Go Back

BlueAdvantage Prime (PPO)

H7917 - 042 - 0

(4.5 / 5)

BlueAdvantage Prime (PPO) is a Medicare Advantage Plan by BlueCross BlueShield of Tennessee.

This page features plan details for 2025 BlueAdvantage Prime (PPO) H7917 – 042 – 0 available in West and Middle TN.

Locations

BlueAdvantage Prime (PPO) is offered in the following locations.

Bedford County, Tennessee

Benton County, Tennessee

Carroll County, Tennessee

Click to see more locations

Plan Overview

BlueAdvantage Prime (PPO) offers the following coverage and cost-sharing.

Insurer:	BlueCross BlueShield of Tennessee
Health Plan Deductible:	$0
MOOP:	$0 In and Out-of-network $0 In-network
Drugs Covered:	Yes

Ready to sign up for BlueAdvantage Prime (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

BlueAdvantage Prime (PPO) has a monthly premium of $206.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.

Part B	Part C	Part D	Part B Give Back	Total
$185.00	$190.40	$15.60	$	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.
You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

BlueAdvantage Prime (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$0.00
Drug Out-Of-Pocket maximum:	$2,000.00
Drug Benefit Type:	Enhanced Alternative
Formulary Link:	Formulary Link

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part D	LIS Full
$15.60	$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$6.00 Copay		$6.00 Copay
2) Generic	$10.00 Copay	$15.00 Copay	$10.00 Copay	$15.00 Copay
3) Preferred Brand	$42.00 Copay	$47.00 Copay	$42.00 Copay	$47.00 Copay
4) Non-Preferred Drug	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance
5) Specialty Tier	33.00% Coinsurance	33.00% Coinsurance	33.00% Coinsurance	33.00% Coinsurance

60 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$12.00 Copay		$12.00 Copay
2) Generic	$10.00 Copay	$30.00 Copay	$10.00 Copay	$30.00 Copay
3) Preferred Brand	$84.00 Copay	$94.00 Copay	$84.00 Copay	$94.00 Copay
4) Non-Preferred Drug	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance
5) Specialty Tier

90 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic		$15.00 Copay		$15.00 Copay
2) Generic	$10.00 Copay	$35.00 Copay	$10.00 Copay	$35.00 Copay
3) Preferred Brand	$105.00 Copay	$135.00 Copay	$105.00 Copay	$135.00 Copay
4) Non-Preferred Drug	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance	50.00% Coinsurance
5) Specialty Tier

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

BlueAdvantage Prime (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

- In-Network: No

Diagnostic procedures/lab services/imaging

Outpatient x-rays
- Out-of-Network: $0 copay (Authorization Required)
Diagnostic tests and procedures
- In-Network: $0 copay (Authorization Required)
- Out-of-Network: $0 copay (Authorization Required)
Lab services
- Out-of-Network: $0 copay (Authorization Required)
Diagnostic radiology services (e.g., MRI)
- In-Network: $0 copay (Authorization Required)
- Out-of-Network: $0 copay (Authorization Required)
Lab services
- In-Network: $0 copay (Authorization Required)
Outpatient x-rays
- In-Network: $0 copay (Authorization Required)

Doctor visits

Primary
- Out-of-Network: $0 copay
Specialist
- Out-of-Network: $0 copay
Primary
- In-Network: $0 copay
Specialist
- In-Network: $0 copay

Emergency care/Urgent care

Emergency
- $0 copay
Urgent care
- $0 copay

Foot care (podiatry services)

Routine foot care
- Not covered
Foot exams and treatment
- In-Network: $0 copay
- Out-of-Network: $0 copay

Ground ambulance

- In-Network: $0 copay
- Out-of-Network: $0 copay

Health plan deductible

- $0

Hearing

Hearing aids OTC
- Not covered
Hearing aids
- In-Network: $199-699 copay (Limits Apply)
- Out-of-Network: $199-699 copay (Limits Apply)
Medicare-Covered Hearing Exam
- Out-of-Network: $0 copay
Fitting/evaluation
- Out-of-Network: $0 copay
- In-Network: $0 copay
Medicare-Covered Hearing Exam
- In-Network: $0 copay

