BlueAdvantage Sapphire (PPO)

H7917 - 040 - 0
5 out of 5 stars (5 / 5)

bluecross-blueshield-of-tennessee medicare provider logo

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

This page features plan details for 2023 BlueAdvantage Sapphire (PPO) H7917 – 040 – 0 available in North Georgia.

IMPORTANT: This page has been updated with plan and premium data for the 2023 Medicare Annual Enrollment Period (AEP).

Locations

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

Plan Overview

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

Insurer:BlueCross BlueShield of Tennessee
Health Plan Deductible:$0.00
MOOP:$8,950 In and Out-of-network
$5,500 In-network
Drugs Covered:Yes

Ready to sign up for BlueAdvantage Sapphire (PPO) ?

Get help from a licensed Medicare agent.

Click to Call 1-877-354-4611 TTY 711. Mon-Fri 8am-9pm EST | Sat 8am-8pm EST.

Premium Breakdown

BlueAdvantage Sapphire (PPO) has a monthly premium of $0.00. 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
$164.90 $0.00 $0.00 $0.00 $164.90
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 Sapphire (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $0.00
Initial Coverage Limit: $4,660.00
Catastrophic Coverage Limit: $7,400.00
Drug Benefit Type: Enhanced
Gap Coverage: Yes
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 D LIS 25% LIS 50% LIS 75% LIS Full
$0.00 $ $ $ $

Initial Coverage Phase

After you pay your $0.00 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 $4,660.00. 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 $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.

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 $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.

Drug TypeCost Share
Generic drugs$4.15 copay or 5% (whichever costs more)
Brand-name drugs$10.35 copay or 5% (whichever costs more)

Additional Benefits

BlueAdvantage Sapphire (PPO) also provides the following benefits.

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

In-Network: No

Dental (comprehensive)

Diagnostic services:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Diagnostic services:Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required)
Endodontics:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Endodontics:Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required)
Extractions:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Extractions:Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required)
Non-routine services:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Non-routine services:Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required)
Periodontics:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Periodontics:Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required)
Prosthodontics, other oral/maxillofacial surgery, other services:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Prosthodontics, other oral/maxillofacial surgery, other services:Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required)
Restorative services:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Restorative services:Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required)

Dental (preventive)

Cleaning:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Cleaning:Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required)
Dental x-ray(s):In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Dental x-ray(s):Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required)
Fluoride treatment: Not covered (no limits)
Oral exam:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Oral exam:Out-of-Network: 50% coinsurance (limits may apply) (authorization not required) (referral not required)

Diagnostic procedures/lab services/imaging

Diagnostic radiology services (e.g., MRI):In-Network: $225 copay (authorization required) (referral not required)
Diagnostic radiology services (e.g., MRI):Out-of-Network: 50% coinsurance (authorization required) (referral not required)
Diagnostic tests and procedures:In-Network: $10-100 copay (authorization required) (referral not required)
Diagnostic tests and procedures:Out-of-Network: 50% coinsurance (authorization required) (referral not required)
Lab services:In-Network: $0-40 copay or 20% coinsurance (authorization required) (referral not required)
Lab services:Out-of-Network: 50% coinsurance (authorization required) (referral not required)
Outpatient x-rays:In-Network: $10-50 copay (authorization required) (referral not required)
Outpatient x-rays:Out-of-Network: 50% coinsurance (authorization required) (referral not required)

Doctor visits

Primary:In-Network: $10 copay per visit
Primary:Out-of-Network: 50% coinsurance per visit
Specialist:In-Network: $35 copay per visit (authorization not required) (referral not required)
Specialist:Out-of-Network: 50% coinsurance per visit (authorization not required) (referral not required)

Emergency care/Urgent care

Emergency: $90 copay per visit (always covered)
Urgent care: $45 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment:In-Network: $35 copay (authorization not required) (referral not required)
Foot exams and treatment:Out-of-Network: 50% coinsurance (authorization not required) (referral not required)
Routine foot care: Not covered

Ground ambulance

In-Network: $295 copay
Out-of-Network: $295 copay

Health plan deductible

$0.00

Health plan deductibles (other)

In-Network: No

Hearing

Fitting/evaluation:In-Network: $0 copay (no limits) (authorization not required) (referral not required)
Fitting/evaluation:Out-of-Network: $0 copay (no limits) (authorization not required) (referral not required)
Hearing aids:In-Network: $399-899 copay (limits may apply) (authorization not required) (referral not required)
Hearing aids:Out-of-Network: $399-899 copay (limits may apply) (authorization not required) (referral not required)
Hearing exam:In-Network: $10 copay (authorization not required) (referral not required)
Hearing exam:Out-of-Network: $10 copay (authorization not required) (referral not required)

