2

2 out of 5 stars* for plan year 2024

Plan ID: H7917-014

What You Need to Know:

  • BlueAdvantage Ruby (PPO) is a Medicare Advantage Health Maintenance Organization Local PPO plan.
  • It must provide all of the same hospital and medical benefits as Medicare Part A and Part B, however, costs may be different.
  • It has additional benefits not included in Medicare Part A and Part B, including prescription drug coverage.
  • The plan's monthly premium is $92, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is .
  • The plan includes an out-of-pocket maximum of $4,300 per year (in-network).
  • BlueAdvantage Ruby (PPO) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is .
  • This plan's Part D Initial Coverage Limit is $45.

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$92

Monthly Premium

Medicare Plan Features
Monthly Premium: $92.00
Part C Premium: $47.20
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$92.00 $47.20 $44.80 $0 $44.80 $0 0.0
Gap Coverage: Yes
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local PPO
Similar Plan: H7917-015
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: Yes, some additional gap coverage.
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $4,300
Annual Deductible: NULL
Annual Initial Coverage Limit ICL: $4,130
Number of Members enrolled in this plan in Overton, Tennessee: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
53 members 4 out of 5 Stars. 2 out of 5 Stars. 4 out of 5 Stars.
Plan Offers Mail Order: Yes
Plan Health Benefits
Total # of Formulary Drugs: 3,688 drugs
Number of Members Enrolled in this Plan in Overton, Tennessee: 5,063 members
Number of Drugs Per Tier: NULL
Preferred Pharmacy Cost Sharing During Initial Coverage Phase: NULL
Special Needs Plan SNP Eligibility Requirement: NULL
Monthly Premium Split as Follows:
Part C Premium Part D Base Premium Part D Supplemental Premium Total Premium
$47.20 $44.80 $0.00 $92.00
Monthly Premium with Extra Help Low Income Subsidy:
LIS100 Subsidy Total Monthly Premium with LIS Parts CD LIS25 Subsidy Monthly PartD Premium with LIS LIS25 Subsidy Total Monthly Premium with LIS Parts CD LIS50 Monthly PartD Premium with LIS LIS50 Subsidy Total Monthly Premium with LIS Parts CD LIS75 Monthly PartD Premium with LIS LIS75 Subsidy Total Monthly Premium with LIS Parts CD
$61.80 $37.20 $84.40 $29.70 $76.90 $22.10 $69.30
Formulary Drug Details:
Tier 1 # of Drugs per Tier Tier 1 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 2 # of Drugs per Tier Tier 2 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 3 # of Drugs per Tier Tier 3 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 4 # of Drugs per Tier Tier 4 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 5 # of Drugs per Tier Tier 6 Preferred Pharmacy Cost Sharing (initial coverage phase)
606 $1.00 1266 $5.00 430 $28.00 556 $65.00 830 33%

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4
Amerivantage Balance Plus (HMO) (2023)Local HMO$6,700$445
New plan - not yet rated.
HumanaChoice R7315-002 (Regional PPO) (2023)Regional PPO$6,700$400
4
BlueAdvantage Diamond (PPO) (2023)Local PPO$3,700$0
2
Amerivantage Balance (HMO) (2023)Local HMO$6,700$445
5
WellCare Dividend (HMO) (2023)Local HMO$6,700$0
4
WellCare Compass (HMO) (2023)Local HMO$4,900$445
4
HumanaChoice H5216-097 (PPO) (2023)Local PPO$6,700$150
4
Aetna Medicare Premier Plan (PPO) (2023)Local PPO$6,700$0
5
WellCare Value (HMO-POS) (2023)Local HMO$5,500$0
4
Cigna Fundamental Medicare (HMO) (2023)Local HMO *$6,700$-
4
Humana Honor (PPO) (2023)Local PPO *$3,400$-
4
Cigna Premier Medicare (HMO-POS) (2023)Local HMO$6,700$200
4
BlueAdvantage Emerald (PPO) (2023)Local PPO$4,900$0
2
Aetna Medicare Value Plus Plan (HMO) (2023)Local HMO$6,700$250
New plan - not yet rated.
HumanaChoice H5216-180 (PPO) (2023)Local PPO$6,700$225
4
Amerivantage Classic (HMO) (2023)Local HMO$6,500$0
5
Humana Gold Plus H4461-037 (HMO-POS) (2023)Local HMO$5,900$0
4
WellCare Patriot (HMO-POS) (2023)Local HMO *$4,500$-
4
Amerivantage Classic Plus (HMO-POS) (2023)Local HMO$4,900$0
New plan - not yet rated.
BlueAdvantage Sapphire (PPO) (2023)Local PPO$5,700$0
2
Cigna Preferred Medicare (HMO) (2023)Local HMO$6,700$0
4
Medicare Advantage Plans by BlueCross BlueShield of Tennessee
BlueAdvantage Diamond (PPO) (2023)Local PPO$3,700$0
2
BlueAdvantage Emerald (PPO) (2023)Local PPO$4,900$0
2
BlueAdvantage Sapphire (PPO) (2023)Local PPO$5,700$0
2

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