Blue Access for Employers

Frequently Asked Questions about
BlueEdgeSM HCA Plans



What is BlueEdge?

BlueEdge is a consumer-driven health plan that works with a spending account option – a Health Care Account (HCA) – that you fund for your employees. BlueEdge gives members control over how they spend their health care dollars and includes four major components:

  1. HCA you provide for your employees are used to pay for covered health care expenses. Money spent from this account, for covered services, counts toward the deductible.
    PPO benefits begin after members meet the deductible. They have the freedom to see any doctor without a referral.
  2. Preventive care and wellness visits are covered – nothing is deducted from the spending account and employees don't need to meet the deductible to enjoy these benefits.
  3. Online decision resources help increase members' awareness and knowledge of health issues and help them keep track of HCA and health care expenses.

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How is BlueEdge different from a traditional health plan?

Most traditional plans pay a percentage of the charges for covered medical expenses only after the member satisfies a plan deductible or copayment. With BlueEdge, your employees' preventive care and wellness services are covered without first meeting the deductible. You may also set aside a specific amount of money for your employees each benefit year in an HCA. The HCA funds pay for other covered health care expenses that are also applied to the deductible. Your employees pay the remaining deductible amount and then PPO benefits begin. Unused HCA funds roll over year to year, as long as members remain in the plan.

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What is a Health Care Account (HCA)?

An HCA is a spending account with an amount of money set aside for your employees to use for covered health care expenses. You fund the HCA for your employees. Charges for covered medical care services are first paid from this account. Money spent from the HCA is also applied toward the annual deductible. Unspent funds roll over from year to year. If a member leaves the plan, the funds return to the employer.

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What is the BlueEdge HCA Plan deductible?

Like most other PPO plans, BlueEdge includes an annual deductible. A deductible is a fixed amount a member is required to pay before health care benefits begin. The HCA pays a portion of the deductible and the member is responsible for paying the remaining part.

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How does the BlueEdge HCA family deductible work?

The family HCA can be used to pay for any covered services received by any family member covered under the plan. The deductible works like most other Blue Cross and Blue Shield of New Mexico PPOs – no family member has to satisfy more than the individual deductible before receiving PPO benefits, and the PPO benefits will be paid for the whole family once the family deductible is met.

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Do my employees have to pay for their preventive medical services from their HCAs?

No. Most preventive medical services (e.g., routine physical exams, age-based testing, and vaccinations) are covered under the BlueEdge HCA Plan when the member receives care from in network doctors. Check your group plan documents for specific coverage details.

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What covered services will my employees have to pay out-of-pocket?

There are three circumstances when a member will have out-of-pocket expenses:

  1. The member has used all of his or her HCA funds, but has not yet met the deductible. The member is responsible for paying for health care services until the deductible has been satisfied.
  2. The member has met the deductible, so PPO benefits are available. If your plan includes coinsurance, the member will be responsible for paying a percentage of the charges. There is an out-of-pocket maximum, so the member won't pay more than this amount during the benefit year as long as services are received in network. Check your plan documents for specific coverage details.
  3. Non-covered services, additional coinsurance (until the member meets the higher out-of-pocket limit), and charges in excess of our allowed amount when services are received out of network.

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How do my employees use the funds in their HCAs?

When a member uses an in-network provider, the provider will submit the claim. Blue Cross and Blue Shield of New Mexico's integrated claim process automatically deducts funds from the HCA and/or pays the claim from the PPO. There is no paperwork for the member to file.

If the member receives care from an out-of-network doctor or hospital, the provider will most likely also file the claim with Blue Cross and Blue Shield of New Mexico. However, if the member needs to file a claim, he or she can download a claim form and send it to the address on the back of the member ID card.

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If an employee has a health care Flexible Spending Account (FSA) and a Health Care Account, which account can the employee use to pay for eligible health expenses?

Eligible expenses are deducted from the HCA first. When that account is depleted, health care expenses can then be reimbursed from the FSA. That is, the funds in the FSA can be used to satisfy the remaining portion of the deductible, or coinsurance payments after the deductible is met, or non-covered eligible charges.

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What if an employee spends all of the money in his or her HCA?

If an employee uses all of your HCA contribution, the employee is responsible for any remaining balance of his or her deductible before PPO benefits begin.

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How does the HCA roll-over feature work?

If there is a remaining balance in an employee's HCA at the end of the benefit year, it automatically rolls over to the next year and is added to the annual contribution that you make for the employee (up to the maximum HCA balance specified in your plan). The total balance remains available as long as the employee participates in the plan. The greater the balance in the HCA, the less the employee has to pay out-of-pocket.

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What happens to the HCA balance if an employee leaves the BlueEdge HCA plan?

If an employee chooses another plan or leaves the company without continuing coverage (e.g., under COBRA), the balance in the Health Care Account returns to the employer.

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How does the prescription drug plan work?

You have chosen one of the prescription drug plans below for your employees. Please refer to your Prescription Drug Plan Rider or BCBSNM member ID card to confirm which plan you selected.

