BlueAdvantage Extra (PPO)

H7917 - 041 - 0
4.5 out of 5 stars (4.5 / 5)

BlueAdvantage Extra (PPO) is a Medicare Advantage (Part C) Plan by BlueCross BlueShield of Tennessee.

This page features plan details for 2024 BlueAdvantage Extra (PPO) H7917 – 041 – 0 available in Statewide TN + Northwest GA.

IMPORTANT: This page has been updated with plan and premium data for 2024.

Locations

BlueAdvantage Extra (PPO) is offered in the following locations.

Plan Overview

BlueAdvantage Extra (PPO) offers the following coverage and cost-sharing.

Insurer:BlueCross BlueShield of Tennessee
Health Plan Deductible:
MOOP:$3,900.00
Drugs Covered:Yes

Ready to sign up for BlueAdvantage Extra (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

Premium Breakdown

BlueAdvantage Extra (PPO) has a monthly premium of $23.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$174.70 $0.00 $23.00 $0.00 $197.70
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

BlueAdvantage Extra (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:$545.00
Initial Coverage Limit:$5,030.00
Catastrophic Coverage Limit:$8,000.00
Drug Benefit Type:Defined Standard Benefit
Additional Gap Coverage:
Formulary Link: Formulary Link

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$23.00$

NOTE:  The Inflation Reduction Act of 2022 has expanded full subsidy eligibility under the LIS program to individuals with incomes up to 150% of the Federal Poverty Level. People who qualify for Extra Help generally will pay no more than $4.50 for each generic drug and $11.20 for each brand-name drug.

Initial Coverage Phase

After you pay your $545.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00. Once you reach that amount, you will enter the next coverage phase.

Gap Coverage Phase

After your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00, you will pay no more than the amounts below for any drug tier until you reach $8,000.00.

Tier Cost
All other tiers (Generic)25%
All other tiers (Brand-name)25%

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs.

Additional Benefits

BlueAdvantage Extra (PPO) also provides the following benefits.

Health plan deductible

$0

Other health plan deductibles?

In-network No

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

$9,550 In and Out-of-network
$3,900 In-network

Optional supplemental benefits

No

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

In-network No

Outpatient hospital coverage

In-network $175 copay per visit (Authorization is required.) (Referral is not required.)
out-of-network $225 copay per visit (Authorization is required.) (Referral is not required.)

Doctor visits

In-network Primary$0 copay (Not applicable.) (Not applicable.)
out-of-network Primary$10 copay per visit (Not applicable.) (Not applicable.)
In-network Specialist$25 copay per visit (Authorization is not required.) (Referral is not required.)
out-of-network Specialist$30 copay per visit (Authorization is not required.) (Referral is not required.)

Preventive care

In-network $0 copay (Authorization is not required.) (Referral is not required.)
out-of-network 50% coinsurance (Authorization is not required.) (Referral is not required.)

Emergency care/Urgent care

Emergency$120 copay per visit (always covered) (Not applicable.) (Not applicable.)
Urgent care$25 copay per visit (always covered) (Not applicable.) (Not applicable.)

Diagnostic procedures/lab services/imaging

In-network Diagnostic tests and procedures$0-100 copay (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic tests and procedures50% coinsurance (Authorization is required.) (Referral is not required.)
In-network Lab services$0-40 copay or 20% coinsurance (Authorization is required.) (Referral is not required.)
out-of-network Lab services50% coinsurance (Authorization is required.) (Referral is not required.)
In-network Diagnostic radiology services (e.g., MRI)$175 copay (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic radiology services (e.g., MRI)50% coinsurance (Authorization is required.) (Referral is not required.)
In-network Outpatient x-rays$0-50 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient x-rays50% coinsurance (Authorization is required.) (Referral is not required.)

Hearing

In-network Hearing exam$10 copay (Authorization is not required.) (Referral is not required.)
out-of-network Hearing exam$10 copay (Authorization is not required.) (Referral is not required.)
In-network Fitting/evaluation$0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.)
out-of-network Fitting/evaluation$0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.)
In-network Hearing aids$199-699 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Hearing aids$199-699 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Preventive dental

In-network Oral exam$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Oral exam50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Cleaning$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Cleaning50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Fluoride treatmentNot covered (There are no limits.) (Not applicable.) (Not applicable.)
In-network Dental x-ray(s)$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Dental x-ray(s)50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Comprehensive dental

