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BlueAdvantage Ruby (PPO)

H7917 - 013 - 0
4.5 out of 5 stars (4.5 / 5)

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

This page features plan details for 2025 BlueAdvantage Ruby (PPO) H7917 – 013 – 0 available in Middle Tennessee.

Locations

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

Bedford County, Tennessee
Cheatham County, Tennessee
Coffee County, Tennessee

Click to see more locations

Plan Overview

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

Insurer:BlueCross BlueShield of Tennessee
Health Plan Deductible:$0
MOOP:$5,750 In and Out-of-network
$4,150 In-network
Drugs Covered:Yes

Ready to sign up for BlueAdvantage Ruby (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 Ruby (PPO) has a monthly premium of $107.00. 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 $100.20 $6.80 $ $
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 Ruby (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 DLIS Full
$6.80$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.

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 Ruby (PPO) also provides the following benefits.

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

    • In-Network: No

Comprehensive Dental

  • Endodontics
    • In-Network: No Coins – No Co pay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Implant Services
    • In-Network: No Coins – No Co pay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Oral and Maxillofacial Surgery
    • In-Network: No Coins – No Co pay (Limits Apply, Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply, Authorization Required)
  • Periodontics
    • In-Network: No Coins – No Co pay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Prosthodontics, fixed
    • In-Network: No Coins – No Co pay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Prosthodontics, removable
    • In-Network: No Coins – No Co pay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Restorative Services
    • In-Network: No Coins – No Co pay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay
    • Out-of-Network: 50% Coins – No Copay
  • Fluoride Treatment
    • In-Network: No Coins – No Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Oral Exams
    • In-Network: No Coins – No Copay
    • Out-of-Network: 50% Coins – No Copay
  • Other Diagnostic Dental Services
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Other Preventive Dental Services
    • In-Network: No Coins – No Copay (Limits Apply)
    • Out-of-Network: 50% Coins – No Copay (Limits Apply)
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay
    • Out-of-Network: 50% Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Outpatient x-rays
    • In-Network: $0-50 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $200 copay (Authorization Required)
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0-100 copay (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: $10-30 copay or 50% coinsurance (Authorization Required)
  • Diagnostic tests and procedures
    • Out-of-Network: $10-30 copay or 50% coinsurance (Authorization Required)
  • Lab services
    • In-Network: $0-40 copay or 20% coinsurance (Authorization Required)
    • Out-of-Network: $10-30 copay or 50% coinsurance (Authorization Required)

Doctor visits

  • Primary
    • In-Network: $0 copay
    • Out-of-Network: $10 copay per visit
  • Specialist
    • Out-of-Network: $30 copay per visit
    • In-Network: $25 copay per visit

Emergency care/Urgent care

  • Emergency
    • $140 copay per visit (always covered)
  • Urgent care
    • $25 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • In-Network: $25 copay
    • Out-of-Network: 50% coinsurance
  • Routine foot care
    • Not covered

Ground ambulance

    • Out-of-Network: $175 copay
    • In-Network: $175 copay

Health plan deductible

    • $0

Hearing

  • Medicare-Covered Hearing Exam
    • Out-of-Network: $10 copay
  • Fitting/evaluation
    • Out-of-Network: $0 copay
  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • In-Network: $10 copay
  • Fitting/evaluation
    • In-Network: $0 copay
  • Hearing aids
    • In-Network: $199-699 copay (Limits Apply)
    • Out-of-Network: $199-699 copay (Limits Apply)

Inpatient hospital coverage

    • In-Network: $205 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)
    • Out-of-Network: $255 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)

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

    • $5,750 In and Out-of-network
      $4,150 In-network

Medical equipment/supplies

  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • In-Network: 0-20% coinsurance per item (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 50% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • Out-of-Network: 50% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 50% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)

Mental health services

  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Outpatient individual therapy visit
    • In-Network: $30 copay (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $20 copay (Authorization Required)
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Outpatient individual therapy visit
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Inpatient hospital – psychiatric
    • Out-of-Network: $255 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $20 copay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $30 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • In-Network: $205 per day for days 1 through 4
      $0 per day for days 5 through 90 (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: 50% coinsurance (Authorization Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • Out-of-Network: $275 copay per visit (Authorization Required)
    • In-Network: $225 copay per visit (Authorization Required)

Preventive care

    • Out-of-Network: 50% coinsurance
    • In-Network: $0 copay

Rehabilitation services

  • Physical therapy and speech and language therapy visit
    • In-Network: $15 copay (Authorization Required)
  • Occupational therapy visit
    • Out-of-Network: 50% coinsurance (Authorization Required)
    • In-Network: $15 copay (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • Out-of-Network: 50% coinsurance (Authorization Required)

Skilled Nursing Facility

    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 100 (Authorization Required)
    • Out-of-Network: 50% per stay (Authorization Required)

Transportation

    • Not covered

Vision

  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • Not covered
  • Eyeglasses (frames and lenses)
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
  • Other
    • Not covered
  • Routine eye exam
    • Out-of-Network: $0 copay (Limits Apply)
  • Upgrades
    • Not covered
  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • Not covered

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

    • Covered

Ready to sign up for BlueAdvantage Ruby (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

Need more information on BlueAdvantage Ruby (PPO)? See 2025 BlueAdvantage Ruby (PPO) at MedicareAdvantageRX.com.

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Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint

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All plan-related information on this site is from CMS.gov and Medicare.gov. We only use data released publicly each year. While our goal is always to provide fact-based, accurate information, information is subject to change, and some data may be inaccurate. Contact a plan for a Summary of Benefits.

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We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

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