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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 Delaware. This plan received an overall rating of 4 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 $105.00. 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 $8950.00 (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 $8950.00 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 prescription drug deductible of $615. For Tier 1 preferred generic drugs, you will pay no copay for a 1-month or 3-month supply at preferred pharmacies, while standard pharmacies charge a $7 copay for a 1-month supply. Tier 2 generic drugs cost a $3 copay for a 1-month supply at preferred pharmacies, compared to a $20 copay at standard pharmacies. Higher-tier medications under this plan require 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 carry a 25% coinsurance. Utilizing preferred pharmacies and preferred mail-order services provides the lowest out-of-pocket costs for your prescription drugs.
Additional Benefits
Complete Blue PPO Distinct (PPO) offers comprehensive medical coverage featuring no copay for primary care doctor visits and a $40 copay for specialists, with no coinsurance for either. For hospital care, inpatient acute stays require a $325 daily copay for days one through five and no copay for subsequent days, while emergency room visits carry a $130 copay. Outpatient hospital services and ambulance transportation are also covered with copays of $325 and $320, respectively, and no coinsurance. Preventive care, routine dental, and home health services are fully covered with no copay and no coinsurance under this plan. Routine vision and hearing exams each require a $40 copay with no coinsurance or deductibles, supplemented by a $350 annual eyewear allowance and prescription hearing aid coverage. Additionally, members pay no copay for diagnostic lab services, home infusions, or cardiac rehabilitation.
Inpatient Hospital See details
Inpatient hospital care is partially covered by Complete Blue PPO Distinct (PPO) with no coinsurance, requiring prior authorization. Acute stays require a $325 daily copay for days 1 to 5 and no copay for days 6 and beyond, while psychiatric stays require a $425 daily copay for days 1 to 3 and no copay for days 4 to 90. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Complete Blue PPO Distinct (PPO) covers outpatient hospital and observation services with a $325 copay and no coinsurance, and ambulatory surgical center services with a $275 copay and no coinsurance. Outpatient substance abuse sessions require a $30 copay with no coinsurance, while outpatient blood services are covered with no copay or coinsurance.
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 Medicare-covered ground and air ambulance services with a $320 copay and no coinsurance, subject to prior authorization. Routine transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Complete Blue PPO Distinct (PPO) covers emergency services with a $130 copay, which is waived if admitted to the hospital within 3 days, and urgently needed services with a $50 copay, both with no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance and copays of $130, $50, and $320, respectively.
Primary Care See details
Complete Blue PPO Distinct (PPO) features primary care doctor visits with no copay and no coinsurance, while specialist visits require a $40 copay and no coinsurance. Other covered services, such as physical therapy, mental health, and telehealth, have copays ranging from $0 to $50 with no coinsurance, though chiropractic care is only partially covered since other chiropractic services are excluded.
Preventive Services See details
Complete Blue PPO Distinct (PPO) preventive services are partially covered, featuring annual physicals, kidney disease education, and other screenings with no copay and no coinsurance. Covered supplemental benefits include memory fitness with no copay and no coinsurance, remote access technologies with a $0 to $40 copay and no coinsurance, and safety devices with 20% coinsurance and no copay. However, 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/dietary benefits, palliative care, in-home support, caregiver support, smoking cessation, telemonitoring, and counseling are not covered.
Hearing Services See details
Hearing services are partially covered by Complete Blue PPO Distinct (PPO), which offers annual routine hearing exams with a $40 copay, no coinsurance, and no deductible. Prescription hearing aids are covered with a $699 to $999 copay and no coinsurance up to a $500 annual limit, though fitting evaluations, OTC hearing aids, and inner, outer, or over-the-ear prescription hearing aids are not covered.
Vision Services See details
Complete Blue PPO Distinct (PPO) partially covers vision services, offering one routine eye exam per year with a $40 copay, no coinsurance, and no deductible, while other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, providing a $350 combined annual maximum for contacts, lenses, frames, and upgrades.
Dental Services See details
Complete Blue PPO Distinct (PPO) dental services are partially covered, featuring preventive care with no copay and no coinsurance, and comprehensive services with no copay and 50% coinsurance (0% to 50% for adjunctive) up to a $1,000 annual limit. Medicare-covered dental requires a $40 copay and no coinsurance, while implants, orthodontics, maxillofacial prosthetics, other diagnostic, and other preventive services 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 drugs, including chemotherapy and insulin, carry a coinsurance of 0% (no coinsurance) up to 20%, with insulin also requiring a $35 copay.
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 carries no coinsurance up to 50% coinsurance, while diabetic equipment, prosthetics, and medical supplies require up to 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. Members pay no copay for lab services, $0 to $10 for diagnostic tests, a $10 copay for outpatient x-rays, and minimum copays of $60 for therapeutic and $275 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
Cardiac Rehabilitation Services are offered by Complete Blue PPO Distinct (PPO) with no copay and no coinsurance. While some services are covered, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Complete Blue PPO Distinct (PPO) 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, 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), which features a meal benefit for chronic illnesses with no copay and no coinsurance. Acupuncture and over-the-counter items are not covered under this benefit.
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