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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 $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 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:
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Drug Coverage
The Complete Blue PPO Distinct (PPO) prescription drug plan has an annual drug deductible of $615. For Tier 1 preferred generic and Tier 2 generic drugs, you will pay no copay for a 1-month or 3-month supply at a preferred pharmacy or through preferred mail order. If you use a standard pharmacy, Tier 1 drugs have a $7 copay for a 1-month supply, and Tier 2 drugs have a $15 copay. Brand-name and specialty medications are covered under coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 20% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both require a 25% coinsurance. These coinsurance rates apply equally across preferred and standard pharmacies as well as mail-order services.
Additional Benefits
The Complete Blue PPO Distinct (PPO) plan offers comprehensive coverage for everyday medical needs, featuring no copays or coinsurance for primary care visits and annual preventive screenings. Specialist visits and rehabilitation therapies require a $20 copay with no coinsurance, while emergency room visits carry a $130 copay. For hospital care, members pay no coinsurance and a $175 daily copay for the first three days of acute inpatient stays, with subsequent days covered at no copay. This plan also includes key dental, vision, and hearing benefits to help minimize your out-of-pocket expenses. Dental care features a $2,500 annual limit with no copay or coinsurance for preventive services, while vision coverage includes a $20 copay for routine exams and up to $350 annually for eyewear with no copay. Additionally, members can access over-the-counter items with no copay or coinsurance up to a limit of $40 every three months.
Inpatient Hospital See details
Complete Blue PPO Distinct (PPO) covers inpatient hospital services with no coinsurance, requiring a $175 copay per day for days 1 to 3 for acute stays and a $425 copay per day for days 1 to 3 for psychiatric stays, with no copay for subsequent days. Prior authorization is required, and certain services such as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Complete Blue PPO Distinct (PPO) offers outpatient services with no coinsurance, including a $300 copay for outpatient hospital and daily observation services, and a $225 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $40 copay with no coinsurance, while outpatient blood services are covered with no copay, coinsurance, or deductible.
Partial Hospitalization See details
Complete Blue PPO Distinct (PPO) covers partial hospitalization services with no copay and no coinsurance.
Ambulance and Transportation Services See details
Complete Blue PPO Distinct (PPO) covers ambulance services with a $365 copay and no coinsurance for both ground and air transport. Transportation services are partially covered with no copay and no coinsurance for unlimited trips to plan-approved locations, but 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, 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 services are covered with no coinsurance and copays ranging from $40 to $365.
Primary Care See details
Complete Blue PPO Distinct (PPO) covers primary care physician services with no copay and no coinsurance, while specialist, occupational, physical, and speech therapies require a $20 copay and no coinsurance. Chiropractic services are partially covered, offering up to 8 routine visits per year for a $15 copay with no coinsurance, though other chiropractic services are not covered. Mental health, psychiatric, and opioid treatment services require a $40 copay and no coinsurance.
Preventive Services See details
Preventive services are covered by Complete Blue PPO Distinct (PPO) with no copay and no coinsurance for annual physical exams, kidney disease education, and other preventive screenings. Additional preventive benefits are partially covered, featuring memory fitness, remote access technologies with a $0 to $20 copay, and home safety devices with a 20% coinsurance. Sub-services such as health education, in-home safety assessments, PERS, 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 are not covered.
Hearing Services See details
Complete Blue PPO Distinct (PPO) provides partially covered hearing services, which include routine hearing exams with a $20 to $25 copay and no coinsurance, but exclude fitting evaluations and OTC hearing aids. Prescription hearing aids are covered up to two per year with a $500 annual maximum, no coinsurance, and copays ranging from $699 to $999, though inner ear, outer ear, and over-the-ear types are not covered.
Vision Services See details
Complete Blue PPO Distinct (PPO) partially covers vision services, providing one routine eye exam per year with a $20 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance, up to a combined maximum plan benefit of $350 every year.
Dental Services See details
Dental services are partially covered under Complete Blue PPO Distinct (PPO), which offers a $2,500 annual limit with no copay and no coinsurance for preventive care, and a $20 copay with no coinsurance for Medicare-covered dental. Covered comprehensive services require no copay and 10% coinsurance (0% to 10% for adjunctive services), but other diagnostic, other preventive, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Complete Blue PPO Distinct (PPO) covers Home Infusion bundled Services with no copay and no coinsurance, though prior authorization and step therapy are required. Covered Medicare Part B drugs, including chemotherapy, radiation, and other drugs, carry no copay and 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Complete Blue PPO Distinct (PPO) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Complete Blue PPO Distinct (PPO) covers medical equipment with no copays, though prior authorization is required. Durable medical equipment ranges from no coinsurance up to 50% coinsurance, diabetic supplies from specified manufacturers range from no coinsurance up to 20% coinsurance, and prosthetics, medical supplies, and diabetic shoes require a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Complete Blue PPO Distinct (PPO) with no coinsurance, though prior authorization is required. Members pay no copay for lab services, up to a $10 copay for diagnostic procedures, a $15 copay for outpatient X-rays, and minimum copays of $60 for therapeutic radiology and $200 for diagnostic radiological services.
Home Health Services See details
Home Health Services are covered by the Complete Blue PPO Distinct (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Complete Blue PPO Distinct (PPO) technically covers Cardiac Rehabilitation Services with no copay and no coinsurance, but the benefit is not covered in practice because standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are all excluded.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Complete Blue PPO Distinct (PPO) with no coinsurance and require prior authorization, but do not require a prior three-day inpatient hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100 per stay, while additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Complete Blue PPO Distinct (PPO) provides partial coverage for other services, which includes over-the-counter (OTC) items and chronic illness meal benefits with no copay and no coinsurance. While OTC items are covered up to $40 every three months, acupuncture and other supplemental services are not covered.
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