BlueAdvantage Diamond (PPO) is a Medicare Advantage plan with drug coverage provided by BlueCross BlueShield of Tennessee.
The drug plan portion of this plan provides Enhanced Alternative (EA) benefits, which are benefits that exceed the required standard.
Check out the premium and drug details below for more information, or reach out to a licensed Medicare agent for help using the call number on this page. Alternatively, if you know what plan you want, you can enroll online yourself using our site as well.
Plan Basics
Contract Year |
2021 |
Medicare Type |
Medicare Advantage Plan (Part C) |
CMS Plan ID |
H7917-010-000 |
Plan Organization |
BlueCross BlueShield of Tennessee |
Plan Type |
Local PPO |
Plan Name |
BlueAdvantage Diamond (PPO) |
Plan Organization Type |
Local CCP |
Drugs Covered |
Yes |
Doctors Choice |
Any Doctor |
Benefit Type |
Enhanced Alternative |
Special Needs Plan |
No |
Overall Star Rating |
4 |
Plan Cost Sharing
Premium |
$217.00 |
Total Premium (Includes Part B) |
$352.50 |
Monthly Part C Premium |
$164.60 |
Monthly Part D Basic Premium |
$52.40 |
Monthly Part D Supplemental Premium |
$0.00 |
Monthly Part D Total Premium |
$52.40 |
Monthly Part D Premium Full Assistance |
$22.20 |
Monthly Part D Premium 75% Assistance |
$29.70 |
Monthly Part D Premium 50% Assistance |
$37.30 |
Monthly Part D Premium 25% Assistance |
$44.80 |
Part D Drug Deductible |
$0.00 |
Part D Initial Coverage Limit |
$4130.00 |
Part D Catastrophic Coverage Threshold |
$6550.00 |
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) |
$3700.00 |
Gap Coverage |
Yes |
Medicare Advantage Plan Health Benefits
Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
In-Network |
- |
- |
No |
Comprehensive Dental
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Diagnostic services |
Yes |
Out-of-Network |
No |
No |
50% coinsurance |
Endodontics |
Yes |
Out-of-Network |
No |
No |
50% coinsurance |
Extractions |
Yes |
Out-of-Network |
No |
No |
50% coinsurance |
Non-routine services |
Yes |
Out-of-Network |
No |
No |
50% coinsurance |
Periodontics |
Yes |
Out-of-Network |
No |
No |
50% coinsurance |
Prosthodontics, other oral/maxillofacial surgery, other services |
Yes |
Out-of-Network |
No |
No |
50% coinsurance |
Restorative services |
Yes |
Out-of-Network |
No |
No |
50% coinsurance |
Diagnostic Procedures/lab Services/imaging
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Diagnostic radiology services (e.g., MRI) |
- |
Out-of-Network |
Yes |
No |
50% coinsurance |
Diagnostic tests and procedures |
- |
Out-of-Network |
Yes |
No |
50% coinsurance |
Lab services |
- |
Out-of-Network |
Yes |
No |
50% coinsurance |
Outpatient x-rays |
- |
Out-of-Network |
Yes |
No |
50% coinsurance |
Doctor Visits
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Primary |
- |
Out-of-Network |
- |
- |
50% coinsurance per visit |
Specialist |
- |
Out-of-Network |
No |
No |
50% coinsurance per visit |
Emergency Care/Urgent Care
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Emergency |
- |
- |
- |
- |
$60 copay per visit (always covered) |
Urgent care |
- |
- |
- |
- |
$55 copay per visit (always covered) |
Foot Care (podiatry Services)
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Foot exams and treatment |
- |
Out-of-Network |
No |
No |
50% coinsurance |
Routine foot care |
- |
- |
- |
- |
Not covered |
Ground Ambulance
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
- |
- |
$150 copay |
Health Plan Deductible
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
- |
- |
$0 |
Hearing
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Fitting/evaluation |
Yes |
Out-of-Network |
No |
No |
$0 copay |
Hearing aids |
Yes |
Out-of-Network |
No |
No |
$299-599 copay |
Hearing exam |
- |
Out-of-Network |
No |
No |
$10 copay |
Inpatient Hospital Coverage
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
Yes |
No |
50% per stay |
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
- |
- |
$10,000 In and Out-of-network$3,700 In-network |
Medical Equipment/supplies
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Diabetes supplies |
- |
Out-of-Network |
Yes |
- |
50% coinsurance per item |
Durable medical equipment (e.g., wheelchairs, oxygen) |
- |
Out-of-Network |
Yes |
- |
50% coinsurance per item |
Prosthetics (e.g., braces, artificial limbs) |
- |
Out-of-Network |
Yes |
- |
50% coinsurance per item |
Medicare Part B Drugs
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Chemotherapy |
- |
Out-of-Network |
Yes |
- |
50% coinsurance |
Other Part B drugs |
- |
Out-of-Network |
Yes |
- |
50% coinsurance |
Mental Health Services
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Inpatient hospital - psychiatric |
- |
Out-of-Network |
Yes |
No |
50% per stay |
Outpatient group therapy visit |
- |
Out-of-Network |
Yes |
No |
50% coinsurance |
Outpatient group therapy visit with a psychiatrist |
- |
Out-of-Network |
Yes |
No |
50% coinsurance |
Outpatient individual therapy visit |
- |
Out-of-Network |
Yes |
No |
50% coinsurance |
Outpatient individual therapy visit with a psychiatrist |
- |
Out-of-Network |
Yes |
No |
50% coinsurance |
Optional Supplemental Benefits
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
- |
- |
No |
Other Health Plan Deductibles?
