• What is BlueEdge?
• How is BlueEdge different from a traditional health plan?
• What is a Health Care Account (HCA)?
• What is the BlueEdge HCA Plan deductible?
• How does the BlueEdge HCA family deductible work?
• Does the employee have to pay for preventive medical services funds from the HCA?
• What covered services will the employee have to pay for out of his/her own pocket?
• How does the employee use the funds in his/her HCA?
• If the employee has a health care Flexible Spending Account (FSA) and an HCA, which account can he/she use to pay eligible health expenses?
• What if the employee spends all of the money in the HCA?
• How does the HCA roll-over feature work?
• What happens to the HCA balance if the employee leaves the BlueEdge HCA plan?
• How does the prescription drug plan work?
• What if I have questions about group plans?
BlueEdge is a consumer-driven health plan that works with a spending account option – a Health Care Account (HCA) – that the employer funds. BlueEdge gives the employee control over how the health care dollars are spent and includes four major components:
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HCA funds from the employer are used to pay for covered health care expenses. Money spent from this account, for covered services, counts toward the deductible.
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PPO benefits begin after the employee meets the deductible. The employee has the freedom to see any doctor without a referral.
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Preventive care and wellness visits are covered – nothing is deducted from the spending account and the employee doesn't need to meet the deductible to enjoy these benefits.
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Online decision resources help increase awareness and knowledge of health issues and help keep track of the HCA and health care expenses.
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 employee satisfies a plan deductible or copayment. With BlueEdge, the preventive care and wellness services are covered without first meeting the deductible. The employer may also set aside a specific amount of money for the employee each benefit year in an HCA. The HCA funds pay for other covered health care expenses that are also applied to your deductible. The employee pays the remaining deductible amount and then PPO benefits begin. Unused HCA funds roll over year to year, as long as the employee remains in the plan.
What is a Health Care Account (HCA)?
A Health Care Account is a spending account with an amount of money set aside for the employee to use for covered health care expenses. The HCA is funded by the employer. 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 the employee leaves the plan, the funds return to the employer.
What is the BlueEdge HCA Plan deductible?
Like most other PPO plans, BlueEdge includes an annual deductible. A deductible is a fixed amount the employee is required to pay before health care benefits begin. The HCA pays a portion of the deductible and the employee is responsible for paying the remaining part.
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.
Does the employee have to pay for preventive medical services funds from the HCA?
No. Most preventive medical services (e.g., routine physical exams, age-based testing, and vaccinations) are covered under the BlueEdge HCA Plan when care is received from in-network doctors. The employee can check the group plan documents for specific coverage details.
What covered services will the employee have to pay for out of his/her own pocket?
There are three circumstances when the employee will have out-of-pocket expenses:
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The employee has used all of the HCA funds, but has not yet met the deductible. The employee is responsible for paying for health care services until the deductible is satisfied.
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The employee has met the deductible, so PPO benefits are available. If the plan includes coinsurance, the employee will be responsible for paying a percentage of the charges. There is an out-of-pocket maximum, so the employee won't pay more than this amount during the benefit year as long as he/she stays in network. The employee can check the plan documents for specific coverage details.
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Non-covered services, additional coinsurance (until the employee meets the higher out-of-pocket limit), and charges in excess of our allowed amount when the employee receives services out of network.
How does the employee use the funds in his/her HCA?
When the employee 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 employee to file.
If the employee 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 employee needs to file a claim, he/she can download a form from online and send it to the address on the back of the member ID card.
The 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.
What if the employee spends all of the money in the HCA?
If the employee uses all of the employer's HCA contribution, he/she is responsible for any remaining balance of the deductible before the PPO benefits begin.
How does the HCA roll-over feature work?
If there is a remaining balance in the HCA at the end of the benefit year, it automatically rolls over to the next year and is added to the annual contribution made by the employer (up to the maximum HCA balance specified the employer's plan). The total balance remains available to the employee as long as he/she participates in the plan. The greater the balance in the HCA, the less the employee has to pay out-of-pocket.
What happens to the HCA balance if the employee leaves the BlueEdge HCA plan?
If the employee chooses another plan or leaves the company without continuing coverage (e.g., under COBRA), the balance in the HCA returns to the employer.
How does the prescription drug plan work?
Your client may select one of the prescription drug plans below. BCBSNM members can refer to the BCBSNM member ID card or the Prescription Drug Plan Rider to confirm which plan they have.
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. The prescription copayments are applied to an annual out-of -pocket limit of $2,500. When this limit is reached, the drug plan pays 100% 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. The member should have prescriptions filled at a participating pharmacy (the member can see the Network Directory or search the Provider Finder®) or through the PrimeMail Pharmacy mail-order service. Coverage is always subject to the limitations of the health care plan. For some medications, prior approval, generic substitution, or quantity limits may apply. See the 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 plans allow the member 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=lowest copayment | The member pays this amount when he/she receives a generic drug. |
| Tier 2=middle copayment* | The member pays this amount when he/she receives a brand-name drug that is on our drug list and no generic is available. |
| Tier 3=highest copayment* | The member pays this amount when he/she receives a brand-name drug that is not on our drug list. |
| Tier 4=specialty drug | The member pays a copay or percentage based on the plan benefits. |
*If the member or his/her doctor prefer that he/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.
Under the PrimeMail Pharmacy Program, the plan may allow the member to receive up to three packages (a 90-day supply) via mail order for only 2-1/2 times the retail copayment.
The member should have prescriptions filled at either a participating pharmacy or through the PrimeMail Pharmacy Program, our managed prescription mail-order service. The member can check the printed Network Directory for participating pharmacies or search the Provider Finder® to locate a pharmacy in New Mexico. Coverage is always subject to the limitations of the health care plan. For some medications, prior approval requirements, generic substitution, or quantity limits may apply.
See the Prescription Drug Plan Rider for details, limitations, exclusions, and Specialty Pharmacy Program information.
3-Tier Drug Plan
The 3-Tier prescription drug plan has three levels of copayments. The member pays 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. The member pays additional costs if he/she receives a brand-name drug when a generic equivalent is available (even if the doctor requests the brand-name drug). The member should have prescriptions filled at either a participating pharmacy or through the PrimeMail Pharmacy mail-order program. The employee can check the printed Network Directory for participating pharmacies or search the Provider Finder® to locate a pharmacy in New Mexico. Coverage is always subject to the limitations of the health care plan and some drugs are not covered. For some medications, prior approval requirements, generic substitution, or quantity limits may apply. See the Prescription Drug Plan Rider for details, limitations, and exclusions.
What if I have questions about group plans?
For more information about our plans for groups, please contact BCBSNM Customer Service toll-free at (800) 432-0750 or email us.
Learn More About BlueEdge HCA for Groups:
Overview
Product Summary
Benefit Information
Spending Account and the Deductible
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