In-network Non-routine services$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Non-routine services50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Diagnostic services$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic services50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Restorative services$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Restorative services50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Endodontics$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Endodontics50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Periodontics$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Periodontics50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Extractions$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Extractions50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Prosthodontics, other oral/maxillofacial surgery, other services$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Prosthodontics, other oral/maxillofacial surgery, other services50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)

Vision

In-network Routine eye exam$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Routine eye exam$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
OtherNot covered (There are no limits.) (Not applicable.) (Not applicable.)
In-network Contact lenses$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Contact lenses$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
In-network Eyeglasses (frames and lenses)$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
out-of-network Eyeglasses (frames and lenses)$0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)
Eyeglass framesNot covered (There are no limits.) (Not applicable.) (Not applicable.)
Eyeglass lensesNot covered (There are no limits.) (Not applicable.) (Not applicable.)
UpgradesNot covered (Not applicable.) (Not applicable.)

Rehabilitation services

In-network Occupational therapy visit$25 copay (Authorization is required.) (Referral is not required.)
out-of-network Occupational therapy visit50% coinsurance (Authorization is required.) (Referral is not required.)
In-network Physical therapy and speech and language therapy visit$25 copay (Authorization is required.) (Referral is not required.)
out-of-network Physical therapy and speech and language therapy visit50% coinsurance (Authorization is required.) (Referral is not required.)

Ground ambulance

In-network $295 copay (Not applicable.) (Not applicable.)
out-of-network $295 copay (Not applicable.) (Not applicable.)

Transportation

In-network $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.)

Foot care (podiatry services)

In-network Foot exams and treatment$35 copay (Authorization is not required.) (Referral is not required.)
out-of-network Foot exams and treatment50% coinsurance (Authorization is not required.) (Referral is not required.)
Routine foot careNot covered (Not applicable.) (Not applicable.)

Medical equipment/supplies

In-network Durable medical equipment (e.g., wheelchairs, oxygen)20% coinsurance per item (Authorization is required.) (Not applicable.)
out-of-network Durable medical equipment (e.g., wheelchairs, oxygen)50% coinsurance per item (Authorization is required.) (Not applicable.)
In-network Prosthetics (e.g., braces, artificial limbs)20% coinsurance per item (Authorization is required.) (Not applicable.)
out-of-network Prosthetics (e.g., braces, artificial limbs)50% coinsurance per item (Authorization is required.) (Not applicable.)
In-network Diabetes supplies0-20% coinsurance per item (Authorization is required.) (Not applicable.)
out-of-network Diabetes supplies50% coinsurance per item (Authorization is required.) (Not applicable.)

Wellness programs (e.g., fitness, nursing hotline)

Covered (Authorization is not required.) (Referral is not required.)

Medicare Part B drugs

In-network Chemotherapy0-20% coinsurance (Authorization is required.) (Not applicable.)
out-of-network Chemotherapy50% coinsurance (Authorization is required.) (Not applicable.)
In-network Other Part B drugs0-20% coinsurance (Authorization is required.) (Not applicable.)
out-of-network Other Part B drugs50% coinsurance (Authorization is required.) (Not applicable.)
In-network Part B Insulin drugs0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.)
out-of-network Part B Insulin drugs50% coinsurance (Authorization is required.) (Not applicable.)

Inpatient hospital coverage

In-network $195 per day for days 1 through 5
$0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.)
out-of-network $295 per day for days 1 through 5
$0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.)

Mental health services

In-network Inpatient hospital – psychiatric$195 per day for days 1 through 5
$0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.)
out-of-network Inpatient hospital – psychiatric$295 per day for days 1 through 5
$0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.)
In-network Outpatient group therapy visit with a psychiatrist$15 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient group therapy visit with a psychiatrist50% coinsurance (Authorization is required.) (Referral is not required.)
In-network Outpatient individual therapy visit with a psychiatrist$25 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient individual therapy visit with a psychiatrist50% coinsurance (Authorization is required.) (Referral is not required.)
In-network Outpatient group therapy visit$15 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient group therapy visit50% coinsurance (Authorization is required.) (Referral is not required.)
In-network Outpatient individual therapy visit$25 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient individual therapy visit50% coinsurance (Authorization is required.) (Referral is not required.)

Skilled Nursing Facility

In-network $0 per day for days 1 through 20
$203 per day for days 21 through 100 (Authorization is required.) (Referral is not required.)
out-of-network 50% per stay (Authorization is required.) (Referral is not required.)

Ready to sign up for BlueAdvantage Extra (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

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