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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, there is no copay for 1-month or 3-month supplies filled at preferred pharmacies or through preferred mail order. Standard pharmacies and standard mail order options charge a copay ranging from $7 to $15 for a 1-month supply of these generic drugs. For brand-name and specialty medications, costs are based on 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 at both preferred and standard pharmacies.
Additional Benefits
The Complete Blue HMO Distinct (HMO) plan offers affordable core medical coverage with no copay for primary care visits and a $25 copay for specialist consultations. For inpatient hospital stays, members pay a $175 daily copay for the first five days and no copay thereafter, with no coinsurance required. Emergency room visits have a $130 copay that is waived upon admission, while urgent care services require a $40 copay. Supplemental benefits include preventive and comprehensive dental services with no copay up to a $3,000 annual limit, and routine eye exams for a $25 copay with a $400 annual eyewear allowance. Routine hearing exams require a $10 copay, and members receive a $40 quarterly over-the-counter allowance with no copay. Durable medical equipment and home health services feature no copays, though some medical equipment requires coinsurance up to 50 percent.
Inpatient Hospital See details
Complete Blue HMO Distinct (HMO) covers inpatient hospital services with no coinsurance, requiring prior authorization. Acute care has a $175 daily copay for days 1 to 5 and no copay for additional days, while psychiatric stays require a $225 copay per admission, though upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
Complete Blue HMO Distinct (HMO) covers outpatient hospital and observation services for a $245 copay and ambulatory surgical center services for a $175 copay, all with no coinsurance. Outpatient substance abuse sessions require a $30 copay with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Complete Blue HMO Distinct (HMO) covers partial hospitalization services with no copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered under prior authorization by Complete Blue HMO Distinct (HMO), with ground and air ambulance services requiring a $355 copay and no coinsurance. Transportation services are partially covered, offering unlimited one-way trips 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, which is waived if admitted to the hospital within three days, and no coinsurance. Urgently needed services require a $40 copay with no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $130, $40, and $355 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. Therapy services require a $20 copay and no coinsurance, whereas chiropractic benefits are only partially covered because other chiropractic services are not covered.
Preventive Services See details
Preventive services under the Complete Blue HMO Distinct (HMO) plan, including annual physical exams and kidney disease education, are covered with no copay and no coinsurance. While supplemental benefits like remote access technologies ($0 to $25 copay, no coinsurance) and safety devices (no copay, 20% coinsurance) are covered, others such as health education and personal emergency response systems are not covered.
Hearing Services See details
Complete Blue HMO Distinct (HMO) partially covers hearing services with no deductible, though OTC hearing aids, fitting/evaluations, and inner, outer, or over-the-ear prescription hearing aids are not covered. Covered routine hearing exams require a $10 copay and no coinsurance (limited to one per year), while covered prescription hearing aids have no coinsurance and a copay ranging from $699 to $999.
Vision Services See details
Complete Blue HMO Distinct (HMO) partially covers vision services with no deductible, offering one routine eye exam per year for a $25 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance, providing up to a $400 annual maximum benefit for contact lenses, eyeglasses, and upgrades.
Dental Services See details
Complete Blue HMO Distinct (HMO) features partially covered dental services with an annual maximum of $3,000. Covered Medicare dental services require a $25 copay and no coinsurance, while other covered preventive and comprehensive services have no copay and no coinsurance. Uncovered services include implants, orthodontics, maxillofacial prosthetics, other diagnostic dental, and other preventive dental services.
Home Infusion bundled Services See details
Complete Blue HMO Distinct (HMO) covers home infusion bundled services with no copay, subject to prior authorization. Medicare Part B chemotherapy, radiation, and other drugs require 0% (no coinsurance) to 20% coinsurance, while covered insulin requires a $35 copay and 0% (no coinsurance) to 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. Durable medical equipment carries a coinsurance of 0% to 50%, diabetic supplies range from no coinsurance to 20% coinsurance, and prosthetic devices, medical supplies, and diabetic shoes or inserts require a 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. Outpatient lab services have no copay, diagnostic tests range from no copay to a $10 copay, outpatient X-rays have a $20 copay, and therapeutic and diagnostic radiology require minimum copays of $50 and $195, respectively.
Home Health Services See details
Complete Blue HMO Distinct (HMO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required for these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the Complete Blue HMO Distinct (HMO) with no copay and no coinsurance. While some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, 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, requiring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and additional days beyond standard Medicare-covered limits are not covered.
Other Services See details
Complete Blue HMO Distinct (HMO) partially covers other services, offering an over-the-counter (OTC) benefit of up to $40 every three months with no copay and no coinsurance. However, acupuncture, meal benefits, and other additional services are not covered under this plan.
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