BlueAdvantage Diamond (PPO) - 2021

H7917-010-000 - BlueCross BlueShield of Tennessee - Local PPO

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

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