Complete Blue PPO Distinct (PPO)
Complete Blue PPO Distinct (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health
Plan ID: H3916-035-001
Pennsylvania Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Pennsylvania Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $27.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $5,500.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $8,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 |
| Specialty doctor visit | Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $10.00 |
| Inpatient hospital care | Out-of-Network: Copayment for Acute Hospital Services per Stay $225.00 |
| Urgent care | Urgent Care: Copayment for Urgent Care $30.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $30.00 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $100.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days Worldwide Coverage: Copayment for Worldwide Emergency Coverage $100.00 Copayment for Worldwide Emergency Transportation $275.00 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $275.00 Air Ambulance: Copayment for Air Ambulance Services $275.00 Non-emergent transport is only covered when Certified Medically Necessary. The copayment is applicable per one way trip. Please see Evidence of Coverage for Prior Authorization rules |
Health Care Services and Medical Supplies
Complete Blue PPO Distinct (PPO) covers a range of additional benefits. Learn more about Complete Blue PPO Distinct (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | Out-of-Network: Chiropractic Services: Copayment for Medicare Covered Chiropractic Services $15.00 Chiropractic Services: Copayment for Non-Medicare Covered Chiropractic Services $15.00 |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Coinsurance for Medicare-covered Diabetic Supplies 0% to 20% Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) |
| Durable medical equipment (DME) | Out-of-Network: Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 30% |
| Diagnostic tests, lab and radiology services, and X-rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $175.00 Copayment for Medicare-covered Therapeutic Radiological Services $50.00 Copayment for Medicare-covered X-Ray Services $20.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | Out-of-Network: $475.00 per day for days 1 to 3 $0.00 per day for days 4 to 90 |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 Prior Authorization Required for Outpatient Mental Health Services |
| Outpatient services/surgery | Out-of-Network: Outpatient Hospital and ASC Services: Copayment for Medicare Covered Outpatient Hospital Services $200.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $175.00 |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $45.00 Copayment for Medicare-covered Group Sessions $45.00 Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Maximum Plan Benefit of $200.00 every three months Out-of-Network: Over-The-Counter (OTC) Items: Maximum Plan Benefit of $200.00 every three months |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $10.00 Copayment for Routine Foot Care $10.00
|
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $203.00 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care |
In Network: Preventive Dental Copayment for Office Visit $0.00 including: Oral Exams · Maximum 1 visit every six months Prophylaxis (Cleaning) · Maximum 1 visit every six months Dental X-Rays · Maximum 1 visit every year Fluoride Treatment · Maximum 1 visit every six months Comprehensive Dental: Coinsurance for Non-Medicare Covered Comprehensive Dental 10% including: Medicare-covered Benefits Non-routine Services Diagnostic Services Restorative Services · Maximum 1 visit every two years Endodontics · Maximum 1 visit every year Periodontics · Maximum 1 visit every year Extractions · Maximum 1 visit every year Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services · Maximum 1 visit Maximum Plan Benefit of $3000.00 every year for in and out of network services combined for Preventive and Non-Medicare Covered Comprehensive combined Prior Authorization Required for Comprehensive Dental Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $10.00 Non-Medicare Covered Dental Services: Coinsurance for Non-Medicare Covered Preventive Dental 30% Coinsurance for Non-Medicare Covered Comprehensive Dental 50% |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Vision benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $10.00 Copayment for Routine Eye Exams $0.00
Eyewear: Standard Eyeglass lenses and frames or contact lenses are covered in full. $150 benefit maximum applies to non-standard frames or specialty contact lenses. Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $10.00 Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eye Exams $50.00 Standard Eyeglass lenses and frames or contact lenses are covered in full. $150 benefit maximum applies to non-standard frames or specialty contact lenses. |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $10.00 Copayment for Routine Hearing Exams $10.00
Hearing Aids: Copayment for Hearing Aids $699.00 to $999.00
You must see a TruHearing provider to use this benefit. Up to two TruHearing hearing aids every year (one per ear per year). Benefit is limited to the TruHearing Advanced ($699) and Premium ($999) hearing aids, which come in various styles and colors, and are available in rechargeable style options. 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 Members have a $500 maximum allowance towards hearing aids that are not the TruHearing Advanced or Premium models. Out-of-Network: Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $10.00 Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $10.00 |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| 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:
Yearly "Wellness" visit |
When reviewing Pennsylvania Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Pennsylvania that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Pennsylvania Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.
