A non-government entity
Complete Blue PPO Distinct (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Complete Blue PPO Distinct (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Complete Blue PPO Distinct (PPO) in 2026, please refer to our full plan details page.
Complete Blue PPO Distinct (PPO) is a PPO plan offered by Highmark Health available for enrollment in 2025 to people living in West Virginia. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Complete Blue PPO Distinct (PPO) 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 PPO Distinct (PPO).
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 PPO Distinct (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $24.00. 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 combined Maximum Out-Of-Pocket cost of $9550.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $9550.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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:
Sign up for Complete Blue PPO Distinct (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Complete Blue PPO Distinct (PPO) plan features an annual prescription drug deductible of $615. Under this plan, members enjoy no copay for Tier 1 preferred generic and Tier 2 generic drugs when filled at a preferred pharmacy or through preferred mail order. If you choose a standard pharmacy, a one-month supply costs a $7.00 copay for Tier 1 and a $15.00 copay for Tier 2. Higher-tier medications are subject to coinsurance rather than flat copays. Tier 3 preferred brands require a 20% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance at both preferred and standard pharmacies. This structure allows members to access necessary brand-name and specialty prescriptions with clear, tier-based cost-sharing.
Additional Benefits
The Complete Blue PPO Distinct (PPO) plan offers comprehensive medical coverage featuring no copay and no coinsurance for primary care visits, annual physicals, and home health services. Specialist visits require a $25 copay with no coinsurance, while acute inpatient hospital stays cost a $195 daily copay for the first three days and no copay thereafter. Emergency room visits have a $130 copay, which is waived if you are admitted within three days, and outpatient hospital services carry a $300 copay with no coinsurance. For everyday wellness, the plan includes dental care with no copay for preventive services and a 10% coinsurance for comprehensive services up to a $2,500 annual limit. Routine vision and hearing exams are available with a $25 copay, and the plan provides a $350 annual allowance for glasses or contacts alongside coverage for prescription hearing aids. Additionally, skilled nursing facility stays feature no copay for the first 20 days, and diagnostic lab services are covered with no copay.
Inpatient Hospital See details
Inpatient hospital services are covered by Complete Blue PPO Distinct (PPO) with no coinsurance, requiring prior authorization for both acute and psychiatric stays. Acute stays cost a $195 copay per day for days 1-3 and no copay for remaining days, while psychiatric stays require a $425 copay per day for days 1-3 and no copay for days 4-90. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Complete Blue PPO Distinct (PPO) covers outpatient services with no coinsurance, featuring a $300 copay for outpatient hospital and daily observation services and a $225 copay for ambulatory surgical center services. Outpatient substance abuse services require a $40 copay with no coinsurance, while outpatient blood services are available with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Partial hospitalization is covered under the Complete Blue PPO Distinct (PPO) plan with no copay and no coinsurance required for services.
Ambulance and Transportation Services See details
Complete Blue PPO Distinct (PPO) covers ambulance services with a $270 copay and no coinsurance for both ground and air transport. Transportation services are partially covered, offering rides to plan-approved health-related locations with no copay or coinsurance, while transportation to any health-related location is not covered.
Emergency Services See details
Emergency services are covered by Complete Blue PPO Distinct (PPO) with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within three days. Urgently needed services have a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays ranging from $40 to $270.
Primary Care See details
Complete Blue PPO Distinct (PPO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $25 copay and no coinsurance. Additional benefits like physical therapy, psychiatric care, and telehealth have copays ranging from $0 to $40 with no coinsurance, while chiropractic care is partially covered, excluding non-routine services.
Preventive Services See details
Complete Blue PPO Distinct (PPO) preventive services are partially covered, offering annual physicals, kidney disease education, and other screenings with no copay and no coinsurance. While remote access technologies are covered with a $0 to $25 copay and no coinsurance, and home safety modifications are covered with 20% coinsurance and no copay, several services are not covered, including health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, medication reconciliation, re-admission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, additional smoking cessation, telemonitoring, and counseling.
Hearing Services See details
Complete Blue PPO Distinct (PPO) partially covers hearing services, offering routine hearing exams for a $25 copay and no coinsurance, and prescription hearing aids with copays ranging from $699 to $999 and no coinsurance. Hearing aid fitting and evaluations, OTC hearing aids, and inner ear, outer ear, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Complete Blue PPO Distinct (PPO) offers partially covered vision services, featuring one routine eye exam per year for a $25 copay and no coinsurance, while other eye exam services are not covered. Covered eyewear options like glasses and contacts have no copay and no coinsurance, subject to a $350 combined annual maximum benefit for both in- and out-of-network services.
Dental Services See details
Complete Blue PPO Distinct (PPO) partially covers dental services with an annual maximum benefit of $2,500, offering Medicare-covered dental for a $25 copay and no coinsurance, and preventive services for no copay and no coinsurance. Covered comprehensive services require no copay and 10% coinsurance (no coinsurance to 10% for adjunctive services), while other diagnostic dental, other preventive dental, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Complete Blue PPO Distinct (PPO) with no copay, although prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs have no copay and a coinsurance of 0% to 20%, while Part B insulin has a $35 copay and a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Complete Blue PPO Distinct (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Complete Blue PPO Distinct (PPO) covers medical equipment with no copays, subject to prior authorization. Durable medical equipment requires between no coinsurance and 50% coinsurance, diabetic supplies range from no coinsurance to 20% coinsurance, and prosthetic devices, medical supplies, and diabetic shoes or inserts carry a 20% coinsurance.
Diagnostic and Radiological Services See details
Complete Blue PPO Distinct (PPO) covers diagnostic and radiological services with no coinsurance, though prior authorization is required. Lab services have no copay, diagnostic tests have a copay of $0 to $10, outpatient X-rays require a $15 copay, and therapeutic and diagnostic radiological services carry minimum copays of $60 and $200, respectively.
Home Health Services See details
Home Health Services are covered by Complete Blue PPO Distinct (PPO) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Complete Blue PPO Distinct (PPO) covers some cardiac rehabilitation services with no copay and no coinsurance, but standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Complete Blue PPO Distinct (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance and no prior three-day hospital stay requirement. Covered stays require prior authorization and feature no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, with additional days not covered.
Other Services See details
Complete Blue PPO Distinct (PPO) partially covers other services, offering a chronic illness meal benefit and over-the-counter (OTC) items with no copay and no coinsurance. While OTC items are covered up to $40 every three months, acupuncture and certain OTC drugs like nicotine replacement therapy and naloxone are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved