2022 BlueAdvantage Emerald (PPO)

BlueAdvantage Emerald (PPO) H7917-035 is a 2022 Medicare Advantage Plan or Part-C by BlueCross BlueShield of Tennessee available to residents in Tennessee. This plan includes additional prescription drug (Part-D) coverage. The BlueAdvantage Emerald (PPO) has a monthly premium of $56.00 and has an in-network maximum out-of-pocket limit of $5,900 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,900 out-of-pocket. This can be a extremely nice safety net.

BlueAdvantage Emerald (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

BlueCross BlueShield of Tennessee works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for BlueAdvantage Emerald (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from BlueCross BlueShield of Tennessee and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from BlueCross BlueShield of Tennessee except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 BlueCross BlueShield of Tennessee Medicare Advantage Plan Costs

BlueAdvantage Emerald (PPO) Part-C Premium

BlueCross BlueShield of Tennessee charges a $25.20 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H7917-035 Part-D Deductible and Premium

BlueAdvantage Emerald (PPO) has a monthly drug premium of $30.80 and a $0.00 drug deductible. This BlueCross BlueShield of Tennessee plan offers a $30.80 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by BlueCross BlueShield of Tennessee above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $30.80 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

BlueCross BlueShield of Tennessee Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This BlueCross BlueShield of Tennessee plan does offer additional coverage through the gap.

Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The BlueAdvantage Emerald (PPO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $7.70 for 75% low income subsidy $15.40 for 50% and $23.10 for 25%.

H7917-035 Formulary or Drug Coverage

BlueAdvantage Emerald (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 BlueAdvantage Emerald (PPO) H7917-035 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$1	$6
Tier 2	$5	$10
Tier 3	$35	$40
Tier 4	$80	$85
Tier 5	33%	33%

*Initial Coverage Phase and 30 day supply

2021 BlueAdvantage Emerald (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	$0 copay
Diagnostic services	50% coinsurance (Out-of-Network)
Endodontics	50% coinsurance (Out-of-Network)
Endodontics	$0 copay
Extractions	$0 copay
Extractions	50% coinsurance (Out-of-Network)
Non-routine services	50% coinsurance (Out-of-Network)
Non-routine services	$0 copay
Periodontics	50% coinsurance (Out-of-Network)
Periodontics	$0 copay
Prosthodontics, other oral/maxillofacial surgery, other services	50% coinsurance (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	$0 copay
Restorative services	$0 copay
Restorative services	50% coinsurance (Out-of-Network)

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$200 copay
Diagnostic radiology services (e.g., MRI)	50% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$10-100 copay
Diagnostic tests and procedures	50% coinsurance (Out-of-Network)
Lab services	50% coinsurance (Out-of-Network)
Lab services	$0-40 copay or 20% coinsurance
Outpatient x-rays	50% coinsurance (Out-of-Network)
Outpatient x-rays	$10-50 copay

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Doctor Visits

Primary	$10 copay per visit
Primary	50% coinsurance per visit (Out-of-Network)
Specialist	50% coinsurance per visit (Out-of-Network)
Specialist	$30 copay per visit

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$60 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	50% coinsurance (Out-of-Network)
Foot exams and treatment	$30 copay
Routine foot care	Not covered

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Ground Ambulance

$200 copay
$200 copay (Out-of-Network)

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Hearing

Fitting/evaluation	$0 copay (Out-of-Network)
Fitting/evaluation	$0 copay
Hearing aids	$499-799 copay (Out-of-Network)
Hearing aids	$499-799 copay
Hearing exam	$10 copay
Hearing exam	$10 copay (Out-of-Network)

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Inpatient Hospital Coverage

$275 per day for days 1 through 5 $0 per day for days 6 through 90 $0 per day for days 91 and beyond
50% per stay (Out-of-Network)

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Medical Equipment/Supplies

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

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Chemotherapy	50% coinsurance (Out-of-Network)
Other Part B drugs	50% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	$275 per day for days 1 through 5 $0 per day for days 6 through 90
Inpatient hospital - psychiatric	50% per stay (Out-of-Network)
Outpatient group therapy visit	$20 copay
Outpatient group therapy visit	50% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$20 copay
Outpatient individual therapy visit	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$30 copay
Outpatient individual therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$30 copay

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MOOP

$10,000 In and Out-of-network $5,900 In-network

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Option

No

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

50% coinsurance per visit (Out-of-Network)
$300 copay per visit

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Preventive Care

50% coinsurance (Out-of-Network)
$0 copay

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Preventive Dental

Cleaning	$0 copay
Cleaning	50% coinsurance (Out-of-Network)
Dental x-ray(s)	$0 copay
Dental x-ray(s)	50% coinsurance (Out-of-Network)
Fluoride treatment	Not covered
Oral exam	$0 copay
Oral exam	50% coinsurance (Out-of-Network)

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Rehabilitation Services

Occupational therapy visit	50% coinsurance (Out-of-Network)
Occupational therapy visit	$20 copay
Physical therapy and speech and language therapy visit	$20 copay
Physical therapy and speech and language therapy visit	50% coinsurance (Out-of-Network)

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Skilled Nursing Facility

$0 per day for days 1 through 20 $172 per day for days 21 through 100
50% per stay (Out-of-Network)

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Transportation

Not covered

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Vision

Contact lenses	$0 copay (Out-of-Network)
Contact lenses	$0 copay
Eyeglass frames	Not covered
Eyeglass lenses	Not covered
Eyeglasses (frames and lenses)	$0 copay (Out-of-Network)
Eyeglasses (frames and lenses)	$0 copay
Other	Not covered
Routine eye exam	$30 copay
Routine eye exam	$30 copay (Out-of-Network)
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for BlueAdvantage Emerald (PPO) H7917

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in BlueAdvantage Emerald (PPO) Plans Performance

Health Plan Customer Service Rating for BlueAdvantage Emerald (PPO)

BlueAdvantage Emerald (PPO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for BlueAdvantage Emerald (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.