2023 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(d). Emergency Services/Accidents
Page 96
Section 5(d). Emergency Services/Accidents
Page 96
Benefit Description
Accidental Injury (cont.)
Note: If you are treated by a non-PPO professional provider in a PPO facility, you will only be responsible for your cost-share and will not owe any difference between our allowance and the billed amount. (See page 32.)
Note: We pay inpatient benefits if you are admitted. See Sections 5(a), 5(b), and 5(c) for those benefits.
Note: See Section 5(g) for dental benefits for accidental injuries.
Standard Option - You Pay
Note: The benefits described on page 95 apply only if you receive care in connection with, and within 72 hours after, an accidental injury. For services received after 72 hours, regular benefits apply. See Sections 5(a), 5(b), and 5(c) for the benefits we provide.
Note: For drugs, services, supplies, and/or durable medical equipment billed by a provider other than a hospital, urgent care center, or physician, see Sections 5(a) and 5(f) for the benefit levels that apply.
Basic Option - You Pay
Note: All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.
Accidental Injury (cont.)
Note: If you are treated by a non-PPO professional provider in a PPO facility, you will only be responsible for your cost-share and will not owe any difference between our allowance and the billed amount. (See page 32.)
Note: We pay inpatient benefits if you are admitted. See Sections 5(a), 5(b), and 5(c) for those benefits.
Note: See Section 5(g) for dental benefits for accidental injuries.
Standard Option - You Pay
Note: The benefits described on page 95 apply only if you receive care in connection with, and within 72 hours after, an accidental injury. For services received after 72 hours, regular benefits apply. See Sections 5(a), 5(b), and 5(c) for the benefits we provide.
Note: For drugs, services, supplies, and/or durable medical equipment billed by a provider other than a hospital, urgent care center, or physician, see Sections 5(a) and 5(f) for the benefit levels that apply.
Basic Option - You Pay
Note: All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Oral surgery except as shown in Section 5(b)
- Injury to the teeth while eating
- Emergency room professional charges for shift differentials
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Medical Emergency
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 15% of the Plan allowance (deductible applies)
Non-participating: 15% of the Plan allowance (deductible applies)
Basic Option - You Pay
Preferred: Nothing
Participating: Nothing
Non-participating: Nothing
Medical Emergency
- Professional provider services in the emergency room, including professional care, diagnostic studies, radiology services, laboratory tests, and pathology services, when billed by a professional provider
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Participating: 15% of the Plan allowance (deductible applies)
Non-participating: 15% of the Plan allowance (deductible applies)
Basic Option - You Pay
Preferred: Nothing
Participating: Nothing
Non-participating: Nothing
Benefit Description
Note: We pay inpatient benefits if you are admitted as a result of a medical emergency. See Section 5(c).
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Member: 15% of the Plan allowance (deductible applies)
Non-member: 15% of the Plan allowance (deductible applies)
Basic Option - You Pay
Preferred emergency room: $250 copayment per day per facility
Member emergency room: $250 copayment per day per facility
Non-member emergency room: $250 copayment per day per facility
Note: If you are admitted directly to the hospital from the emergency room, you do not have to pay the $250 emergency room copayment. However, the $250 per day copayment for Preferred inpatient care still applies.
Note: All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.
- Outpatient hospital emergency room services and supplies, including professional provider services, diagnostic studies, radiology services, laboratory tests, and pathology services, when billed by the hospital
Note: We pay inpatient benefits if you are admitted as a result of a medical emergency. See Section 5(c).
Standard Option - You Pay
Preferred: 15% of the Plan allowance (deductible applies)
Member: 15% of the Plan allowance (deductible applies)
Non-member: 15% of the Plan allowance (deductible applies)
Basic Option - You Pay
Preferred emergency room: $250 copayment per day per facility
Member emergency room: $250 copayment per day per facility
Non-member emergency room: $250 copayment per day per facility
Note: If you are admitted directly to the hospital from the emergency room, you do not have to pay the $250 emergency room copayment. However, the $250 per day copayment for Preferred inpatient care still applies.
Note: All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.
Medical Emergency - continued on next page