Complete Blue PPO Distinct (PPO) 2025 Plan Details for Washington County, Pennsylvania Residents
Complete Blue PPO Distinct (PPO) 2025 Plan Details for Washington County, Pennsylvania Residents
Navigating your Medicare Advantage options in Washington County for 2025 can be overwhelming, but we're here to help. With Complete Blue PPO Distinct (PPO) included in your plan options, you can evaluate it alongside other plans to make an informed decision. Enroll online quickly, or consult with a licensed agent if you need assistance.
Based on May, 2025 CMS enrollment data, an estimated 49,633 Medicare beneficiaries are enrolled in this plan, with 3,763 members in Washington County, PA.
Complete Blue PPO Distinct Overview
| Plan ID H3916-035-1 Overview | |
|---|---|
| Health Plan ID: | H3916-035-1 |
| Medicare Advantage Plan Type: | PPO |
| Plan Year: | 2025 |
| Monthly Premium: | $12.00 Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Annual Out-of-Pocket Maximum: | $5,500.00 (In-Network) |
| Part B Give Back: | $0.00/mo |
| Part D Drug Plan Benefit: | Enhanced, $0.00 deductible |
| Additional Benefits: | Dental, Vision, Hearing |
| Availability: | Washington County, PA |
| Insured By: | Highmark Blue Cross Blue Shield or Highmark Blue Shield |
Why Choose Complete Blue PPO Distinct ?
This Medicare Advantage MAPD PPO plan combines hospital, medical, and prescription drug coverage with the flexibility to see providers in or out of the plan’s network. With a monthly premium of $12.00, Complete Blue PPO Distinct includes all the core benefits of Medicare Part A and Part B, plus built-in drug coverage to help manage your prescriptions. The annual Part D deductible is $0.00.
Primary care visits have a not covered, while seeing a specialist comes with a $10 copay. Urgent care services carry a $30 copay, and ground ambulance transportation is $260 copay. These costs apply toward the plan’s annual maximum out-of-pocket (MOOP) limit of $5,500.00 — and once that’s reached, all in-network services are fully covered for the rest of the year.
This plan is registered with CMS under ID H3916-035-1. Below, you’ll find a summary of cost sharing for key services. Still have questions? Check the FAQ section for more details.
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Out-of-Pocket Expenses
Complete Blue PPO Distinct has cost-sharing, meaning you'll have out-of-pocket costs when using approved healthcare services. The table below details the most common in-network out-of-pocket expenses for plan H3916-035-1.
Find out the costs for visiting your primary care doctor and specialists, as well as coverage for wellness and preventive programs.
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | Not Covered |
| Specialist: | $10 Copay |
Review the costs for emergency services, urgent care, ambulance services, inpatient hospital stays, and skilled nursing facility care.
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $125 Copay |
| Urgent care: | $30 Copay |
| Ground ambulance: | $260 Copay |
| Inpatient hospital care: | $275.00 per stay |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $214.00 per day for days 21 and beyond |
This section covers Medicare-approved foot care services, including exams and routine foot care.
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | $10 Copay |
| Routine Foot Care: | $10 Copay |
Understand the coverage for Medicare-approved chiropractic services and routine chiropractic care.
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | $15 Copay Prior Authorization Required |
| Routine chiropractic: | Not Covered |
This section explains the costs for mental health services, including individual and group therapy, and inpatient care.
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | $40 Copay |
| Outpatient group therapy: | $40 Copay |
| Inpatient psychiatric hospital care: | $425.00 per day for days 1 through 3 $0.00 per day for days 4 and beyond |
See the cost details for rehabilitation services, including physical therapy, speech therapy, and occupational therapy.
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | $5 Copay Prior Authorization Required |
| Occupational therapy: | $30 Copay Prior Authorization Required |
Learn about the costs associated with medical equipment and supplies, including diabetes supplies, durable medical equipment, and prosthetics.
