A special rarely given grade of the medal, known as the Presidential Medal of Freedom with Distinction, has a larger execution of the same medal design worn as a star on the left chest along with a sash over the right shoulder (similar to how the insignia of a Grand Cross is worn), with its rosette (blue with white edge, bearing the central disc of the medal at its center) resting on the left hip. When the medal With Distinction is awarded, the star may be presented descending from a neck ribbon and can be identified by its larger size than the standard medal (compare the size of medals in pictures below).