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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 Southeast 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 $147.00. 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 prescription drug plan features an annual drug deductible of $250. For Tier 1 preferred generic drugs, members pay no copay when using a preferred pharmacy or preferred mail order service, while standard pharmacies charge a copay starting at $6 for a one-month supply. Tier 2 generic drugs are also highly affordable, requiring a low $5 copay at preferred pharmacies and preferred mail order, compared to a $10 one-month copay at standard pharmacies. Tier 3 preferred brand drugs require a $28 copay for a one-month supply at preferred pharmacies and preferred mail order, or $33 at standard locations. For higher-tier prescriptions, Tier 4 non-preferred drugs carry a 50% coinsurance, while Tier 5 specialty drugs require a 30% coinsurance across all pharmacy options for a one-month supply.
Additional Benefits
The BlueAdvantage Diamond (PPO) plan offers strong coverage with no copay and no coinsurance for primary care visits, home health services, and covered preventive care. For hospital care, members pay a $65 daily copay for the first four days of inpatient stays and no copay for days five through ninety. Outpatient hospital services, emergency care, and specialist visits are also covered with flat copayments and no coinsurance. In addition to medical care, this plan features dental coverage up to a $3,500 annual limit and routine vision care with no copay or deductible. Members also benefit from routine hearing exams and affordable hearing aid copays, along with an over-the-counter item allowance of up to $156 every three months. Medical equipment and dialysis services are covered with no copay and a standard 20% coinsurance.
Inpatient Hospital See details
BlueAdvantage Diamond (PPO) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $65 daily copay for days 1 through 4 and no copay for days 5 through 90. Prior authorization is required, and while unlimited additional acute days are covered, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
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 require a $20 copay for individual sessions and a $10 copay for group sessions with no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
BlueAdvantage Diamond (PPO) covers partial hospitalization services with a $35.00 copay and no coinsurance. Prior authorization is required to receive this covered benefit.
Ambulance and Transportation Services See details
BlueAdvantage Diamond (PPO) covers emergency ambulance services with a $175 copay for ground transport and a 20% coinsurance for air transport, both of which require prior authorization. Additional transportation services to health-related locations are not covered under this plan.
Emergency Services See details
BlueAdvantage Diamond (PPO) covers emergency services with a $150 copay and urgently needed services with a $25 copay, both featuring no coinsurance and no deductible, with 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 therapy services have a $10 copay and no coinsurance, but podiatry is not covered, and chiropractic care is only partially covered with routine services excluded.
Preventive Services See details
Preventive services are partially covered by BlueAdvantage Diamond (PPO) with no copay and no coinsurance for covered care, including annual physical exams and kidney disease education. Sub-services that are not covered under this plan include health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs for chemotherapy-related hair loss, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, additional smoking cessation counseling, telemonitoring, home and bathroom safety devices, and counseling services.
Hearing Services See details
Hearing services are partially covered by BlueAdvantage Diamond (PPO), which offers one routine hearing exam per year for a $10 copay and no coinsurance, alongside unlimited fitting evaluations. Up to two prescription hearing aids are covered annually with a copay ranging from $99.00 to $599.00 and no coinsurance, though inner ear, outer ear, over the ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
BlueAdvantage Diamond (PPO) covers vision services with no copay, no coinsurance, and no deductible, including one routine eye exam annually and a $300 combined maximum every two years for contact lenses or eyeglasses (lenses and frames). This benefit is partially covered, as other eye exam services, individual eyeglass lenses, individual eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services are partially covered by BlueAdvantage Diamond (PPO), offering preventive and select comprehensive care with no copay and either no coinsurance or 20% coinsurance, up to a $3,500 annual limit. Medicare-covered dental services require a $20 copay and no coinsurance, but adjunctive general services, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
BlueAdvantage Diamond (PPO) covers Home Infusion bundled Services with no copay, though prior authorization and step therapy are required. Associated Medicare Part B chemotherapy, radiation, and other drugs carry a 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the BlueAdvantage Diamond (PPO) plan with no copay and a 20% coinsurance, subject to prior authorization.
Medical Equipment See details
Medical equipment benefits under BlueAdvantage Diamond (PPO) include durable medical equipment (DME) and prosthetics covered with no copay and a 20% coinsurance. Diabetic supplies are covered with no copay and 0% to 50% coinsurance, while diabetic therapeutic shoes and inserts require a $10 copay and applicable coinsurance.
Diagnostic and Radiological Services See details
BlueAdvantage Diamond (PPO) covers diagnostic and radiological services with prior authorization required. Diagnostic procedures have a copay of $0 to $100 and no coinsurance, while lab services have no copay and a minimum 20% coinsurance. Radiological services feature no coinsurance, with outpatient X-rays having no copay, therapeutic services requiring a minimum $30 copay, and diagnostic radiological services requiring a minimum $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
BlueAdvantage Diamond (PPO) covers some cardiac rehabilitation services with no copay, no coinsurance, and prior authorization required. However, standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by BlueAdvantage Diamond (PPO) with no coinsurance, featuring no copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, but the plan does not require a prior three-day hospital stay, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by BlueAdvantage Diamond (PPO), excluding acupuncture. Covered benefits include chronic illness meal support and over-the-counter (OTC) items up to $156 every three months, both featuring no copay and no coinsurance.
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