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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 2026, 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 North Georgia. This plan received an overall rating of 4 out of 5 stars in 2026.
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 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 $9550.00 (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 $9550.00 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) Medicare plan features a $250 annual drug deductible and offers cost-effective options for generic medications. For Tier 1 preferred generics, you will pay no copay when using a preferred pharmacy or preferred mail-order service, while standard pharmacies charge a copay starting at $6. Tier 2 generics are also highly affordable, costing a flat $10 copay at preferred locations or starting at $15 at standard pharmacies. For brand-name and high-tier medications, the plan utilizes a combination of copayments and coinsurance. Tier 3 preferred brand drugs require a copay starting at $42 at preferred pharmacies, while Tier 4 non-preferred drugs carry a 50% coinsurance. Tier 5 specialty drugs are covered with a 30% coinsurance for a one-month supply at both preferred and standard pharmacies.
Additional Benefits
The BlueAdvantage Sapphire (PPO) plan offers affordable healthcare coverage with no copay and no coinsurance for primary care visits, home health services, and annual preventive care. Specialized services like specialist visits, urgent care, and emergency room visits feature low, fixed copayments and no coinsurance. For hospital care, inpatient stays require a $295 daily copay for the first six days with no copay thereafter, while outpatient hospital services carry a $325 copay. This plan also provides robust supplemental benefits, including comprehensive dental coverage up to a $2,000 annual limit with no copay for preventive services and 20% coinsurance for restorative care. Vision and hearing benefits are also included, featuring no copay for routine annual eye exams, a $300 eyewear allowance every two years, and low copays for hearing exams and prescription hearing aids. Additionally, members receive a quarterly $46 allowance for over-the-counter items with no copay or coinsurance.
Inpatient Hospital See details
BlueAdvantage Sapphire (PPO) inpatient hospital services are partially covered with no coinsurance, though prior authorization is required. Medicare-covered acute and psychiatric stays require a $295 daily copay for days 1 through 6 and no copay for days 7 through 90, while upgrades and non-Medicare-covered stays are not covered.
Outpatient Services See details
BlueAdvantage Sapphire (PPO) covers outpatient services with no coinsurance, including outpatient hospital services for a $325 copay, observation services for a $200 copay per stay, and ambulatory surgical center services for a $275 copay. Outpatient substance abuse services carry a $20 to $30 copay with no coinsurance, while outpatient blood services are covered with no copay, coinsurance, or deductible.
Partial Hospitalization See details
BlueAdvantage Sapphire (PPO) covers partial hospitalization services with a $45.00 copay and no coinsurance, although prior authorization is required.
Ambulance and Transportation Services See details
BlueAdvantage Sapphire (PPO) covers ground ambulance services with a $295.00 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay. Prior authorization is required for ambulance services, fees are not waived if admitted to the hospital, and transportation services are not covered.
Emergency Services See details
Emergency services are covered by BlueAdvantage Sapphire (PPO) with a $130 copay and no coinsurance, and urgently needed services are covered 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 available for a $90 copay and no coinsurance, while worldwide emergency transportation is covered with a $295 copay and 20% coinsurance.
Primary Care See details
BlueAdvantage Sapphire (PPO) covers primary care and telehealth services with no copay and no coinsurance, while specialist visits require a $30 copay and no coinsurance. Physical, occupational, and speech therapies have a $15 copay and no coinsurance, while psychiatric, mental health, and opioid treatments have copays ranging from $20 to $30 and no coinsurance. Podiatry is not covered, and chiropractic services are only partially covered, with routine and other chiropractic services excluded from coverage.
Preventive Services See details
BlueAdvantage Sapphire (PPO) preventive services are covered with no copay and no coinsurance, including annual physical exams, kidney disease education, and glaucoma screenings. Additional preventive services are partially covered with no copay and no coinsurance, which includes memory fitness, enhanced disease management, and remote access technologies, though sub-services like health education, in-home safety assessments, and personal emergency response systems are not covered.
Hearing Services See details
BlueAdvantage Sapphire (PPO) hearing services include exams with a $10 copay and no coinsurance or deductible. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $399 to $899, but OTC hearing aids, as well as prescription hearing aids for the inner ear, outer ear, and over the ear, are not covered.
Vision Services See details
BlueAdvantage Sapphire (PPO) offers partially covered vision services with no copay and no coinsurance, including one routine eye exam every year and a $300 combined maximum benefit every two years for contact lenses or eyeglasses (lenses and frames). Other eye exam services, separate eyeglass lenses, separate eyeglass frames, and upgrades are not covered.
Dental Services See details
BlueAdvantage Sapphire (PPO) offers partially covered dental services with an annual maximum of $2,000, though adjunctive general services, maxillofacial prosthetics, implants, and orthodontics are not covered. Medicare-covered dental has a $30 copay and no coinsurance, while preventive services, endodontics, and periodontics have no copay and no coinsurance, and restorative services, prosthodontics, and oral surgery have no copay and a 20% coinsurance.
Home Infusion bundled Services See details
Home infusion bundled services are covered under the BlueAdvantage Sapphire (PPO) with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs carry no coinsurance to 20% coinsurance, while Part B insulin is covered with a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
BlueAdvantage Sapphire (PPO) covers dialysis services with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
BlueAdvantage Sapphire (PPO) covers durable medical equipment and prosthetics with no copay and 20% coinsurance. Covered diabetic supplies require no coinsurance to 50% coinsurance, while diabetic therapeutic shoes and inserts require a $10 copay and no coinsurance.
Diagnostic and Radiological Services See details
BlueAdvantage Sapphire (PPO) covers diagnostic and radiological services, with prior authorization required for both categories. Diagnostic tests and procedures have a copay ranging from no copay to $100 plus coinsurance, lab services require no copay with a minimum 20% coinsurance, and radiological services have no coinsurance with copays ranging from no copay for X-rays to minimum copays of $60 for therapeutic and $225 for diagnostic radiology.
Home Health Services See details
Home Health Services are covered by the BlueAdvantage Sapphire (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under BlueAdvantage Sapphire (PPO) with no coinsurance and require prior authorization. While some services are covered, standard cardiac, intensive cardiac, and pulmonary rehabilitation services (each with a $15 copay) and SET for PAD services (with a $10 copay) are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by BlueAdvantage Sapphire (PPO) with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, though a prior three-day inpatient hospital stay is not required for admission.
Other Services See details
BlueAdvantage Sapphire (PPO) offers partially covered other services, which include over-the-counter (OTC) items and meal benefits for chronic illnesses with no copay and no coinsurance, while acupuncture is not covered. The OTC benefit provides up to $46 every three months, though unused funds do not carry over.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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