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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 $8.00. 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) plan features an annual drug deductible of $615. Under this plan, you will pay no copay for Tier 1 preferred generic and Tier 2 generic medications when using a preferred pharmacy or preferred mail-order service. If you choose a standard pharmacy or standard mail-order, Tier 1 drugs carry a $7 copay and Tier 2 drugs carry a $15 copay for a one-month supply. For higher-tier medications, costs transition to coinsurance percentages instead of flat copays. Tier 3 preferred brand drugs require a 23% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance across all pharmacy networks and mail-order options.
Additional Benefits
The Complete Blue HMO Distinct (HMO) plan offers robust medical coverage featuring no copay and no coinsurance for primary care visits, while specialist and therapy visits require a $20 copay. For hospital care, inpatient acute stays carry a $300 copay per admission with no coinsurance, and outpatient hospital services require a $245 copay. Emergency room visits have a $130 copay, which is waived if admitted within three days, while urgent care services require a $40 copay. This plan also provides valuable supplemental benefits, including dental care with no copay for most covered services up to a $3,000 annual limit, and a $400 yearly allowance for eyewear with no copay. Additionally, members can access unlimited transportation to plan-approved locations and an over-the-counter benefit of up to $90 every three months with no copay or coinsurance. Routine hearing exams carry a $10 to $20 copay, and prescription hearing aids are covered with copays ranging from $699 to $999.
Inpatient Hospital See details
Complete Blue HMO Distinct (HMO) partially covers inpatient hospital services, requiring prior authorization and no coinsurance for all covered stays. Medicare-covered acute stays require a $300 copay per admission, while psychiatric stays require a $225 copay per admission; however, 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 with no coinsurance, while outpatient blood services are covered with no copay or coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered by the Complete Blue HMO Distinct (HMO) plan with no copay and no coinsurance.
Ambulance and Transportation Services See details
Complete Blue HMO Distinct (HMO) covers ambulance and transportation services, though transportation is only partially covered because transportation to any health-related location is not covered. Ground and air ambulance services require a $200 copay and no coinsurance, while unlimited transportation to plan-approved locations is provided with no copay and no coinsurance.
Emergency Services See details
Emergency services are covered by Complete Blue HMO Distinct (HMO) with a $130 copay and no coinsurance, which is 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 services with no copay and no coinsurance, while specialist, physical therapy, occupational therapy, and podiatry visits require a $20 copay and no coinsurance. Chiropractic services are partially covered, excluding other chiropractic services, and require a $10 copay and no coinsurance for routine care. Mental health, psychiatric, and opioid treatment services are covered with a $30 copay and no coinsurance.
Preventive Services See details
Complete Blue HMO Distinct (HMO) preventive services are partially covered, offering annual physical exams, kidney disease education, and other preventive screenings with no copay and no coinsurance. Covered supplemental benefits include memory fitness, disease management, remote access technologies (with a copay ranging from no copay to $20 and no coinsurance), and home safety devices (with a 20% coinsurance and no copay). However, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, smoking cessation, telemonitoring, and counseling are not covered.
Hearing Services See details
Complete Blue HMO Distinct (HMO) provides partial coverage for hearing services, excluding fitting and evaluation exams, OTC hearing aids, and inner, outer, or over-the-ear prescription hearing aids. Covered routine hearing exams are limited to one per year with a copay of $10.00 to $20.00 and no coinsurance, while up to two prescription hearing aids are covered annually with a copay of $699.00 to $999.00 and no coinsurance.
Vision Services See details
Vision services are partially covered by Complete Blue HMO Distinct (HMO), featuring one routine eye exam per year with a $20 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance, offering a combined maximum benefit of $400 per year for contacts, eyeglasses, frames, lenses, and upgrades.
Dental Services See details
Dental services are partially covered by Complete Blue HMO Distinct (HMO), 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. Non-covered services include other diagnostic dental, other preventive dental, maxillofacial prosthetics, implant services, and orthodontics.
Home Infusion bundled Services See details
Complete Blue HMO Distinct (HMO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Covered Medicare Part B drugs, including chemotherapy and radiation, require no copay and a coinsurance ranging from no coinsurance to 20%, while Part B insulin is available for a $35 copay and no coinsurance 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. Durable medical equipment has coinsurance ranging from no coinsurance up to 50%, while diabetic supplies, therapeutic shoes, prosthetics, and medical supplies carry coinsurance ranging from no coinsurance to 20%.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Complete Blue HMO Distinct (HMO) with no coinsurance, though prior authorization is required. Members will pay no copay for lab services, between $0 and $10 for diagnostic tests, a $20 copay for outpatient X-rays, and minimum copays of $50 for therapeutic radiology and $165 for diagnostic radiology.
Home Health Services See details
Home Health Services are covered under the Complete Blue HMO Distinct (HMO) plan with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under Complete Blue HMO Distinct (HMO) with no copay and no coinsurance, though only some services are covered in practice as cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Complete Blue HMO Distinct (HMO) with no coinsurance and no prior three-day inpatient hospital stay requirement. There is no copay for days 1 through 20 and a $218 copay for days 21 through 100, though prior authorization is required and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Complete Blue HMO Distinct (HMO) partially covers other services, providing an over-the-counter (OTC) benefit with no copay and no coinsurance up to a maximum of $90 every three months. Acupuncture and meal benefits are not covered under this plan.
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