Inpatient hospital coverage

- Out-of-Network: $0 copay (Authorization Required)
- In-Network: $0 copay (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

- $0 In and Out-of-network
  $0 In-network

Medical equipment/supplies

Diabetes supplies
- In-Network: $0 copay (Authorization Required)
Durable medical equipment (e.g., wheelchairs, oxygen)
- In-Network: $0 copay (Authorization Required)
- Out-of-Network: $0 copay (Authorization Required)
Prosthetics (e.g., braces, artificial limbs)
- In-Network: $0 copay (Authorization Required)
- Out-of-Network: $0 copay (Authorization Required)
Diabetes supplies
- Out-of-Network: $0 copay (Authorization Required)

Medicare Part B drugs

Chemotherapy
- Out-of-Network: $0 copay (Authorization Required)
Other Part B drugs
- Out-of-Network: $0 copay (Authorization Required)
Chemotherapy
- In-Network: $0 copay (Authorization Required)
Other Part B drugs
- In-Network: $0 copay (Authorization Required)

Mental health services

Inpatient hospital – psychiatric
- In-Network: $0 copay (Authorization Required)
Outpatient group therapy visit with a psychiatrist
- In-Network: $0 copay (Authorization Required)
- Out-of-Network: $0 copay (Authorization Required)
Inpatient hospital – psychiatric
- Out-of-Network: $0 copay (Authorization Required)
Outpatient group therapy visit
- In-Network: $0 copay (Authorization Required)
- Out-of-Network: $0 copay (Authorization Required)
Outpatient individual therapy visit
- Out-of-Network: $0 copay (Authorization Required)
Outpatient individual therapy visit with a psychiatrist
- In-Network: $0 copay (Authorization Required)
Outpatient individual therapy visit
- In-Network: $0 copay (Authorization Required)
Outpatient individual therapy visit with a psychiatrist
- Out-of-Network: $0 copay (Authorization Required)

Optional supplemental benefits

- Yes

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- In-Network: $0 copay (Authorization Required)
- Out-of-Network: $0 copay (Authorization Required)

Preventive care

- Out-of-Network: $0 copay
- In-Network: $0 copay

Rehabilitation services

Physical therapy and speech and language therapy visit
- In-Network: $0 copay (Authorization Required)
Occupational therapy visit
- Out-of-Network: $0 copay (Authorization Required)
- In-Network: $0 copay (Authorization Required)
Physical therapy and speech and language therapy visit
- Out-of-Network: $0 copay (Authorization Required)

Skilled Nursing Facility

- Out-of-Network: $0 copay (Authorization Required)
- In-Network: $0 copay (Authorization Required)

Transportation

- Not covered

Vision

Eyeglass lenses
- Not covered
Eyeglasses (frames and lenses)
- Not covered
Upgrades
- Not covered
Eyeglass frames
- Not covered
Routine eye exam
- Not covered
Contact lenses
- Not covered
Other
- Not covered

Wellness programs (e.g., fitness, nursing hotline)

- Covered

Dental and Vision

Comprehensive Dental

Restorative Services, Endodontics, Periodontics, Prosthodontics, removable, Implant Services, Prosthodontics, fixed, Oral and Maxillofacial Surgery
- Monthly Premium: $39.00
- Max Coverage: $1000.00
- Coverage Periodicity: Every year

Diagnostic and Preventive Dental

Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment, Other Preventive Dental Services
- Monthly Premium: $39.00
- Max Coverage: $1000.00
- Coverage Periodicity: Every year

Eye Exams

Routine Eye Exams
- Monthly Premium: $39.00
- Max Coverage: $1000.00
- Coverage Periodicity: Every year

Eyewear

Contact Lenses, Eyeglasses (lenses and frames)
- Monthly Premium: $39.00
- Max Coverage: $1000.00
- Coverage Periodicity: Every year