Complete Blue PPO Distinct (PPO)

3.5 out of 5 stars
$24.00
Monthly Premium

Complete Blue PPO Distinct (PPO) is a PPO plan offered by Highmark Health

Plan ID: H5106-029

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) - H5106-029 by Highmark Health as well as other Medicare Advantage plans available in your area.

$24.00
Monthly Premium

West Virginia Counties Served

BerkeleyCabellClayFayetteFrederickMarshallOhioWayne

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $615
Out of Pocket Max In-Network: $6750
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
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $25
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$195 per day for days 1 to 3
$0 per day for days 4 to 90
Prior Authorization Required for Acute Hospital Services
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 $270
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $270
Non-emergent transport is only covered when Certified Medically Necessary. The copayment is applicable per one way trip.

Air Ambulance:
Copayment for Air Ambulance Services $270
Prior Authorization Required for Air Ambulance
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
  • Maximum 8 Routine Care every year
Prior Authorization Required for Chiropractic Services
Diabetes Supplies, Training, Nutrition Therapy and Monitoring


Out-of-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 40%
Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 40%
Glucometers, test strips, lancets, control solution, replacement batteries, platforms, lens shield, and non-invasive vagus nerve stimulator are supplied at the minimum coinsurance. All other Medicare covered Diabetic Supplies at the maximum coinsurance.Diabetic glucometer, test strip, and lancet brands dispensed via retail or mail order pharmacy are limited to Abbott and Trividia. Continuous glucose monitors, sensors and transmitters dispensed via retail or mail order pharmacy are limited to Abbott and Dexcom. All other desired brands will need to be obtained via an exception process or from a Durable Medical Equipment (DME) supplier.
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


Out-of-Network:

Diagnostic Procedures/Tests Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40%
Coinsurance for Medicare Covered Lab Services 40%
Coinsurance for Medicare Covered Diagnostic Radiological Services 40%
Coinsurance for Medicare Covered Therapeutic Radiological Services 40%
Coinsurance for Medicare Covered Outpatient X-Ray Services 40%
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:
$500 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
In-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $40
Copayment for Medicare-covered Group Sessions $40
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $300
Prior Authorization Required for Outpatient Hospital Services
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 Observation Services:
Copayment for Medicare Covered Observation Services - Per day $300
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.

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $225
Prior Authorization Required for Ambulatory Surgical Center Services
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

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 $40
Copayment 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 $40 every three months
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
  • Maximum 10 visits every year

Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 40%
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$218 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Private accommodations will be covered when medically necessary.

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care


Out-of-Network:

Preventive Dental Services:
Coinsurance for Covered Routine Dental 30%

Comprehensive Dental Services:

Coinsurance for Covered Comprehensive Dental services 50%

Please see Evidence of Coverage for details

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%

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 $25

  • Maximum 1 visit every year


Hearing Aids:
Copayment for Hearing Aids $699 to $999

  • Maximum 2 Hearing Aids every year

Maximum Plan Benefit of $500 every year for any other hearing aid.
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 models Benefit 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).

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
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
Tobacco use cessation
Yearly "Wellness" visit

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
  • Preferred cost-share mail order N/A
  • Standard retail $7.00
  • Standard mail order N/A
  • Preferred cost-share retail $0.00
Generic
  • Preferred cost-share mail order N/A
  • Standard retail $15.00
  • Standard mail order N/A
  • Preferred cost-share retail $0.00
Annual Drug Deductible $615 (excludes Tiers 1 and 2)
Preferred Generic
  • Preferred cost-share mail order N/A
  • Standard retail N/A
  • Standard mail order N/A
  • Preferred cost-share retail N/A
Generic
  • Preferred cost-share mail order N/A
  • Standard retail N/A
  • Standard mail order N/A
  • Preferred cost-share retail N/A
Annual Drug Deductible $615 (excludes Tiers 1 and 2)
Preferred Generic
  • Preferred cost-share mail order $0.00
  • Standard retail $21.00
  • Standard mail order $21.00
  • Preferred cost-share retail $0.00
Generic
  • Preferred cost-share mail order $0.00
  • Standard retail $45.00
  • Standard mail order $45.00
  • Preferred cost-share retail $0.00
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