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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 North and South WV 15 Counties. 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 $54.00. 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) plan features an annual drug deductible of $615 before coverage begins. For Tier 1 preferred generics and Tier 2 generics, you will pay no copay when using a preferred pharmacy or preferred mail order service. If you choose a standard pharmacy or standard mail order instead, Tier 1 drugs require a $7 copay for a 1-month supply, while Tier 2 drugs carry a $15 copay. For brand-name and specialty medications, costs transition from copays to coinsurance percentages. Tier 3 preferred brands require a 20% coinsurance across all pharmacy types, while Tier 4 non-preferred drugs and Tier 5 specialty drugs incur a 25% coinsurance. This structure helps you estimate out-of-pocket costs for prescription drugs based on your specific tier needs and pharmacy preferences.
Additional Benefits
The Complete Blue PPO Distinct (PPO) plan offers robust medical coverage with predictable out-of-pocket costs, featuring no copay and no coinsurance for primary care visits and preventive services. For inpatient hospital stays, members pay a $250 daily copay for the first five days and no copay thereafter, while outpatient hospital services require a $325 copay. Emergency room visits carry a $130 copay, which is waived if admitted, and urgent care is available with a $50 copay. In addition to core medical care, this plan provides valuable supplemental benefits including dental coverage up to a $2,000 annual limit, featuring no copay for preventive dental services. Members also benefit from a $350 annual eyewear allowance with no copay, routine hearing exams for a $25 copay, and unlimited one-way transportation to approved health locations with no copay or coinsurance. Additional perks include home health services with no copay and a $50 quarterly over-the-counter item allowance.
Inpatient Hospital See details
Complete Blue PPO Distinct (PPO) covers inpatient acute hospital stays with no coinsurance and a $250 daily copay for days 1 through 5, followed by no copay for unlimited additional days. Inpatient psychiatric hospital stays are also covered with no coinsurance and a $425 daily copay for days 1 through 3, followed by no copay for days 4 through 90, though upgrades, additional psychiatric days, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Complete Blue PPO Distinct (PPO) covers outpatient services with no coinsurance, requiring a $325 copay for outpatient hospital and observation services and a $275 copay for ambulatory surgical center services. Outpatient substance abuse sessions have a $40 copay with no coinsurance, while outpatient blood services are 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 $535 copay and no coinsurance, subject to prior authorization. Transportation services are partially covered, offering unlimited one-way 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
Complete Blue PPO Distinct (PPO) covers emergency services with a $130 copay (waived if admitted within three days) and urgently needed services with a $50 copay, both with no coinsurance. Worldwide emergency and urgent services are also covered with no coinsurance, featuring a $130 copay for emergency care, a $50 copay for urgent care, and a $535 copay for emergency transportation.
Primary Care See details
Complete Blue PPO Distinct (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits, physical therapy, occupational therapy, and mental health services require a $40 copay and no coinsurance. Chiropractic care is partially covered with a $15 copay and no coinsurance for routine care, though other chiropractic services are not covered.
Preventive Services See details
Preventive Services are partially covered by Complete Blue PPO Distinct (PPO), offering annual physicals, kidney disease education, and Medicare preventive services with no copay and no coinsurance, remote access technologies with a $0 to $40 copay, and safety devices with 20% coinsurance. Sub-services that are not covered include health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, additional tobacco cessation counseling, telemonitoring, and counseling services.
Hearing Services See details
Hearing services are partially covered by Complete Blue PPO Distinct (PPO), offering no coinsurance and no deductible for covered benefits. Routine hearing exams require a $25 copay (limited to one per year), and prescription hearing aids carry a copay of $699 to $999 with a $500 annual coverage limit. Fitting and evaluation exams, OTC hearing aids, and inner ear, outer ear, or over-the-ear prescription devices are not covered.
Vision Services See details
Complete Blue PPO Distinct (PPO) provides partially covered vision services, which include one routine eye exam per year for a $40 copay and no coinsurance, though other eye exam services are not covered. Eyewear, including contacts, lenses, and frames, is covered with no copay and no coinsurance up to a combined maximum of $350 annually.
Dental Services See details
Complete Blue PPO Distinct (PPO) provides partially covered dental services up to a $2,000 annual maximum for both in-network and out-of-network care. Medicare-covered dental has a $40 copay and no coinsurance, while preventive services have no copay and no coinsurance, and covered comprehensive services have no copay and 50% coinsurance (0% to 50% for adjunctive services). Other diagnostic services, other preventive services, maxillofacial prosthetics, implants, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered under the Complete Blue PPO Distinct (PPO) plan with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs carry a coinsurance ranging from no coinsurance to 20%, while Part B insulin is covered with a $35 copay and a coinsurance ranging from no coinsurance to 20%.
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, though prior authorization is required. Durable medical equipment requires no coinsurance to 50% coinsurance, diabetic supplies require no coinsurance to 20% coinsurance, and prosthetics, medical supplies, and diabetic therapeutic shoes or inserts require 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. Diagnostic procedures and tests have a copay ranging from $0 to $10, lab services have no copay, and outpatient X-rays require a $15 copay. Diagnostic radiological services carry a minimum copay of $200, while therapeutic radiological services have a minimum copay of $60.
Home Health Services See details
Home Health Services are covered under 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) covers some Cardiac Rehabilitation Services with no copay and no coinsurance, although 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, offering no copay for days 1 through 20 and a $218 copay for days 21 through 100. Prior authorization is required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Complete Blue PPO Distinct (PPO) partially covers other services, offering Over-the-Counter (OTC) items up to $50 every three months and meals for chronic illnesses with no copay and no coinsurance. Acupuncture is not covered under this benefit.
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