BlueAdvantage Total Heart and Diabetes (PPO C-SNP)

Available to residents of Fayette County, TN for 2026. Contract H7917, plan 045, segment 0.

New for 2026. This plan has no 2025 predecessor in the CMS crosswalk.

Plan details

Monthly premium (Part C + D)	$0.00
— medical (Part C) part	$0.00
— drug (Part D) part	$0.00?
Monthly premium with full Extra Help (LIS)	$0.00?
Part B premium reduction (giveback)	None
In-network out-of-pocket maximum	$6,700.00?
In- and out-of-network out-of-pocket maximum	$10,100.00
Drug deductible	$250.00Tier 1 and 2 exempt
Drug out-of-pocket threshold	$2,100.00
Plan type	PPO C-SNP?
Special needs plan	Chronic-condition SNP
Contract / plan	H7917-045-0
Offered by	BlueCross BlueShield of Tennessee
Parent organization	BlueCross BlueShield of Tennessee
Formulary drugs	3,455
Formulary exception tier	4?
Pharmacy search	bcbstmedicare.com
Member services	(800)292-5146TTY 711

CMS star ratings

Overall: 4 out of 5 stars for Overall
Health plan (Part C): 4 out of 5 stars for Health plan (Part C)
Drug plan (Part D): 4 out of 5 stars for Drug plan (Part D)

Published per contract — every plan under contract H7917 shares this rating.

