HMO), featuring one annual routine eye exam for a $20 copay and no coinsurance or deductible, while other eye exam services are not covered. Eyewear is covered with no copay, coinsurance, or deductible up to a $400 annual maximum allowance.
Dental Services See details
Complete Blue HMO Distinct (HMO) partially covers dental services up to a $3,000 annual limit, offering Medicare-covered services for a $20 copay and no coinsurance, and other covered dental services with no copay and no coinsurance. Services not covered under this plan include other diagnostic dental, other preventive dental, maxillofacial prosthetics, implant services, and orthodontics.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Complete Blue HMO Distinct (HMO) with no copay and no coinsurance, subject to prior authorization. Medicare Part B chemotherapy and other drugs carry no copay and a 0% to 20% coinsurance, while Medicare Part B insulin is covered with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Complete Blue HMO Distinct (HMO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Complete Blue HMO Distinct (HMO) covers medical equipment with no copays, though prior authorization is required. Durable medical equipment (DME) carries coinsurance ranging from no coinsurance up to 50%, diabetic supplies range from no coinsurance to 20% coinsurance, and prosthetics, medical supplies, and diabetic shoes require 20% coinsurance.
Diagnostic and Radiological Services See details
Complete Blue HMO Distinct (HMO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Lab services have no copay, diagnostic tests range from no copay to a $10 copay, outpatient X-rays require a $20 copay, and diagnostic and therapeutic radiology require minimum copays of $150 and $50 respectively.
Home Health Services See details
Home health services are covered under the Complete Blue HMO Distinct (HMO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Complete Blue HMO Distinct (HMO) does not cover Cardiac Rehabilitation Services, which includes standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services.
Skilled Nursing Facility (SNF) See details
Complete Blue HMO Distinct (HMO) covers skilled nursing facility (SNF) services with no coinsurance, featuring no copay for days 1 through 20 and a $218 copay for days 21 through 100 per stay. Prior authorization is required, a prior three-day inpatient hospital stay is not required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by Complete Blue HMO Distinct (HMO), which offers an over-the-counter (OTC) item benefit of $80 every three months with no copay and no coinsurance. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone are not covered.
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