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Complete Blue PPO Distinct (PPO)
The Centers for Medicare & Medicaid Services (CMS) publishes annual Star Ratings that reflect how each Medicare Advantage plan performs across a range of metrics, using a system of one to five stars.
$23.00
Monthly Premium
Complete Blue PPO Distinct (PPO) is a PPO plan offered by Highmark Health
Plan ID: H3916-035
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.
Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.
Learn more about Medicare Advantage plans such as Complete Blue PPO Distinct (PPO) - H3916-035 by Highmark Health as well as other Medicare Advantage plans available in your area.
$23.00
Monthly Premium
Pennsylvania Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $615 |
| Out of Pocket Max |
In-Network: $6500 Out-of-Network: 9550 |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $2100 |
| Primary Care Doctor Visit | Out-of-Network: Doctor Office Visit Services: Coinsurance for Medicare Covered Primary Care Office Visit $40% |
| Specialty Doctor Visit | Out-of-Network: Doctor Specialty Visit Services: Coinsurance for Medicare Covered Physician Specialist Office Visit $40% |
| Inpatient Hospital Care | Out-of-Network: Acute Hospital Services: $275 per day for days 1 to 3 $0 per day for days 4 to 90 Private accommodations will be covered when medically necessary. Inpatient rehabilitation is subject to the same cost sharing as Inpatient Acute Hospital Care. |
| Urgent Care | Urgent Care: Copayment for Urgent Care $40 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $40 |
| Emergency Room Visit | Emergency Care: Copayment for Emergency Care $130 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $130 Copayment for Worldwide Emergency Transportation $260 |
| Ambulance Transportation | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $260 Coinsurance for Medicare Covered Ambulance Services - Ground $30% Copayment for Medicare Covered Ambulance Services - Air $260 Coinsurance for Medicare Covered Ambulance Services - Air $30% Non-emergent transport is only covered when Certified Medically Necessary. The copayment is applicable per one way trip. |
Health Care Services and Medical Supplies
Complete Blue PPO Distinct (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 40% In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Copayment for Routine Care $15
Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 40% In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Copayment for Routine Care $15
|
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: |
| Durable Medical Equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 50% Prior Authorization Required for Durable Medical Equipment The minimum coinsurance applies to compression stockings and the maximum coinsurance applies to Oxygen, Ventilators, Wheelchairs and Wheelchair Accessories, all other DME items will have an intermediate coinsurance applied. |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $10 Copayment for Medicare-covered Lab Services $0 to $10 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services The minimum copayment applies for Medicare-covered diagnostic procedures/tests and lab services provided at free standing labs. The maximum copayment applies for Medicare-covered diagnostic procedures/tests and lab services at all other places of service. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $175 Copayment for Medicare-covered Therapeutic Radiological Services $50 Copayment for Medicare-covered X-Ray Services $20 |
| Home Health Care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| Mental Health Inpatient Care | Out-of-Network: Psychiatric Hospital Services: $475 per day for days 1 to 3 $0 per day for days 4 to 90 Private accommodations will be covered when medically necessary. Inpatient substance abuse is subject to the same cost sharing as Inpatient Psychiatric Hospital. |
| Mental Health Outpatient Care | Out-of-Network: Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
| Outpatient Services / Surgery | Out-of-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $250 Copayment for Medicare Covered Ambulatory Surgical Center Services $225 Copayment applies per visit/per day/per provider for outpatient surgical services. Same day visits to the same provider for the same procedure receives one copayment. |
| Outpatient Substance Abuse Care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $45 Copayment for Medicare-covered Group Sessions $45 Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $45 Copayment for Medicare-covered Group Sessions $45 Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
| Over-the-counter (OTC) Items | Out-of-Network: Over-The-Counter (OTC) Items Services: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0 Maximum Plan Benefit of $95 An OTC catalog of CMS-approved non-prescription over-the-counter medications and health-related items is available. Quantity limits and plan restrictions may apply. |
| Podiatry Services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $25 Copayment for Routine Foot Care $25
Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 40% Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 40% In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $25 Copayment for Routine Foot Care $25
|
| Skilled Nursing Facility Care | Coinsurance for Skilled Nursing Facility Services 30% |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | Out-of-Network: Preventive Dental Services: Coinsurance for Medicare Covered Preventive Dental 40% |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | Out-of-Network: Eye Exams Services: Coinsurance for Medicare Covered Eye Exams 40% Copayment for Medicare Covered Eyewear $0 |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $25 Copayment for Routine Hearing Exams $10
Hearing Aids: Copayment for Hearing Aids $699 to $999
Members must use our contracted provider to use this benefit. Up to two hearing aids every year (one per ear per year). Benefit is limited to the Advanced (minimum cost sharing) and Premium (maximum cost sharing) hearing aids, which come in various styles and colors, and are available in rechargeable style options at no additional charge.Hearing aid purchase includes:- First year of follow-up provider visits- 60-day trial period- 3-year extended warranty- 80 batteries per aid for non-rechargeable modelsBenefit does not include or cover any of the following: • Additional cost for optional hearing aid rechargeability • Ear molds • Hearing aid accessories • Additional provider visits • Additional batteries - batteries when a rechargeable hearing aid is purchased • Hearing aids that are not TruHearing-branded hearing aids • Costs associated with loss & damage warranty claims Costs associated with excluded items are the responsibility of the member and not covered by the plan.Services not covered under any condition:Hearing aids and provider visits to service hearing aids (except as specifically described in the Covered Benefits), ear molds, hearing aid accessories, warranty claim fees, and hearing aid batteries (beyond the 80 free batteries per non-rechargeable aid purchased).Members have a $500 maximum allowance towards hearing aids that are not the Advanced or Premium models. |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | Out-of-Network: Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
Prescription Drug Costs and Coverage
The Complete Blue PPO Distinct (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $615 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $615 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $615 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $615 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|