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
In-Network |
- |
- |
No |
Outpatient Hospital Coverage
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
Yes |
No |
50% coinsurance per visit |
Preventive Care
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
No |
No |
50% coinsurance |
Preventive Dental
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Cleaning |
Yes |
Out-of-Network |
No |
No |
50% coinsurance |
Dental x-ray(s) |
Yes |
Out-of-Network |
No |
No |
50% coinsurance |
Fluoride treatment |
No |
- |
- |
- |
Not covered |
Oral exam |
Yes |
Out-of-Network |
No |
No |
50% coinsurance |
Rehabilitation Services
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Occupational therapy visit |
- |
Out-of-Network |
Yes |
No |
50% coinsurance |
Physical therapy and speech and language therapy visit |
- |
Out-of-Network |
Yes |
No |
50% coinsurance |
Skilled Nursing Facility
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
Yes |
No |
50% per stay |
Transportation
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
- |
- |
Not covered |
Vision
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Contact lenses |
Yes |
Out-of-Network |
No |
No |
$0 copay |
Eyeglass frames |
No |
- |
- |
- |
Not covered |
Eyeglass lenses |
No |
- |
- |
- |
Not covered |
Eyeglasses (frames and lenses) |
Yes |
Out-of-Network |
No |
No |
$0 copay |
Other |
No |
- |
- |
- |
Not covered |
Routine eye exam |
Yes |
Out-of-Network |
No |
No |
$20 copay |
Upgrades |
- |
- |
- |
- |
Not covered |
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
No |
No |
Covered |
Official Medicare Contact
Medicare Phone |
1-800-MEDICARE (1-800-633-4227) |
Medicare TTY User |
1-877-486-2048 |
Plan Available in these Counties
Anderson County, Tennessee,
Bledsoe County, Tennessee,
Blount County, Tennessee,
Bradley County, Tennessee,
Campbell County, Tennessee,
Cannon County, Tennessee,
Claiborne County, Tennessee,
Clay County, Tennessee,
Cocke County, Tennessee,
Cumberland County, Tennessee,
Dekalb County, Tennessee,
Fentress County, Tennessee,
Franklin County, Tennessee,
Grainger County, Tennessee,
Grundy County, Tennessee,
Hamblen County, Tennessee,
Hamilton County, Tennessee,
Jackson County, Tennessee,
Jefferson County, Tennessee,
Knox County, Tennessee,
Loudon County, Tennessee,
Macon County, Tennessee,
Marion County, Tennessee,
Mcminn County, Tennessee,
Meigs County, Tennessee,
Monroe County, Tennessee,
Morgan County, Tennessee,
Overton County, Tennessee,
Pickett County, Tennessee,
Polk County, Tennessee,
Putnam County, Tennessee,
Rhea County, Tennessee,
Roane County, Tennessee,
Scott County, Tennessee,
Sequatchie County, Tennessee,
Sevier County, Tennessee,
Smith County, Tennessee,
Union County, Tennessee,
Van Buren County, Tennessee,
Warren County, Tennessee,
White County, Tennessee
NOTE: Information on MedicarePolicyHelper.com is for educational purposes only. We are not affiliated with Medicare, or CMS. Medicare has not reviewed or endorsed the information on our site. All plan data on our site comes directly from medicare.gov and is subject to change.