BlueAdvantage Extra (PPO) Plan Details for Decatur County, TN
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*CMS rated this BlueCross BlueShield of Tennessee plan (H7917-041-0) 4.5 (Good+) out of 5 stars.
BlueAdvantage Extra (PPO) is a Medicare Advantage plan with a prescription drug plan. The 2025 Annual Enrollment period starts October 15. Plan benefits begin January 1.
See more Medicare Advantage Plans in Decatur County, Tennessee.
BlueAdvantage Extra Basic Details
| Plan Basics | |
|---|---|
| Plan ID: | H7917-041-0 |
| Plan Type: | PPO |
| Plan Year: | 2025 |
| Premium: | $26.00/mo Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | 4,200.00 /yr |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Basic, $590.00 deductible |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | Decatur County, TN |
| Insured By: | BlueCross BlueShield of Tennessee |
| Summary of Benefits |
|---|
BlueCross BlueShield of Tennessee Out-of-Pocket Costs
This BlueCross BlueShield of Tennessee Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H7917-041-0.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
Doctor's Office Visits
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | Not Covered |
| Specialist: | $25 Copay |
Emergency, Urgent, and Inpatient Hospital Coverage
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $125 Copay |
| Urgent care: | $25 Copay |
| Ground ambulance: | $295 Copay |
| Inpatient hospital care: | $195.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $214.00 per day for days 21 and beyond |
Foot Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | $35 Copay |
| Routine Foot Care: | Not Covered |
Chiropractic Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | $20 Copay Prior Authorization Required |
| Routine chiropractic: | Not Covered |
Mental Health Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | $25 Copay |
| Outpatient group therapy: | $15 Copay |
| Inpatient psychiatric hospital care: | $195.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Rehabilitation Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | $25 Copay Prior Authorization Required |
| Occupational therapy: | $25 Copay Prior Authorization Required |
Medical Equipment and Supplies
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | 20% Coinsurance Prior Authorization Required |
| Durable medical equipment: | 20% Coinsurance Prior Authorization Required |
| Prosthetics: | 20% Coinsurance |
Diagnostics, Lab Services, and Imaging
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | $175 Copay Prior Authorization Required |
| Lab services: | 20% Coinsurance Prior Authorization Required |
| Outpatient x-rays: | $50 Copay Prior Authorization Required |
| Diagnostic tests and procedures: | $100 Copay Prior Authorization Required |
Medicare Part B Drugs
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered): | 20% Coinsurance |
Dental Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare Covered Preventive Dental | $25 Copay |
| Oral exam | $0 |
| Dental x-rays | $0 |
| Cleaning | $0 |
| Periodontics | Not Covered |
| Endodontics | Not Covered |
| Restorative Services | Not Covered |
| Maximum dental benefit: | $2,500.00 (Every year) |
Hearing Aids and Services
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Not Covered |
| Hearing exam | Covered Limits may apply |
Vision Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam (in-network) | |
| Routine eye exam (in-network) | Covered Limits may apply |
| Eyewear benefits | None |
Feel free to download our BlueAdvantage Extra Summary of Benefits information.
Prescription Drug Plan Costs & Benefits
BlueAdvantage Extra includes a basic benefit Medicare Part D plan (PDP). Basic plans meet the minimum coverage standards set by the Centers for Medicare & Medicaid Services (CMS). These plans may have higher cost-sharing, deductibles, or limited drug coverage compared to enhanced plans, but they still provide essential prescription drug coverage at a lower premium.
As of 2023, approximately 75% of people on Medicare are enrolled in enhanced plans.
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. LIS, also known as Extra Help, is a Social Security program that helps people with limited income and resources lower or cut Part D costs.
The following table outlines the premium details of this prescription drug plan.
| Basic Part D Premium: | $26.00 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $26.00 |
| Low Income Premium Subsidy: | $40.01 |
| Low Income Premium Subsidy CMS Pays: | $26.00 |
| Low Income Subsidy Premium: | $0.00 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $590.00. You must pay this amount at the pharmacy before BlueCross BlueShield of Tennessee begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, BlueAdvantage Extra has out-of-pocket costs you must pay when you pick up your prescriptions.
| Drug Tier | Retail | Mail Order | Out of Network |
|---|---|---|---|
| Cost data not available. | |||
| *The Part D deductible does not apply. | |||
CMS 5-Star Rating Marks
The following table shows the quality ratings for this BlueCross BlueShield of Tennessee plan. Each year CMS rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories using a 5-star rating system. Here are the most recent ratings for BlueAdvantage Extra .
| CMS Measure | Star Rating |
|---|---|
| 2025 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
- BlueAdvantage Ruby
- BlueAdvantage Diamond
- BlueAdvantage Ruby
- BlueAdvantage Sapphire
- BlueAdvantage Garnet
- BlueAdvantage Prime
- BlueAdvantage Extra
If you are enrolled in a Part C plan with prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D plan, regardless of your chosen insurance company.
You cannot be enrolled in a Part C health plan and simultaneously hold Medicare Supplement Insurance (Medigap). Medicare Supplement plans are only compatible with Medicare Parts A and B.
Contact BlueCross BlueShield of Tennessee
| Website: | BlueCross BlueShield of Tennessee Plan Page |
|---|---|
| Providers: | BlueCross BlueShield of Tennessee Providers Page |
| Formulary: | BlueCross BlueShield of Tennessee Formulary Page |
| Pharmacy: | BlueCross BlueShield of Tennessee Pharmacy Page |
| New Member Health Plan Help: | (800)292-5146 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (800)292-5146 |
| New Member Part D TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Part C program on www.medicare.gov or call 1-800-MEDICARE.
Citations & References
- BlueCross BlueShield of Tennessee, http://bcbstmedicare.com, Last Accessed February 20, 2024
- Medicare.gov, "Your health plan options", Last Accessed February 20, 2024
- Medicare.gov, "How Original Medicare Works", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You Handbook", Last Accessed February 19, 2024
- Medicare.gov, "What Medicare Covers", Last Accessed February 7, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.