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Complete Blue PPO Merit (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Complete Blue PPO Merit (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 Merit (PPO) in 2026, please refer to our full plan details page.
Complete Blue PPO Merit (PPO) is a PPO plan offered by Highmark Health available for enrollment in 2026 to people living in North and South WV 41 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 Merit (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 Merit (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 Merit (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $96.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $200.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
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 $13000.00 (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 $13000.00 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 Merit (PPO) Medicare plan features an annual prescription drug deductible of $615. For Tier 1 preferred generic drugs, you will pay no copay at preferred pharmacies or through preferred mail order, compared to a $7 copay for a one-month supply at standard pharmacies. Tier 2 generic medications cost a low $3 copay for a one-month supply at preferred pharmacies, while standard pharmacies charge a $20 copay. For brand-name and specialty medications, costs shift from flat copays to coinsurance. Tier 3 preferred brand drugs 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. Choosing preferred network pharmacies and mail-order options can help you minimize your out-of-pocket prescription costs under this plan.
Additional Benefits
The Complete Blue PPO Merit (PPO) plan offers robust medical coverage with no copay or coinsurance for primary care visits, home health services, and preventive care. For specialist visits, members pay a $50 copay, while inpatient hospital stays require a $455 daily copay for the first five days and no copay for days six and beyond. Emergency room visits have a $115 copay, which is waived if admitted, and urgent care is available with a $40 copay. Routine dental cleanings and exams feature no copay or coinsurance up to a $1,000 annual limit, while comprehensive dental services require 50% coinsurance and no copay. Vision benefits include a $50 copay for routine eye exams and up to $350 annually for eyewear with no copay, and hearing exams are covered with a $40 copay. Additionally, the plan covers unlimited transportation to approved health-related locations with no copay and no coinsurance.
Inpatient Hospital See details
Complete Blue PPO Merit (PPO) covers inpatient acute hospital stays with no coinsurance and a $455 daily copay for days 1-5, with no copay for days 6 and beyond. Inpatient psychiatric stays are covered with no coinsurance and a $645 daily copay for days 1-3, then no copay for days 4-90, though upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Complete Blue PPO Merit (PPO) covers outpatient hospital and observation services with a $375 copay and no coinsurance, and ambulatory surgical center services with a $325 copay and no coinsurance. Outpatient substance abuse sessions have a $40 copay and no coinsurance, while outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Complete Blue PPO Merit (PPO) covers partial hospitalization benefits with a $60.00 copay and no coinsurance.
Ambulance and Transportation Services See details
Complete Blue PPO Merit (PPO) covers ambulance services with a $370 copay and no coinsurance for both ground and air transport. Transportation services are partially covered, offering unlimited rides to plan-approved health-related locations with no copay and no coinsurance, though transportation to any health-related location is not covered.
Emergency Services See details
Complete Blue PPO Merit (PPO) covers emergency services with a $115 copay and no coinsurance, with the copay waived if you are admitted to the hospital within three days. Urgently needed services are covered with a $40 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with no coinsurance and copays of $115, $40, and $370 respectively.
Primary Care See details
Complete Blue PPO Merit (PPO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $50 copay and no coinsurance. Other services like therapy, mental health, and podiatry require copays ranging from $25 to $50 and no coinsurance, while chiropractic care is only partially covered since other chiropractic services are not covered.
Preventive Services See details
Complete Blue PPO Merit (PPO) offers partially covered preventive services, featuring Medicare-covered preventive care, annual physical exams, and kidney disease education with no copay and no coinsurance. While memory fitness, remote access technologies ($0 to $50 copay), and home safety devices (20% coinsurance) are included, services like health education, personal emergency response systems, nutritional counseling, and alternative therapies are not covered.
Hearing Services See details
Hearing services are partially covered by Complete Blue PPO Merit (PPO), offering one annual routine hearing exam for a $40 copay and no coinsurance, and prescription hearing aids with copays ranging from $699 to $999 and no coinsurance up to a $500 annual maximum. Fitting and evaluation exams, OTC hearing aids, and inner, outer, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Complete Blue PPO Merit (PPO) covers one routine eye exam per year with a $50 copay, no coinsurance, and no deductible, though other eye exam services are not covered. Eyewear, including contacts, frames, lenses, and upgrades, is covered with no copay, no coinsurance, and no deductible up to a combined maximum benefit of $350 annually.
Dental Services See details
Complete Blue PPO Merit (PPO) partially covers dental services, offering Medicare-covered dental for a $50 copay and no coinsurance, and preventive care like cleanings and exams with no copay or coinsurance up to a $1,000 annual limit. Covered comprehensive services—including restorative, endodontics, periodontics, prosthodontics, and oral surgery—require no copay and 50% coinsurance (0% to 50% for adjunctive services), but implants, orthodontics, maxillofacial prosthetics, other diagnostic, and other preventive services are not covered.
Home Infusion bundled Services See details
Complete Blue PPO Merit (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Under this plan, Medicare Part B chemotherapy, radiation, and other drugs have 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
Dialysis services are covered by Complete Blue PPO Merit (PPO) with no copay and a 20% coinsurance.
Medical Equipment See details
Complete Blue PPO Merit (PPO) covers medical equipment, including durable medical equipment, prosthetics, and diabetic equipment, with no copay and a 20% coinsurance for most items. Prior authorization is required for these services, and diabetic supplies range from no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Complete Blue PPO Merit (PPO) with no coinsurance, though prior authorization is required. There is no copay for lab services, while diagnostic procedures cost up to $10, X-rays cost $75, therapeutic radiology has a minimum $60 copay, and diagnostic radiology has a minimum $300 copay.
Home Health Services See details
Complete Blue PPO Merit (PPO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Complete Blue PPO Merit (PPO) plan, including intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services.
Skilled Nursing Facility (SNF) See details
Complete Blue PPO Merit (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring 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 the standard Medicare-covered limit are not covered.
Other Services See details
Other Services, including acupuncture, over-the-counter (OTC) items, and meal benefits, are not covered under the Complete Blue PPO Merit (PPO) plan.
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