Plan health benefits

Service	In-network	Out-of-network?
Doctor visits
Primary care doctor	$0 copay	50% coinsurance
Specialist	$15 copay	50% coinsurance
Other health care professional	$15–$25 copay(authorization required)	50% coinsurance
Additional telehealth services	$0 copay(authorization required)	—
Preventive care
Medicare-covered preventive services	$0 copay	50% coinsurance
Annual physical exam	$0 copay	50% coinsurance
Kidney disease education	$0 copay	50% coinsurance
Glaucoma screening	$0 copay	50% coinsurance
Diabetes self-management training	$0 copay	20% coinsurance
Diagnostic tests, labs and imaging
Diagnostic tests and procedures	$0–$100 copay(authorization required)	50% coinsurance
Lab services	$0 copay(authorization required)	50% coinsurance
Diagnostic radiology (e.g. MRI, CT)	$225 copay(authorization required)	50% coinsurance
Therapeutic radiology	20% coinsurance(authorization required)	50% coinsurance
Outpatient x-rays	$0–$25 copay(authorization required)	50% coinsurance
Emergency and urgent care
Emergency room	$130 copay	—
Urgent care	$50 copay	—
Worldwide emergency coverage	$0 copay	—
Worldwide urgent care	$0 copay	—
Worldwide emergency transportation	$295 copay; 20% coinsurance	—
Hospital care
Inpatient hospital stay	$390 per day for days 1–6; $0 per day for days 7–90(authorization required)	50% coinsurance per stay
Outpatient hospital services	$395 copay(authorization required)	50% coinsurance
Outpatient observation	$395 copay	50% coinsurance
Ambulatory surgical center	$345 copay(authorization required)	50% coinsurance
Outpatient blood services	$0 copay	$0 copay
Skilled nursing and home health
Skilled nursing facility	$0 per day for days 1–20; $218 per day for days 21–100(authorization required)	50% coinsurance per stay
Home health care	$0 copay(authorization required)	50% coinsurance
Kidney dialysis	20% coinsurance(authorization required)	20% coinsurance
Rehabilitation
Occupational therapy	$15 copay(authorization required)	50% coinsurance
Physical therapy and speech-language therapy	$15 copay(authorization required)	50% coinsurance
Cardiac rehabilitation	$0 copay(authorization required)	50% coinsurance
Pulmonary rehabilitation	$15 copay(authorization required)	50% coinsurance
Mental health and substance use
Inpatient psychiatric hospital stay	$390 per day for days 1–6; $0 per day for days 7–90(authorization required)	50% coinsurance per stay
Outpatient mental health, individual session	$25 copay(authorization required)	50% coinsurance
Outpatient mental health, group session	$15 copay(authorization required)	50% coinsurance
Psychiatrist, individual session	$25 copay(authorization required)	50% coinsurance
Psychiatrist, group session	$15 copay(authorization required)	50% coinsurance
Partial hospitalization	$105 copay(authorization required)	50% coinsurance
Intensive outpatient program	$105 copay(authorization required)	50% coinsurance
Outpatient substance use, individual session	$25 copay(authorization required)	50% coinsurance
Outpatient substance use, group session	$15 copay(authorization required)	50% coinsurance
Opioid treatment program	$0 copay(authorization required)	50% coinsurance
Ambulance and transportation
Ground ambulance	$295 copay(authorization required)	$295 copay
Air ambulance	20% coinsurance(authorization required)	20% coinsurance
Transportation to plan-approved locations	$0 copay(limits apply)	$0 copay
Medical equipment and supplies
Durable medical equipment (e.g. wheelchairs, oxygen)	20% coinsurance(authorization required)	50% coinsurance
Prosthetics (e.g. braces, artificial limbs)	20% coinsurance(authorization required)	50% coinsurance
Medical supplies	20% coinsurance(authorization required)	50% coinsurance
Diabetes supplies	0%–50% coinsurance(authorization required)	50% coinsurance
Diabetic therapeutic shoes or inserts	$0 copay(authorization required)	50% coinsurance
Chiropractic, acupuncture and foot care
Chiropractic (Medicare-covered)	$15 copay(authorization required)	50% coinsurance
Routine chiropractic care	Not covered	—
Acupuncture	Not covered	—
Foot exams and treatment (Medicare-covered)	$15 copay	50% coinsurance
Routine foot care	$15 copay(limits apply)	50% coinsurance
Dental?
Medicare-covered dental services	20% coinsurance(authorization required)	50% coinsurance
Preventive dental plan limit	$1,000 plan limit every year	—
Oral exams	$0 copay(limits apply)	50% coinsurance
Cleanings	$0 copay(limits apply)	50% coinsurance
Fluoride treatment	$0 copay(authorization required, limits apply)	50% coinsurance
Dental x-rays	$0 copay(limits apply)	50% coinsurance
Other diagnostic dental services	$0 copay(authorization required)	50% coinsurance
Other preventive dental services	$0 copay	50% coinsurance
Restorative services (fillings, crowns)	20% coinsurance(authorization required, limits apply)	50% coinsurance
Endodontics (root canals)	$0 copay(authorization required, limits apply)	50% coinsurance
Periodontics (gum disease)	$0 copay(authorization required, limits apply)	50% coinsurance
Dentures and other removable prosthodontics	50% coinsurance(authorization required, limits apply)	50% coinsurance
Maxillofacial prosthetics	Not covered	—
Implants	Not covered	—
Bridges and other fixed prosthodontics	50% coinsurance(authorization required, limits apply)	50% coinsurance
Oral and maxillofacial surgery	20% coinsurance(authorization required)	50% coinsurance
Orthodontics	Not covered	—
Adjunctive general services	Not covered	—
Vision?
Eye exam (Medicare-covered)	$0 copay	—
Routine eye exam	$0 copay(limits apply)	$0 copay
Eyewear after cataract surgery (Medicare-covered)	$0 copay(limits apply)	—
Eyewear plan limit	$250 plan limit every two years	—
Contact lenses	$0 copay(limits apply)	$0 copay
Eyeglasses (frames and lenses)	$0 copay(limits apply)	$0 copay
Eyeglass lenses	Not covered	—
Eyeglass frames	Not covered	—
Eyewear upgrades	Not covered	—
Hearing?
Hearing exam (Medicare-covered)	$0 copay	—
Routine hearing exam	$0 copay(limits apply)	$0 copay
Hearing aid fitting and evaluation	$0 copay	$0 copay
Hearing aids (all types)	$399–$899 copay(limits apply)	$399–$899 copay
Hearing aids, inner ear	Not covered	—
Hearing aids, outer ear	Not covered	—
Hearing aids, over the ear	Not covered	—
Medicare Part B drugs
Part B insulin	0%–20% coinsurance(authorization required, step therapy may apply)	$35 copay
Chemotherapy and radiation drugs	0%–20% coinsurance(authorization required, step therapy may apply)	50% coinsurance
Other Part B drugs	0%–20% coinsurance(authorization required, step therapy may apply)	50% coinsurance
Other extra benefits?
Over-the-counter (OTC) allowance	$60 allowance every month	—
Meals after a hospital stay or for a chronic condition	$0 copay	$0 copay
Fitness benefit	$0 copay	$0 copay
Health education	Not covered	—
Nutritional / dietary benefit	Not covered	—
Extra smoking and tobacco cessation counseling	Not covered	—
Enhanced disease management	$0 copay	$0 copay
Telemonitoring	Not covered	—
Remote access technologies (web/phone, nurse line)	$0 copay	$0 copay
Home and bathroom safety devices	Not covered	—
Counseling services	Not covered	—
In-home safety assessment	Not covered	—
Personal emergency response system (PERS)	Not covered	—
Medical nutrition therapy	Not covered	—
Post-discharge in-home medication reconciliation	Not covered	—
Re-admission prevention	Not covered	—
Wigs for hair loss from chemotherapy	Not covered	—
Weight management programs	Not covered	—
Alternative therapies	Not covered	—
Therapeutic massage	Not covered	—
Adult day health services	Not covered	—
Home-based palliative care	Not covered	—
In-home support services	Not covered	—
Support for caregivers	Not covered	—

