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Blue Access for Producers

BlueEdgeSM HCA


The BlueEdge HCA plans are another part of the BCBSTX portfolio of consumer-driven health plans. BlueEdge HCA plans put members in charge of their health by empowering them to make their own decisions about how their health care dollars are spent. BCBSTX provides online tools and resources to help members make wise and informed decisions about their health care and better manage their health care benefits. Here is what makes BlueEdge HCA an exciting option:

Standard plans provide the following:

  • The HCA pays for the member's eligible expenses that are applied to the deductible until the balance is depleted. When the HCA balance reaches zero, any additional charges the member incurs for services covered under the PPO plan are then subject to the "self-pay corridor" portion of the deductible. The "self-pay corridor" is the difference between the calendar year deductible and the employer-funded HCA. It is the member's responsibility portion of the plan deductible that must be satisfied before benefits under the PPO health coverage begin.
  • Preventive care services are covered at 100% with no calendar year deductible when services are received from in-network providers. The claims are paid directly from the PPO plan and not from the HCA.
  • BlueEdge provides a seamless approach to claims payment.
  • Members do not have to pay for services up front or submit claims for reimbursement when receiving services from in-network providers.
  • Your client only funds claims as they are paid. Unused account balances remain part of the company's cash flow.
  • If there is a remaining balance of unused HCA funds at the end of the calendar year, that amount rolls over to the next year and is added to your client's annual contribution.
  • The total balance remains available to the member as long as he/she participates in the plan; however, to limit the company's financial liability, the amount that accumulates in this account is capped at the amount of the plan deductible.
  • If the HCA balance equals the calendar year deductible amount, no additional contribution to the HCA is required by your client for that calendar year.
  • If a member changes jobs or medical plans, the HCA funds remain with your client.
  • No referral needed to the doctor(s) of their choice.

Benefits

  • Well-child and adult care, including immunizations, and screenings such as cholesterol, breast cancer, prostate cancer, and cervical cancer are covered at 100% of the allowable amount when received by in-network providers.
  • Standard PPO plan coverage includes, but is not limited to: office visits, hospital and surgical care, diagnostic testing, emergency benefits, maternity care, rehabilitation therapy (physical, speech, and occupational therapy), mental health and chemical dependency, and prescription drug coverage.

BCBSTX offers a variety of BlueEdge HCA plans to large clients with customized deductible and coinsurance options on an insured or self-funded basis.

Benefit levels vary depending on whether care is received in-network or out-of-network. Members must use network providers to receive the higher (in-network) level of benefits for all of their care under the PPO plan.

BlueEdge HCA plans are available to clients through the BlueChoice Network, one of the largest networks in Texas. BlueChoice provides:

  • Access to the national BlueCard® network when members are outside of Texas
  • Over 600 participating hospitals and facilities in Texas
  • More than 800,000 doctors and 6,000 hospitals contracting with Blue Cross and Blue Shield plans nationwide

For care outside of Texas, members have access to the BlueCard national network of providers.

BCBSTX offers a variety of PPO plans with varying deductible, coinsurance and copayment amount options. All plans include an outpatient prescription drug benefit with either a three-tier or four-tier pharmacy copay design.

The three-tier pharmacy copay plan design includes three tiers of medications that are comprised of:

  • Generic drugs
  • Preferred brand-name drugs
  • Non-preferred brand-name drugs

The four-tier pharmacy copay plan design includes four tiers of medications that are comprised of:

  • Generic drugs
  • Preferred brand-name drugs
  • Non-preferred brand-name/preferred specialty drugs
  • Non-preferred specialty drugs

Prescription drugs are available through retail pharmacies throughout Texas and mail order pharmacy services.

For more detailed information on available benefit designs, a description of the services and supplies that are covered, a listing of those services and supplies that are limited or excluded, terms and general administration, or for any questions you may have regarding our products and services, contact us for the phone number of the regional sales office near you.

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