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BlueAdvantage Sapphire (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for BlueAdvantage Sapphire (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on BlueAdvantage Sapphire (PPO) in 2025, please refer to our full plan details page.
BlueAdvantage Sapphire (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 Sapphire (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 Sapphire (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 Sapphire (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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 Sapphire (PPO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs have a $10 copay at a preferred pharmacy. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered Part D drugs. If you qualify for the low-income subsidy, your Part D costs will be $0.
Additional Benefits
The BlueAdvantage Sapphire (PPO) plan offers comprehensive coverage, including inpatient and outpatient hospital services, with varying copays depending on the specific service. Emergency and urgent care services are covered, both in the U.S. and worldwide, with set copays and coinsurance for transportation. The plan also includes coverage for primary care, preventive services, hearing, vision, and dental services with copays or coinsurance applying to most services. Additional benefits include ambulance services, partial hospitalization, home health, and skilled nursing facility care, all with specific copays or coinsurance. Diagnostic, radiological, and home infusion services are also covered, with copays or coinsurance applying. The plan offers an OTC benefit, with a $70 benefit every three months, and a meal benefit for chronic illness.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a copay of $215 for days 1-5 and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered stays and Upgrades for Inpatient Hospital-Acute are not covered, as are Additional Days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a $225 copay, Observation Services with a $200 copay, Ambulatory Surgical Center (ASC) Services with a $250 copay, and Outpatient Substance Abuse Services, including individual sessions with a $30 copay and group sessions with a $20 copay. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the BlueAdvantage Sapphire (PPO) plan, but requires prior authorization. You will have a $45 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the BlueAdvantage Sapphire (PPO) plan. Ground ambulance services have a $250 copay, while air ambulance services have a 20% coinsurance, and transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services are covered by the BlueAdvantage Sapphire (PPO) plan with a $140 copay, and Urgently Needed Services have a $25 copay. Worldwide Emergency Services include Worldwide Emergency Coverage with a $90 copay, Worldwide Urgent Coverage with a $90 copay, and Worldwide Emergency Transportation with a 20% coinsurance and a $250 copay.
Primary Care See details
The BlueAdvantage Sapphire (PPO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have a $20 copay, physician specialist services have a $30 copay, occupational therapy services have a $15 copay, physical therapy and speech-language pathology services have a $15 copay, and other services have varying copays. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The BlueAdvantage Sapphire (PPO) plan covers preventive services, including Medicare-covered services, annual physical exams, health education, nutritional/dietary benefits, fitness benefits, enhanced disease management, telemonitoring services, remote access technologies, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. However, in-home safety assessments, personal emergency response systems, 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, in-home support services, 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
Hearing Services with the BlueAdvantage Sapphire (PPO) plan includes hearing exams with a $10 copay, fitting/evaluation for hearing aids, and prescription hearing aids with a copay between $399 and $899 per year, but inner ear, outer ear, and over the ear prescription hearing aids are not covered. OTC hearing aids are also not covered.
Vision Services See details
The BlueAdvantage Sapphire (PPO) plan covers vision services, including routine eye exams with one exam per year, and eyewear with a combined maximum benefit of $250 per year for both in-network and out-of-network services. Contact lenses and eyeglasses (lenses and frames) are also covered, with one pair allowed per year. However, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The BlueAdvantage Sapphire (PPO) plan covers Medicare Dental Services with a $30 copay. Other dental services include oral exams (2 per year), dental x-rays (1 per 12 months), other diagnostic dental services, prophylaxis (cleaning) (2 per year), fluoride treatment (1 per year), other preventative dental services, restorative services (1 per year), endodontics (1 per tooth per 60 months), periodontics (1 per 3 years), prosthodontics removable (1 per 60 months), implant services (1 per tooth per lifetime), prosthodontics fixed (1 per 60 months), and oral and maxillofacial surgery; however, adjunctive general services, maxillofacial prosthetics, and orthodontics are not covered. The plan has a maximum benefit of $3250 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the BlueAdvantage Sapphire (PPO) plan, and prior authorization is required. For Medicare Part B Insulin Drugs, there is a $35 copay with coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the BlueAdvantage Sapphire (PPO) plan with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical equipment is covered, with Durable Medical Equipment (DME) subject to a 20% coinsurance and Prosthetic Devices, and Medical Supplies also subject to a 20% coinsurance. Diabetic Supplies have a 0-20% coinsurance and Medicare-covered Diabetic Therapeutic Shoes or Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the BlueAdvantage Sapphire (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $100, while Lab Services have no copay and a coinsurance of at most 20%. Diagnostic Radiological Services have a copay of at most $225, Therapeutic Radiological Services have a copay of at most $60, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the BlueAdvantage Sapphire (PPO) plan with no copay and no coinsurance, but require authorization. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but not for Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services. Prior authorization is required, and the copay is dependent on the specific service.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the BlueAdvantage Sapphire (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214 per day; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items with a $70 benefit every three months, as well as a Meal Benefit for chronic illness, but Acupuncture, Dual Eligible SNPs with Highly Integrated Services, and many other services are not covered.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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