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | 20% Coinsurance Prior Authorization Required |
| Durable medical equipment: | 20% Coinsurance Prior Authorization Required |
| Prosthetics: | 20% Coinsurance |
This section outlines the costs for diagnostic services, lab tests, x-rays, and other imaging services.
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | $175 Copay Prior Authorization Required |
| Lab services: | Not Covered |
| Outpatient x-rays: | $20 Copay Prior Authorization Required |
| Diagnostic tests and procedures: | Not Covered |
Review the cost-sharing details for chemotherapy and other Medicare Part B-covered drugs.
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered): | 20% Coinsurance |
This section details the dental services covered under your plan including, Medicare-covered preventive dental, oral exams, x-rays, dental cleanings, and comprehensive dental.
| Service | Member Cost (in-network) |
|---|---|
| Medicare Covered Preventive Dental | $10 Copay |
| Oral exam | $0 |
| Dental x-rays | $0 |
| Cleaning | $0 |
| Periodontics | Not Covered |
| Endodontics | Not Covered |
| Restorative Services | Not Covered |
This section outlines the coverage for hearing-related services, including exams, fittings, and hearing aids.
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Covered Limits may apply |
| Hearing exam | Not Covered |
Learn about the costs for vision-related services, including eye exams, eyeglasses, and contact lenses.
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam (in-network) | $10 Copay |
| Routine eye exam (in-network) | Covered Limits may apply |
| Eyewear benefits | Eyeglasses: Yes Contact Lenses: Yes Eyeglass Lenses: Yes Eyeglass Frames: Yes Eyewear Upgrades: Yes |
Maximum eyewear benefit: | $400.00 Every year |
Certain preventive services are covered 100% by Complete Blue PPO Distinct as a Part B benefit.
Part D Prescription Drug Costs & Benefits
Complete Blue PPO Distinct includes an enhanced benefit Medicare Part D plan (PDP), which offers greater coverage than basic plans. An enhanced benefit plan has a higher actuarial value, meaning it covers a larger percentage of your healthcare costs.
Part D Plan Premium
The Part D prescription drug plan premium is included in your overall Medicare Advantage plan cost. However, additional expenses or subsidies may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help. LIS, provided by Social Security, helps those with limited income and resources to lower or eliminate Part D costs. LIS benefits are not part of Medicare Advantage coverage.
| Basic Part D Premium: | $6.70 |
|---|---|
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $6.70 |
| Low-Income Premium Subsidy: | ${part_d_lips_amount} |
| Low-Income Premium Subsidy Paid by CMS: | $6.70 |
| Low-Income Subsidy Premium: | $0.00 |
For more details, visit the Social Security Extra Help program.
Prescription Drug Plan Deductible
This plan has a $0.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Highmark Blue Cross Blue Shield or Highmark Blue Shield starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, Complete Blue PPO Distinct may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 | $0.00 |
| Generic | $0.00 | $0.00 |
| Preferred Brand | 25.00% | 0.00% |
| Non-Preferred Drug | 50.00% | 0.00% |
| Specialty Tier | 33.00% | 33.00% |
| *Deductible does not apply. | ||
Understanding CMS Star Ratings
The Centers for Medicare & Medicaid Services (CMS) reviews and rates Medicare Advantage (Part C) and drug plans (Part D) annually, using a 5-star system to measure aspects such as member satisfaction, preventive services, and management of chronic conditions.
Higher star ratings generally indicate better plan performance, which can be a useful factor to consider when deciding on a plan that aligns with your healthcare goals and preferences.
| CMS Measure | Star Rating |
|---|---|
| 2025 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
If you are new to Medicare or Medicare Advantage plans, the following information will help you understand the enrollment process and restrictions.
Am I Eligible for Complete Blue PPO Distinct ?
To enroll in Complete Blue PPO Distinct , you must meet the following criteria:
- Be eligible for Medicare Part A and Part B.
- Reside in the plan’s service area.
If you meet these requirements, you are eligible to enroll in Complete Blue PPO Distinct and benefit from its comprehensive coverage options.
