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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 $25.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 features an annual drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic medications, members pay no copay when using a preferred pharmacy or preferred mail order service. If you choose a standard pharmacy, a 1-month supply costs a $7 copay for Tier 1 and a $15 copay for Tier 2 drugs. Brand-name and specialty drugs require a coinsurance payment rather than a flat copay. You will pay 23% coinsurance for Tier 3 preferred brand drugs and 25% coinsurance for Tier 4 non-preferred drugs. Tier 5 specialty drugs also carry a 25% coinsurance for a 1-month supply at both preferred and standard pharmacies.
Additional Benefits
The Complete Blue HMO Distinct (HMO) plan offers robust medical coverage with predictable out-of-pocket costs, featuring no copay and no coinsurance for primary care visits and routine preventive services. For specialized care, members pay a low $25 copay for specialists and no coinsurance, while inpatient hospital stays require a $300 copay per stay with no coinsurance. Emergency care is accessible with a $130 copay, which is waived if you are admitted, and urgently needed services require a $40 copay. This plan also provides valuable supplemental benefits, including dental coverage with no copay up to a $3,000 annual limit and a $400 annual allowance for eyewear with no copay. Additionally, members can take advantage of unlimited health-related transportation with no copay, a $10 copay for annual routine hearing exams, and a $75 quarterly over-the-counter item allowance. Home health services are also fully covered with no copay and no coinsurance, ensuring affordable care at home.
Inpatient Hospital See details
Complete Blue HMO Distinct (HMO) covers inpatient hospital services with no coinsurance, requiring a $300 copay per stay for acute care and a $225 copay per stay for psychiatric care. The benefit is partially covered, as upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services are covered by Complete Blue HMO Distinct (HMO) with no coinsurance across all services, featuring a $245 copay for outpatient hospital and daily observation services, and a $175 copay for ambulatory surgical center services. Outpatient substance abuse services require a $30 copay per individual or group session with no coinsurance, while outpatient blood services are covered with no copay and no 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
Ambulance and transportation services are covered by Complete Blue HMO Distinct (HMO), requiring a $345 copay and no coinsurance for ground or air ambulance trips. Unlimited one-way transportation to plan-approved health-related locations is covered with no copay and no coinsurance, while 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, 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 $345 respectively.
Primary Care See details
Complete Blue HMO Distinct (HMO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $25 copay and no coinsurance. Physical therapy ($20 copay), mental health sessions ($30 copay), and podiatry ($25 copay) also feature no coinsurance, though chiropractic care is only partially covered as other non-routine chiropractic services are excluded.
Preventive Services See details
Complete Blue HMO Distinct (HMO) preventive services are partially covered, offering annual physical exams, kidney disease education, and screenings with no copay and no coinsurance. Additional benefits include memory fitness and disease management (no copay, no coinsurance), remote access technologies ($0 to $25 copay, no coinsurance), and home safety devices (no copay, 20% coinsurance). Non-covered services include health education, PERS, in-home safety assessments, medical nutrition therapy, medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, smoking cessation, telemonitoring, and counseling.
Hearing Services See details
Complete Blue HMO Distinct (HMO) provides partially covered hearing services with no coinsurance, featuring a $10 copay for annual routine hearing exams and a $699 to $999 copay for prescription hearing aids. 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 covered by Complete Blue HMO Distinct (HMO) with no deductibles, featuring one routine eye exam annually for a $25 copay and no coinsurance, though other eye exam services are not covered. Eyewear is also covered with no copay or coinsurance, providing up to a $400 annual maximum for contacts, frames, lenses, and upgrades.
Dental Services See details
Complete Blue HMO Distinct (HMO) dental services are partially covered, featuring a $25 copay and no coinsurance for Medicare-covered dental, and no copay or coinsurance for other dental services up to a $3,000 annual limit. While many preventive and restorative treatments are covered, non-covered services include other diagnostic, other preventive, maxillofacial prosthetics, implants, and orthodontics.
Home Infusion bundled Services See details
Complete Blue HMO Distinct (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Covered Medicare Part B drugs, including chemotherapy and radiation, require between no coinsurance and 20% coinsurance, while insulin is covered with a $35 copay and between no coinsurance and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by Complete Blue HMO Distinct (HMO) 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. Members will pay no coinsurance to 50% coinsurance for durable medical equipment, 20% coinsurance for prosthetics and medical supplies, and no coinsurance to 20% coinsurance for diabetic supplies and services.
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 pay no copay for lab services, a $0 to $10 copay for diagnostic procedures, a $20 copay for outpatient X-rays, and minimum copays of $50 for therapeutic radiology and $195 for diagnostic radiology.
Home Health Services See details
Home Health Services are covered by 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) covers Cardiac Rehabilitation Services with no copay and no coinsurance. While some services are covered, Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
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. Prior authorization is required, and while a prior three-day hospital stay is not required, additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Complete Blue HMO Distinct (HMO) partially covers Other Services, offering over-the-counter (OTC) items with no copay and no coinsurance up to a maximum benefit of $75 every three months. Acupuncture, meal benefits, and highly integrated dual eligible SNP services are not covered.
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