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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 East 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 $9250.00 (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 $9250.00 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 will pay nothing for covered Part D drugs. If you qualify for the low-income subsidy, your costs for drugs are $0.
Additional Benefits
The BlueAdvantage Sapphire (PPO) plan offers a range of benefits including inpatient hospital stays with a copay, outpatient services, and coverage for ambulance and emergency services. Primary care, preventive services, hearing, vision, and dental services are also included, with specific copays and limitations on certain services. This plan also covers home health services, skilled nursing facilities, and diagnostic services. Additional benefits include coverage for home infusion, dialysis, medical equipment, and over-the-counter items. However, certain services like acupuncture and private duty nursing are not covered.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care, with a $250 copay for days 1-5, and no copay for days 6-90. Additional days for inpatient hospital-acute are covered. Non-Medicare-covered stays and upgrades are not covered.
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 $275 copay, and Outpatient Substance Abuse Services with a $30 copay for individual sessions and a $20 copay for group sessions. Outpatient Blood Services are also covered, with a waived deductible for three pints.
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 by the BlueAdvantage Sapphire (PPO) plan, with prior authorization required for all ambulance services. Ground Ambulance Services have a $295 copay, while Air Ambulance Services have a 20% coinsurance, and Transportation Services are not covered.
Emergency Services See details
Emergency Services are covered by the BlueAdvantage Sapphire (PPO) plan, with a $125 copay and no coinsurance. Urgently Needed Services have a $25 copay and no coinsurance, while Worldwide Emergency Services have varying costs depending on the service, including a $90 copay for Worldwide Emergency and Urgent Coverage, and a $295 copay with 20% coinsurance for Worldwide Emergency Transportation.
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 services, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have a $20 copay, while occupational therapy has a $15 copay, and specialist services have a $30 copay. Mental health specialty services have a copay between $20-$30, other health care professional services have a copay between $20-$30, psychiatric services have a copay between $20-$30, physical therapy and speech-language pathology services have a $15 copay, and opioid treatment program services have a copay between $20-$30. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The BlueAdvantage Sapphire (PPO) plan covers preventive services, including annual physical exams, health education, nutritional/dietary benefits, fitness benefits, enhanced disease management, telemonitoring services, remote access technologies, kidney disease education services, 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 are covered by the BlueAdvantage Sapphire (PPO) plan, including routine hearing exams with a $10 copay. Prescription hearing aids (all types) are covered, with a copay between $399 and $899, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include coverage for routine eye exams, contact lenses, and eyeglasses (lenses and frames). Routine eye exams are covered once per year. Contact lenses and eyeglasses (lenses and frames) are covered once per year. Eyewear has a combined maximum benefit of $250.00 per year. 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, and also covers other dental services with a $2,750 maximum benefit per year. Oral exams are covered for 2 visits per year, and dental x-rays are covered with limitations. Other services like fluoride treatment, restorative services, endodontics, periodontics, prosthodontics (removable and fixed), implant services, and oral and maxillofacial surgery are covered with limitations.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the BlueAdvantage Sapphire (PPO) plan, requiring prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the BlueAdvantage Sapphire (PPO) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment benefits are covered, including Durable Medical Equipment with 20% coinsurance and Prosthetic Devices with 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Medical Supplies and Diabetic Supplies have a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a $10 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the BlueAdvantage Sapphire (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $100, and 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 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 covered, but the plan does not cover the services of Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, or SET for PAD. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the BlueAdvantage Sapphire (PPO) plan, but require prior authorization. There is no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The BlueAdvantage Sapphire (PPO) plan 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. The plan covers Over-the-Counter (OTC) Items with a maximum benefit of $55.00 every three months, and Meal Benefits for chronic illnesses.
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