Enrollment Periods for Complete Blue PPO Distinct
To ensure you don’t miss your chance to enroll in Complete Blue PPO Distinct , be aware of these important enrollment periods:
- Initial Enrollment Period (IEP): Your IEP offers a seven-month window around your 65th birthday to sign up for Medicare.
- Annual Enrollment Period (AEP): The AEP, occurring from October 15 to December 7 each year, allows you to enroll in or make changes to your Medicare Advantage plan if you are currently enrolled in a Medicare Advantage plan.
- Medicare Advantage Open Enrollment Period (MA OEP): From January 1 to March 31, the MA OEP provides an opportunity to switch Medicare Advantage plans or return to Original Medicare.
- Special Enrollment Periods (SEPs): Certain life changes, like moving or losing insurance coverage, may qualify you for a SEP, giving you a chance to make adjustments outside the standard periods.
Need help figuring out the right time to enroll? Call HealthCompare (our trusted enrollment partner) at 1-833-748-3201 (TTY 711) to get assistance from a licensed insurance agent.
How to Enroll in Complete Blue PPO Distinct
Joining Complete Blue PPO Distinct is straightforward. Here are the steps you can take:
- Online: Use our online enrollment partner's Secure Online Enrollment Form to sign up.
- By Phone: Reach out to HealthCompare (our trusted enrollment partner) at 1-833-748-3201 (TTY 711). A licensed insurance agent will help you with the enrollment process and answer any questions you might have.
- Through Medicare.gov: Enroll directly through the official Medicare website. Visit Medicare.gov, log in or create an account, and follow the steps to join Complete Blue PPO Distinct .
- Direct Enrollment: You can also choose to enroll directly with Complete Blue PPO Distinct . The contact information can be found below in the "Contact" section.
Make sure you enroll during the appropriate period to activate your coverage as soon as possible.
Here are some of the most frequently asked questions people have about plan ID H3916-035-1:
Is there a premium for this plan in 2025?
Members pay their Part B premium and the plan's of $12.00 per month to be in this 2025 plan.
How high can my costs go in a worst-case year?
The annual in-network MOOP is $5,500.00 , protecting you from larger bills once you hit that limit.
What’s the prescription-drug deductible for 2025?
Yes. The Part D deductible is $0.00. The plan does not have a drug tier without a deductible.
What’s the CMS star score for Complete Blue PPO Distinct ?
CMS rates it ★4.5 out of 5 stars for 2025.
Is Complete Blue PPO Distinct popular?
CMS reports 49,633 members in the latest file.
Contact Highmark Blue Cross Blue Shield or Highmark Blue Shield
| Website: | Highmark Blue Cross Blue Shield or Highmark Blue Shield Plan Page |
|---|---|
| Providers: | Highmark Blue Cross Blue Shield or Highmark Blue Shield Providers Page |
| Formulary: | Highmark Blue Cross Blue Shield or Highmark Blue Shield Formulary Page |
| Pharmacy: | Highmark Blue Cross Blue Shield or Highmark Blue Shield Pharmacy Page |
| New Member Health Plan Help: | (833)544-1060 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (833)544-1060 |
| New Member Part D TTY Users: | 711 |
If you're eligible for Medicare but haven't enrolled or need to verify your enrollment status, visit the Social Security Administration website. For more information about Medicare Advantage, visit medicare.gov.
- Highmark Blue Cross Blue Shield or Highmark Blue Shield, http://medicare.highmark.com, Last Accessed June 1, 2025
- CMS.gov, "Medicare Advantage Plan Fact Sheet", Last Accessed 25 May, 2025
- NCOA.org, "5 Steps to Choosing the Right Medicare Plan for You", Last Accessed 25 May, 2025
- Medicare.gov, "Compare Original Medicare & Medicare Advantage", Last Accessed 25 May, 2025
- CMS.gov, Landscape Source Files, Last Accessed October 15, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed October 15, 2024
- CMS.gov, Plan Benefits Package, Last Accessed October 15, 2024
- CMS.gov, Monthly Enrollment by Contract/Plan/State/County, Last Accessed June 6, 2025
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