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Complete Blue PPO Distinct (PPO)

4.5 out of 5 stars* for plan year 2024
$27.00 Monthly Premium

Complete Blue PPO Distinct (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Highmark Health

Plan ID: H3916-035-001

$27.00 Monthly Premium

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 visitIn-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 transportationIn-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 monitoringIn-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-raysIn-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 careIn-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 careIn-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 careIn-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 itemsIn-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 servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $10.00
Copayment for Routine Foot Care $10.00
  • Maximum 4 visits every year
Skilled Nursing Facility (SNF) careIn-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 benefitsIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $10.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

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 benefitsIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $10.00
Copayment for Routine Hearing Exams $10.00
  • Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00
  • Maximum 2 Hearing Aids every year
Maximum Plan Benefit of $500.00 every year both ears combined for in and out of network services combined
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 programsIn-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

    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.

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