Percent/Coinsurance Drug Plan

The copayment for prescription drugs purchased through this drug plan is 25 percent of the covered charge for generic drugs and 50 percent of the covered charge for brand-name drugs. If the percentage of the covered charge falls between the minimum/maximum copayment, the member will pay the actual percentage amount.

Program Percentage Member Pays Minimum Amount Maximum Amount
Retail Pharmacy: Up to a 30-day supply or 180 units, whichever is less.
Generic drug 25% $20 $75
Brand-name drug 50% $40 $125
PrimeMail Pharmacy Mail-Order Service: Up to a 90-day supply or 540 units, whichever is less.
Generic drug 25% $40 $150
Brand-name drug 50% $80 $250
Prior-approved enteral nutritional products and special medical foods. 50% N/A – member pays 50% N/A – member pays 50%

The copayment will never exceed the maximum copayment listed. Prescription copayments are applied to an annual out-of-pocket limit of $2,500. When this limit is reached, the drug plan pays 100 percent of covered charges for the remainder of the calendar year. The out-of-pocket limit, which includes coinsurance and copayments, is separate from the medical plan's out-of-pocket limit. Advise your employees to fill prescriptions at a participating pharmacy (search the Provider Finder®) or through the PrimeMail Pharmacy mail-order service. Coverage is always subject to the limitations of your group's health care plan. For some medications, prior approval, generic substitution, or quantity limits may apply. See your Prescription Drug Plan Rider for details, limitations, and exclusions.

The BCBSNM Drug List does not apply to the 25/50 Percent Prescription Drug Plan.

4-Tier Drug Plan

The 4-Tier prescription drug plan allows members to get a prescription drug even if it's not on the BCBSNM Drug List and to get a brand-name drug even when a generic-equivalent is available. The copayment is based on whether the member is receiving a generic drug or a brand-name drug AND whether the drug is on our Drug List.

Prescription drug payments are based on the following tier structure for a 30-day supply or 120 units, whichever is less.

Tier 1
copayment
The member pays this amount for a generic drug.
Tier 2
copayment*
The member pays this amount for a brand-name drug that is on our drug list when no generic is available.
Tier 3
copayment*
The member pays this amount for a brand-name drug that is not on our drug list or when receiving a preferred specialty drug**.
Tier 4
copayment for non-preferred specialty drugs**
The member pays 15% of covered charges or up to a $250 maximum copayment per prescription for non-preferred specialty drugs.

* If a member or a member's doctor prefers that he or she receive a brand-name drug when a generic equivalent is available, the member will pay the Tier 1 copayment PLUS the difference in cost between the generic and brand-name drug.

** Specialty pharmacy drugs are used to treat serious and/or chronic conditions such as multiple sclerosis, pulmonary hypertension, hepatitis, and rheumatoid arthritis. These medications are typically injectable and can be administered by a patient or family member. Members must use a contracting specialty network pharmacy to fill these specific prescriptions.

Under the PrimeMail Pharmacy Program, you can select a plan that allows your employees to receive up to three packages (a 90-day supply) via mail order for only 2-1/2 times the retail copayment.

Advise your employees to have prescriptions filled at either a participating pharmacy or through the PrimeMail Pharmacy Program, our managed prescription mail-order service. Search the Provider Finder to locate a participating pharmacy in New Mexico. Coverage is always subject to the limitations of your group's health care plan. For some medications, prior approval requirements, generic substitution, or quantity limits may apply.

See your Prescription Drug Plan Rider for details, limitations, exclusions, and Specialty Pharmacy Program information.

3-Tier Drug Plan (For groups 51+ only)

The 3-Tier prescription drug plan has three levels of copayments. Members pay the Tier 1 copayment (the lowest) for a generic drug; the Tier 2 copayment for a brand-name formulary drug (if a generic is not available); and the Tier 3 copayment for a covered drug that is not on the BCBSNM drug list. Members pay additional costs if receiving a brand-name drug when a generic equivalent is available (even if the member's doctor requests the brand-name drug). Advise your employees to have prescriptions filled at either a participating pharmacy or through the PrimeMail Pharmacy mail-order program. Members can search the Provider Finder to locate a participating pharmacy in New Mexico. Coverage is always subject to the limitations of your group's health care plan and some drugs are not covered. For some medications, prior approval requirements, generic substitution, or quantity limits may apply. See your Prescription Drug Plan Rider for details, limitations, and exclusions.

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What if my employees have questions about their benefits?

BCBSNM's customer service representatives are available to answer your employees' questions 6 a.m. to 8 p.m. MT, Monday through Friday, and 8 a.m. to 5 p.m. MT weekends and holidays (closed Thanksgiving and Christmas Day). If a member calls after hours, he or she can leave a message and we will return the call by the next business day. Members should call the toll-free number printed on the back of the member ID card and should have the ID card available when calling. They may also contact customer service with a secure message through Blue Access for MembersSM.

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Learn More About BlueEdge HCA

Overview
Benefit Information
How BlueEdge HCA Works
Spending Account and the Deductible
Common FAQs

 

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