In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.

Drug tiers — preferred pharmacy, initial coverage

Tier	Cost-sharing
Tier 1	$0.00
Tier 2	$0.00
Tier 3	$42.00
Tier 4	50%
Tier 5	30%

Rx cost-sharing by coverage phase

Tier	30-day supply			90-day supply
Tier	Preferred	Standard	Mail Order	Preferred	Standard	Mail Order
Initial deductible phase
Tier 1: Preferred Generic	$0.00	$6.00	$0.00	$0.00	$15.00	$0.00
Tier 2: Generic	$0.00	$15.00	$0.00	$0.00	$35.00	$0.00
Initial coverage phase
Tier 1: Preferred Generic	$0.00	$6.00	$0.00	$0.00	$15.00	$0.00
Tier 2: Generic	$0.00	$15.00	$0.00	$0.00	$35.00	$0.00
Tier 3: Preferred Brand	$42.00	$47.00	$42.00	$105.00	$135.00	$105.00
Tier 4: Non-Preferred Drug	50%	50%	50%	n/a	n/a	n/a
Tier 5: Specialty Tier	30%	30%	30%	n/a	n/a	n/a
Catastrophic coverage phase
Tier 1: Preferred Generic	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 2: Generic	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 3: Preferred Brand	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 4: Non-Preferred Drug	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 5: Specialty Tier	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00

Also available in 45 other TN counties

Benefits in plain text

BlueAdvantage Total Heart and Diabetes (PPO C-SNP) (H7917-045-0) is a 2026 PPO C-SNP Medicare Advantage plan offered by BlueCross BlueShield of Tennessee, available to residents of Fayette County, TN.

The monthly premium is $0.00 (Part C and Part D together).

With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.

Its in-network out-of-pocket maximum is $6,700.00.

The combined in- and out-of-network out-of-pocket maximum is $10,100.00.

The drug deductible is $250.00. Tier 1 and 2 exempt.

It is a special needs plan (Chronic-condition SNP).

The plan's formulary lists 3,455 drugs.

At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $0.00; tier 3: $42.00; tier 4: 50%; tier 5: 30%.

CMS gives the plan's contract (H7917) an overall rating of 4 out of 5 stars.

Email a copy of the plan benefit details

Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.