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BlueAdvantage Diamond (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for BlueAdvantage Diamond (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on BlueAdvantage Diamond (PPO) in 2026, please refer to our full plan details page.
BlueAdvantage Diamond (PPO) is a PPO plan offered by BlueCross BlueShield of Tennessee available for enrollment in 2025 to people living in Middle and West Tennessee. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that BlueAdvantage Diamond (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about BlueAdvantage Diamond (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For BlueAdvantage Diamond (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $157.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $250.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $5750.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $5750.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The BlueAdvantage Diamond (PPO) Medicare plan features an annual prescription drug deductible of $250. For Tier 1 preferred generic drugs, you will pay no copay when using preferred pharmacies or preferred mail-order services, while standard pharmacies charge a $6 copay for a one-month supply. Tier 2 generic medications cost a flat $5 copay at preferred pharmacies for a one-, two-, or three-month supply, compared to a $10 one-month copay at standard pharmacies. Tier 3 preferred brand drugs carry a $28 copay for a one-month supply through preferred channels and a $33 copay at standard pharmacies. Higher-tier prescriptions require coinsurance, with Tier 4 non-preferred drugs requiring 50% coinsurance and Tier 5 specialty drugs requiring 30% coinsurance for a one-month supply. Utilizing preferred pharmacies and mail-order options under this BlueAdvantage Diamond PPO plan is the most cost-effective way to manage your prescription expenses.
Additional Benefits
The BlueAdvantage Diamond (PPO) plan offers comprehensive medical coverage with no copay for primary care visits and preventive services, while specialist visits require a low $20 copay. For hospital care, inpatient stays feature a $75 daily copay for the first four days followed by no copay, and outpatient hospital services carry a $175 copay. Emergency care is covered with a $150 copay, which is waived if you are admitted to the hospital within 24 hours. This plan also includes valuable extra benefits, such as dental coverage up to a $3,500 annual limit with no copay for preventive care, and a $300 eyewear allowance every two years. Additionally, members receive a $131 quarterly allowance for over-the-counter items with no copay, and hearing aid coverage with copays ranging from $99 to $599. Skilled nursing facility stays and home health services are also covered, offering no copays for initial care periods.
Inpatient Hospital See details
BlueAdvantage Diamond (PPO) covers inpatient hospital services with no coinsurance, requiring a $75 daily copay for days 1 through 4 and no copay for days 5 through 90 per stay. This partially covered benefit requires prior authorization and does not cover upgrades, non-Medicare-covered stays, or additional days for psychiatric admissions.
Outpatient Services See details
BlueAdvantage Diamond (PPO) covers outpatient services with no coinsurance, featuring a $175 copay for outpatient hospital services, a $150 copay per stay for observation services, and a $125 copay for ambulatory surgical center services. Outpatient substance abuse services also have no coinsurance with copays ranging from $10 to $20, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial Hospitalization benefits are covered by BlueAdvantage Diamond (PPO) with a $35.00 copay and no coinsurance. Prior authorization is required to receive these services.
Ambulance and Transportation Services See details
BlueAdvantage Diamond (PPO) covers ground ambulance services with a $175 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, with prior authorization required for both. Routine transportation services to health-related locations are not covered.
Emergency Services See details
BlueAdvantage Diamond (PPO) covers emergency services with a $150 copay and no coinsurance, and urgently needed services with a $25 copay and no coinsurance, with both copays waived if admitted to the hospital within 24 hours. Worldwide emergency and urgent care are covered with a $60 copay and no coinsurance, while worldwide emergency transportation requires a $175 copay and 20% coinsurance.
Primary Care See details
BlueAdvantage Diamond (PPO) provides primary care and telehealth services with no copay and no coinsurance, while specialist visits require a $20 copay and no coinsurance. Physical, occupational, and speech therapies have a $10 copay and no coinsurance, but podiatry and chiropractic services are not covered.
Preventive Services See details
BlueAdvantage Diamond (PPO) offers preventive services, including annual physical exams, kidney disease education, and diabetes self-management training, with no copay and no coinsurance. Additional preventive services are partially covered with no copay and no coinsurance, offering benefits like memory fitness and remote access technologies while excluding services such as health education, nutritional therapy, and personal emergency response systems.
Hearing Services See details
Hearing services are covered by BlueAdvantage Diamond (PPO), featuring a $10 copay and no coinsurance for an annual routine exam and unlimited fitting evaluations. Prescription hearing aids are partially covered with a $99 to $599 copay and no coinsurance for up to two aids per year, though OTC hearing aids and inner ear, outer ear, and over the ear prescription aids are not covered.
Vision Services See details
BlueAdvantage Diamond (PPO) partially covers vision services with no copay, no coinsurance, and no deductible, providing one routine eye exam per year and a $300 combined eyewear allowance every two years. Covered eyewear includes one pair of contact lenses or eyeglasses every two years, while other eye exam services, separate eyeglass lenses or frames, and upgrades are not covered.
Dental Services See details
BlueAdvantage Diamond (PPO) partially covers dental services up to a $3,500 annual limit, with no copay and no coinsurance for preventive care, diagnostics, endodontics, and periodontics. Medicare-covered dental requires a $20 copay and no coinsurance, while restorative services, prosthodontics, and oral surgery have no copay and 20% coinsurance. Adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered under the BlueAdvantage Diamond (PPO) with no copay, though prior authorization is required. Covered Medicare Part B drugs, including chemotherapy, radiation, and insulin, are subject to a $35 copay for insulin and a coinsurance ranging from no coinsurance up to 20%.
Dialysis Services See details
Dialysis Services are covered under the BlueAdvantage Diamond (PPO) with no copay and a 20% coinsurance, and prior authorization is required.
Medical Equipment See details
BlueAdvantage Diamond (PPO) covers durable medical equipment and prosthetics with no copay and 20% coinsurance. Diabetic supplies are covered with 0% to 50% coinsurance, and diabetic therapeutic shoes or inserts require a $10 copay.
Diagnostic and Radiological Services See details
BlueAdvantage Diamond (PPO) covers diagnostic and radiological services, requiring prior authorization for both categories. Diagnostic procedures have a $0 to $100 copay along with coinsurance, and lab services require a 20% coinsurance with no copay. Radiological services feature no coinsurance, with outpatient X-rays having no copay, therapeutic radiology starting at a $30 copay, and diagnostic radiology starting at a $175 copay.
Home Health Services See details
BlueAdvantage Diamond (PPO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by BlueAdvantage Diamond (PPO) with no copay and no coinsurance, though some services are covered while standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered. Prior authorization is required for covered rehabilitation services.
Skilled Nursing Facility (SNF) See details
BlueAdvantage Diamond (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, though prior authorization is required. There is no copay for days 1 through 20, a $218 copay for days 21 through 100, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by BlueAdvantage Diamond (PPO), which offers a meal benefit for chronic illnesses and up to $131 every three months for over-the-counter (OTC) items with no copay and no coinsurance. Acupuncture and other additional services are not covered.
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