• 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?
• Do I have to pay for preventive medical services funds from my HCA?
• What covered services will I have to pay for out of my own pocket?
• How do I use the funds in my HCA?
• If I have a health care Flexible Spending Account (FSA) and an HCA, which account can I use to pay my eligible health expenses?
• What if I spend all of the money in my HCA?
• How does the HCA roll-over feature work?
• What happens to the HCA balance if I leave the BlueEdge HCA plan?
• How does the prescription drug plan work?
• What if I have questions about my benefits?
BlueEdge is a consumer-driven health plan that works with a spending account option – a Health Care Account (HCA) – that your employer funds. BlueEdge gives you control over how you spend your health care dollars and includes four major components:
- HCA funds from your employer are used to pay for covered health care expenses. Money spent from this account, for covered services, counts toward your deductible.
- PPO benefits begin after you meet the deductible. You have the freedom to see any doctor without a referral.
- Preventive care and wellness visits are covered – nothing is deducted from the spending account and you don't need to meet the deductible to enjoy these benefits.
- Online decision resources help increase your awareness and knowledge of health issues and help you keep track of your 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 you satisfy a plan deductible or copayment. With BlueEdge, your preventive care and wellness services are covered without first meeting the deductible. Your employer may also set aside a specific amount of money for you each benefit year in an HCA. The HCA funds pay for other covered health care expenses that are also applied to your deductible. You pay the remaining deductible amount and then PPO benefits begin. Unused HCA funds roll over year to year, as long as you remain 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 you to use for covered health care expenses. The HCA is funded by your employer. Charges for covered medical care services are first paid from this account. Money spent from the HCA is also applied toward your annual deductible. Unspent funds roll over from year to year. If you leave the plan, the funds return to your employer.
What is the BlueEdge HCA Plan deductible?
Like most other PPO plans, BlueEdge includes an annual deductible. A deductible is a fixed amount you are required to pay before health care benefits begin. The HCA pays a portion of the deductible and you are 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.
Do I have to pay for preventive medical services funds from my HCA?
No. Most preventive medical services (e.g., routine physical exams, age-based testing, and vaccinations) are covered under the BlueEdge HCA Plan when you receive care from in-network doctors. Check your group plan documents for specific coverage details.
What covered services will I have to pay for out of my own pocket?
There are three circumstances when you will have out-of-pocket expenses:
- You've used all your HCA funds, but have not yet met your deductible. You are responsible for paying for health care services until you satisfy the deductible.
- You've met your deductible, so PPO benefits are available. If your plan includes coinsurance, you will be responsible for paying a percentage of the charges. There is an out-of-pocket maximum, so you won't pay more than this amount during the benefit year as long as you stay in network. Check your plan documents for specific coverage details.
- Non-covered services, additional coinsurance (until you meet the higher out-of-pocket limit) and charges in excess of our allowed amount when you receive services out of network.
How do I use the funds in my HCA?
When you use an in-network provider, the provider will submit the claim for you. 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 you to file.
If you receive care from an out-of-network doctor or hospital, the provider will most likely also file your claim with Blue Cross and Blue Shield of New Mexico. However, if you need to file a claim yourself, you can download a form from online and send it to the address on the back of your member ID card.
Your eligible expenses are deducted from your 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 I spend all of the money in my HCA?
If you use all of your employer's HCA contribution, you are responsible for any remaining balance of your deductible before your PPO benefits begin.
How does the HCA roll-over feature work?
If there is a remaining balance in your 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 your employer (up to the maximum HCA balance specified your employer's plan). The total balance remains available to you as long as you participate in the plan. The greater the balance in your HCA, the less you have to pay out-of-pocket.
What happens to the HCA balance if I leave the BlueEdge HCA plan?
If you choose another plan or leave the company without continuing your coverage (e.g., under COBRA), the balance in the HCA returns to your employer.
How does the prescription drug plan work?
You have one of the prescription drug plans below. Please refer to your BCBSNM member ID card or your Prescription Drug Plan Rider to confirm which plan you have.
Percent/Coinsurance Drug Plan
Your 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, you will pay the actual percentage amount.
| Program | Percentage You Pay | 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 – you pay 50% | N/A – you pay 50% |
Your copayment will never exceed the maximum copayment listed. Your 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. Be sure to have your prescriptions filled 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 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 plans allow you 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. Your copayment is based on whether you are 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 | You pay this amount when you receive a generic drug. |
| Tier 2=middle copayment* | You pay this amount when you receive a brand-name drug that is on our drug list and no generic is available. |
| Tier 3=highest copayment* | You pay this amount when you receive a brand-name drug that is not on our drug list. |
| Tier 4=specialty drug | You pay a copay or percentage based on your plan benefits. |
*If you or your doctor prefer that you receive a brand-name drug when a generic equivalent is available, you'll pay the Tier 1 copayment PLUS the difference in cost between the generic and brand-name drug.
Under the PrimeMail Pharmacy Program, your plan may allow you to receive up to three packages (a 90-day supply) via mail order for only 2-1/2 times the retail copayment.
Make sure to have your 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 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
The 3-Tier prescription drug plan has three levels of copayments. You 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. You pay additional costs if you receive a brand-name drug when a generic equivalent is available (even if your doctor requests the brand-name drug). Make sure to have your prescriptions filled at either a participating pharmacy or through the PrimeMail Pharmacy mail-order program. Search the Provider Finder® to locate a participating pharmacy in New Mexico. Coverage is always subject to the limitations of your 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.
What if I have questions about my benefits?
BCBSNM's customer service representatives are available to answer your questions 6 a.m. to 8 p.m. MT, Monday through Friday, and 8 a.m. to 5 p.m. MT on weekends and holidays (closed Thanksgiving and Christmas Day). If you call after hours, you can leave a message and we will return your call by the next business day. Call the toll-free number printed on the back of your member ID card. Please have your ID card available when you call. You may also email your questions to BCBSNM Customer Service.
Learn More About BlueEdge HCA
Overview
Benefit Information
How BlueEdge HCA Works
Spending Account and the Deductible
