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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 2025, 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 Northeast Tennessee. This plan received an overall rating of 4.5 out of 5 stars in 2025.
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 $89.00. 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 no drug deductible. Your prescription medication coverage will start immediately.
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) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay a copay for generic drugs, which ranges from $5 to $10 depending on the pharmacy. For brand-name and non-preferred drugs, you'll pay coinsurance of either 33% or 50%. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs. This plan offers an enhanced alternative drug benefit. If you qualify for the low-income subsidy (LIS), you may have reduced premium costs.
Additional Benefits
The BlueAdvantage Diamond (PPO) plan offers a range of benefits with varying costs. This plan includes coverage for inpatient and outpatient services, with copays ranging from $20 to $175, and coinsurance for some services. You'll also find coverage for primary care, preventive, hearing, vision, and dental services, along with medical equipment and home health services.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a copay of $125 for days 1-4, and no copay for days 5-90. Additional days for Inpatient Hospital-Acute are covered, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a $175 copay, Observation Services with a $150 copay, Ambulatory Surgical Center (ASC) Services with a $125 copay, Outpatient Substance Abuse Services with a $20 copay for individual sessions and a $10 copay for group sessions, and Outpatient Blood Services.
Partial Hospitalization See details
Partial Hospitalization is covered by the BlueAdvantage Diamond (PPO) plan, but requires prior authorization. You will have a $35 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground ambulance services have a $175 copay, while air ambulance services have a 20% coinsurance; transportation services to any health-related location are not covered.
Emergency Services See details
Emergency services are covered by the BlueAdvantage Diamond (PPO) plan, with a $140 copay, and urgently needed services have a $25 copay; both have no coinsurance. Worldwide emergency services are also covered, with a $60 copay for worldwide emergency and urgent coverage, and a 20% coinsurance and $175 copay for worldwide emergency transportation.
Primary Care See details
The BlueAdvantage Diamond (PPO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have a $20 copay, while individual mental health and psychiatric sessions have a $20 copay, and group sessions have a $10 copay.
Preventive Services See details
The BlueAdvantage Diamond (PPO) plan covers preventive services, including annual physical exams, health education, nutritional/dietary benefits, in-home support services, fitness benefits, enhanced disease management, telemonitoring services, remote access technologies, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit. Some services like In-Home Safety Assessment, Personal Emergency Response System, Medical Nutrition Therapy, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Home-Based Palliative Care, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
The BlueAdvantage Diamond (PPO) plan covers hearing exams with a $10 copay, as well as routine hearing exams and fitting/evaluation for hearing aids. Prescription hearing aids are covered with a copay between $99 and $599, while inner ear, outer ear, and over the ear prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision services include routine eye exams with no copay, and coverage for eyewear with a combined maximum of $250 every year. Contact lenses and eyeglasses (lenses and frames) are covered, each with a limit of one per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The BlueAdvantage Diamond (PPO) plan covers dental services, including oral exams with a $20 copay, dental x-rays, other diagnostic dental services, prophylaxis (cleaning) with a $20 copay, fluoride treatment, other preventative dental services, restorative services, endodontics, periodontics, prosthodontics (removable), implant services, prosthodontics (fixed), and oral and maxillofacial surgery; however, adjunctive general services, maxillofacial prosthetics, and orthodontics are not covered. The plan has a maximum benefit of $4,500 per year for both in-network and out-of-network services.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the BlueAdvantage Diamond (PPO) plan. Medicare Part B Insulin Drugs have a $35 copay and between 0-20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have between 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the BlueAdvantage Diamond (PPO) plan. You will pay 20% coinsurance for this benefit.
Medical Equipment See details
The BlueAdvantage Diamond (PPO) plan covers Durable Medical Equipment (DME) with a 15% coinsurance and requires prior authorization. Prosthetics and Medical Supplies are covered with a 15% coinsurance, while Diabetic Therapeutic Shoes/Inserts have a $10 copay, and Diabetic Supplies have a 0-20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for diagnostic procedures and tests with a copay between $0 and $100, lab services with no copay and a coinsurance of at most 20%, diagnostic radiological services with a copay of at most $175, therapeutic radiological services with a copay of at most $30, and outpatient X-ray services with no copay. Prior authorization is required for all diagnostic and radiological services.
Home Health Services See details
Home Health Services are covered by the BlueAdvantage Diamond (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the BlueAdvantage Diamond (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the BlueAdvantage Diamond (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The BlueAdvantage Diamond (PPO) plan covers Over-the-Counter (OTC) Items with a maximum benefit of $80 every three months, but does not cover Acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services. Meal Benefits are covered for a chronic illness.
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