Hospital coverage (inpatient)

In-Network: $300 per day for days 1 through 5
$0 per day for days 6 through 90
$0 per day for days 91 and beyond (authorization required) (referral not required)
Out-of-Network: 50% per stay (authorization required) (referral not required)

Hospital coverage (outpatient)

In-Network: $325 copay per visit (authorization required) (referral not required)
Out-of-Network: 50% coinsurance per visit (authorization required) (referral not required)

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

$8,950 In and Out-of-network
$5,500 In-network

Medical equipment/supplies

Diabetes supplies:In-Network: $0 copay (authorization required)
Diabetes supplies:Out-of-Network: 50% coinsurance per item (authorization required)
Durable medical equipment (e.g., wheelchairs, oxygen):In-Network: 20% coinsurance per item (authorization required)
Durable medical equipment (e.g., wheelchairs, oxygen):Out-of-Network: 50% coinsurance per item (authorization required)
Prosthetics (e.g., braces, artificial limbs):In-Network: 20% coinsurance per item (authorization required)
Prosthetics (e.g., braces, artificial limbs):Out-of-Network: 50% coinsurance per item (authorization required)

Medicare Part B drugs

Chemotherapy:In-Network: 20% coinsurance (authorization required)
Chemotherapy:Out-of-Network: 50% coinsurance (authorization required)
Other Part B drugs:In-Network: 20% coinsurance (authorization required)
Other Part B drugs:Out-of-Network: 50% coinsurance (authorization required)

Mental health services

Inpatient hospital – psychiatric:In-Network: $300 per day for days 1 through 5
$0 per day for days 6 through 90 (authorization required) (referral not required)
Inpatient hospital – psychiatric:Out-of-Network: 50% per stay (authorization required) (referral not required)
Outpatient group therapy visit:In-Network: $20 copay (authorization required) (referral not required)
Outpatient group therapy visit:Out-of-Network: 50% coinsurance (authorization required) (referral not required)
Outpatient group therapy visit with a psychiatrist:In-Network: $20 copay (authorization required) (referral not required)
Outpatient group therapy visit with a psychiatrist:Out-of-Network: 50% coinsurance (authorization required) (referral not required)
Outpatient individual therapy visit:In-Network: $30 copay (authorization required) (referral not required)
Outpatient individual therapy visit:Out-of-Network: 50% coinsurance (authorization required) (referral not required)
Outpatient individual therapy visit with a psychiatrist:In-Network: $30 copay (authorization required) (referral not required)
Outpatient individual therapy visit with a psychiatrist:Out-of-Network: 50% coinsurance (authorization required) (referral not required)

Optional supplemental benefits

No

Preventive care

In-Network: $0 copay (authorization not required) (referral not required)
Out-of-Network: 50% coinsurance (authorization not required) (referral not required)

Rehabilitation services

Occupational therapy visit:In-Network: $35 copay (authorization required) (referral not required)
Occupational therapy visit:Out-of-Network: 50% coinsurance (authorization required) (referral not required)
Physical therapy and speech and language therapy visit:In-Network: $35 copay (authorization required) (referral not required)
Physical therapy and speech and language therapy visit:Out-of-Network: 50% coinsurance (authorization required) (referral not required)

Skilled Nursing Facility

In-Network: $0 per day for days 1 through 20
$196 per day for days 21 through 100 (authorization required) (referral not required)
Out-of-Network: 50% per stay (authorization required) (referral not required)

Transportation

Not covered

Vision

Contact lenses:In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Contact lenses:Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglass frames: Not covered (no limits)
Eyeglass lenses: Not covered (no limits)
Eyeglasses (frames and lenses):In-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Eyeglasses (frames and lenses):Out-of-Network: $0 copay (limits may apply) (authorization not required) (referral not required)
Other: Not covered (no limits)
Routine eye exam:In-Network: $35 copay (limits may apply) (authorization not required) (referral not required)
Routine eye exam:Out-of-Network: $35 copay (limits may apply) (authorization not required) (referral not required)
Upgrades: Not covered

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

Covered (authorization not required) (referral not required)

Ready to sign up for BlueAdvantage Sapphire (PPO) ?

Get help from a licensed Medicare agent.

Click to Call 1-877-354-4611 TTY 711. Mon-Fri 8am-9pm EST | Sat 8am-8pm EST.

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