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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 2026 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:
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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 generics and Tier 2 generics, you will pay no copay for a 1-month or 3-month supply when using a preferred pharmacy or preferred mail order. If you use standard pharmacies or standard mail order services, Tier 1 drugs require a $7 copay for a 1-month supply, and Tier 2 drugs carry a $15 copay. For brand-name and specialty medications, your costs are determined by coinsurance. Tier 3 preferred brand drugs require a 20% coinsurance at both preferred and standard pharmacies. Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance, ensuring you know what to expect for higher-tier prescription costs.
Additional Benefits
The Complete Blue PPO Distinct (PPO) plan offers affordable everyday healthcare, featuring no copay for primary care physician visits, preventive screenings, and home health services. For specialized medical needs, members pay a $25 copay for specialist visits and a $130 copay for emergency room services. Inpatient hospital stays require a daily copay of $195 for acute stays or $425 for psychiatric stays for the first three days, after which there is no copay. Supplemental coverage includes preventive dental services with no copay up to a $2,500 annual maximum, as well as a $350 yearly allowance for eyewear with no copay. Members also benefit from unlimited approved transportation and over-the-counter items with no copay, while durable medical equipment and dialysis require no copay and coinsurance up to 50%.
Inpatient Hospital See details
Complete Blue PPO Distinct (PPO) covers inpatient hospital services with no coinsurance, requiring prior authorization and a copay of $195 per day for days 1 to 3 of acute stays and $425 per day for days 1 to 3 of psychiatric stays, with no copay for subsequent days. 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 individual and group sessions require a $40 copay, while outpatient blood services are fully covered with no copay, no coinsurance, and no 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 ground and air ambulance services with a $270 copay and no coinsurance. Transportation services are partially covered, offering unlimited one-way trips to plan-approved locations with no copay and no coinsurance, while transportation to any other health-related locations is not covered.
Emergency Services See details
Complete Blue PPO Distinct (PPO) 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 with no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $130, $40, and $270 respectively.
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. Most other healthcare services, including mental health, therapy, and podiatry, range from a $0 to $40 copay with no coinsurance, while chiropractic care is only partially covered because other chiropractic services are excluded.
Preventive Services See details
Preventive Services are partially covered by Complete Blue PPO Distinct (PPO), featuring no copay and no coinsurance for annual physical exams, kidney disease education, and routine screenings. Covered supplemental benefits include memory fitness, remote access technologies ($0 to $25 copay and no coinsurance), and home safety devices (20% coinsurance and no copay), while services such as health education, PERS, and nutritional therapy are not covered.
Hearing Services See details
Complete Blue PPO Distinct (PPO) partially covers hearing services, offering routine hearing exams for a $25 copay and no coinsurance, while hearing aid fittings and OTC hearing aids are not covered. Prescription hearing aids are covered with copays from $699 to $999 and no coinsurance up to a $500 annual limit, though inner ear, outer ear, and over-the-ear types are excluded.
Vision Services See details
Complete Blue PPO Distinct (PPO) partially covers vision services, offering one routine eye exam per year with a $25 copay and no coinsurance, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and a $350 combined annual maximum benefit for contact lenses, eyeglasses, and frames.
Dental Services See details
Dental services are partially covered by Complete Blue PPO Distinct (PPO) up to a $2,500 annual maximum, with a $25 copay and no coinsurance for Medicare dental services, no copay and no coinsurance for preventive care, and no copay with 10% coinsurance (0% to 10% for adjunctive services) for comprehensive care. Orthodontics, implants, maxillofacial prosthetics, other diagnostic dental, and other preventive dental services are not covered.
Home Infusion bundled Services See details
Complete Blue PPO Distinct (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs require no coinsurance to 20% coinsurance, while Part B insulin drugs have a $35 copay and no coinsurance 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 copay, though prior authorization is required for these services. Coinsurance ranges from no coinsurance to 50% for durable medical equipment, is 20% for prosthetics and medical supplies, and ranges from no coinsurance to 20% for diabetic equipment from specified manufacturers.
Diagnostic and Radiological Services See details
Complete Blue PPO Distinct (PPO) covers diagnostic and radiological services with no coinsurance, subject to prior authorization. Outpatient lab services have no copay, diagnostic tests range from a $0 to $10 copay, outpatient x-rays cost $15, and diagnostic and therapeutic radiological services require minimum copays of $200 and $60, respectively.
Home Health Services See details
Home Health Services are covered by Complete Blue PPO Distinct (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Complete Blue PPO Distinct (PPO) with no copay and no coinsurance. Although some services are covered, 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) stays with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100 per stay, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by Complete Blue PPO Distinct (PPO), providing over-the-counter (OTC) items and chronic illness meal benefits with no copay and no coinsurance. Acupuncture is not covered under this benefit.
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