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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 $7.00. 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. For Tier 1 preferred generic and Tier 2 generic drugs, beneficiaries pay no copay when using preferred retail pharmacies or preferred mail-order services. If you use standard pharmacies or standard mail-order services, Tier 1 drugs require a $7 to $21 copay, while Tier 2 drugs require a $15 to $45 copay. For brand-name and specialty medications, the plan utilizes coinsurance instead of flat copays. Tier 3 preferred brand drugs require a 23% coinsurance, whereas Tier 4 non-preferred drugs and Tier 5 specialty drugs both incur a 25% coinsurance. This percentage-based cost sharing applies equally across all preferred and standard pharmacy and mail-order options.
Additional Benefits
The Complete Blue HMO Distinct (HMO) plan offers robust medical coverage featuring no copay for primary care physician visits and a $20 copay for specialist visits. For hospital care, members pay a $300 copay per inpatient acute stay with no coinsurance, while emergency room visits carry a $130 copay. Outpatient hospital services require a $245 copay, but standard preventive care and home health services are covered with no copay or coinsurance. This plan also includes valuable supplemental benefits such as dental coverage with no copay for covered services up to a $3,000 annual limit. Vision care provides routine eye exams and up to a $400 annual allowance for eyewear with no copay, while hearing exams are available with a $10 copay. Additionally, members receive a $90 quarterly allowance for over-the-counter items and pay no copay for the first 20 days in a skilled nursing facility.
Inpatient Hospital See details
Complete Blue HMO Distinct (HMO) covers inpatient acute hospital stays with a $300 copay per stay and psychiatric stays with a $225 copay per stay, both requiring prior authorization and featuring no coinsurance. While unlimited additional acute care days are covered with no copay, upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services under Complete Blue HMO Distinct (HMO) are covered with no coinsurance, featuring a $245 copay for outpatient hospital and observation services, and a $175 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $30 copay with no coinsurance, while outpatient blood services are provided with no copay or coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by Complete Blue HMO Distinct (HMO) with no copay and no coinsurance.
Ambulance and Transportation Services See details
Complete Blue HMO Distinct (HMO) covers ambulance services with a $200 copay and no coinsurance for both ground and air transport, subject to prior authorization. Transportation services are partially covered, offering unlimited rides to plan-approved health-related locations with no copay and no coinsurance, though transportation to any other health-related location is not covered.
Emergency Services See details
Emergency services are covered by Complete Blue HMO Distinct (HMO) with a $130 copay and no coinsurance, with the copay waived if you are 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
Complete Blue HMO Distinct (HMO) covers primary care physician visits with no copay and no coinsurance, and specialist visits with a $20 copay and no coinsurance. Other services like therapy and mental health sessions require copays of $15 to $30 with no coinsurance, while chiropractic care is partially covered because other chiropractic services are not covered.
Preventive Services See details
Complete Blue HMO Distinct (HMO) covers Medicare-covered preventive services, annual physical exams, kidney disease education, and screenings with no copay and no coinsurance. Additional preventive benefits are partially covered, including memory fitness, remote access technologies with a $0 to $20 copay, and home safety devices with 20% coinsurance, while services like health education, personal emergency response systems, and nutritional/dietary benefits are not covered.
Hearing Services See details
Hearing services are partially covered by Complete Blue HMO Distinct (HMO), featuring routine hearing exams with a $10 copay, general exams with a $20 copay, and no coinsurance or deductibles. Up to two annual prescription hearing aids are covered with copays ranging from $699 to $999 and no coinsurance, though fitting evaluations, over-the-counter aids, and inner, outer, or over-the-ear prescription models are not covered.
Vision Services See details
Complete Blue HMO Distinct (HMO) vision services are partially covered, providing one routine eye exam per year with a $20 copay and no coinsurance, while other eye exam services are not covered. Eyewear, including contacts and eyeglasses, is covered with no copay and no coinsurance up to a $400 combined maximum annual limit.
Dental Services See details
Complete Blue HMO Distinct (HMO) offers dental services featuring a $20 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for other covered services up to a $3,000 annual maximum. The benefit is partially covered, as orthodontic, implant, maxillofacial prosthetic, and certain other diagnostic or preventive dental services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Complete Blue HMO Distinct (HMO) with no copay, though prior authorization and step therapy may apply. Covered Medicare Part B chemotherapy, radiation, and other drugs have between no coinsurance and 20% coinsurance, while Part B insulin drugs are covered with a $35 copay and up to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Complete Blue HMO Distinct (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by Complete Blue HMO Distinct (HMO) with no copays, though prior authorization is required. Coinsurance ranges from no coinsurance up to 50% for durable medical equipment, is 20% for prosthetics and medical supplies, and ranges from no coinsurance up to 20% for diabetic equipment and supplies.
Diagnostic and Radiological Services See details
Complete Blue HMO Distinct (HMO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Outpatient lab services have no copay, diagnostic procedures have a $0 to $10 copay, outpatient X-rays carry a $20 copay, and diagnostic and therapeutic radiological services require minimum copays of $165 and $50, respectively.
Home Health Services See details
Home Health Services are covered by Complete Blue HMO Distinct (HMO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered by Complete Blue HMO Distinct (HMO) with no copay and no coinsurance, but in practice, specific services including cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation are not covered.
Skilled Nursing Facility (SNF) See details
Complete Blue HMO Distinct (HMO) covers skilled nursing facility services with no coinsurance, requiring prior authorization but no preceding three-day hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, though 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 over-the-counter (OTC) items with no copay and no coinsurance up to a maximum benefit of $90 every three months. However, acupuncture, meal benefits, nicotine replacement therapy, and naloxone are not covered under this plan.
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