2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(d). Emergency Services/Accidents


Note: The calendar year deductible applies to almost all benefits in this Section. We say "(No deductible)" when it does not apply.
 
Benefit Description

Medical Emergency
Outpatient medical or surgical services and supplies related to a medical emergency to include:

 
  • 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
     
  • 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

Notes:

 
  • All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.
     
  • If you are treated by a non-PPO professional provider in a PPO facility, you will be responsible for your cost-share for the services, plus any difference between our allowance and the billed amount.
     
  • We pay inpatient benefits if you are admitted as a result of a medical emergency. See Section 5(c).
     
  • Regular benefit levels apply to covered services provided in settings other than the emergency room. See Section 5(c) for those benefits.

You Pay
Preferred: 30% of the Plan allowance

Non-preferred professional providers (Participating and Non-participating):

 
  • Participating: 30% of the Plan allowance
     
  • Non-participating: 30% of the Plan allowance, plus any difference between our allowance and the billed amount

Non-preferred facilities (Member/Non-member):

 
  • Member: 30% of the Plan allowance
     
  • Non-member: 30% of the Plan allowance
 
Benefit Description
  • Urgent care center services and supplies, including professional providers’ services, diagnostic studies, radiology services, laboratory tests and pathology services, when billed by the urgent care provider

Note: Benefits for crutches, splints, braces, etc. when billed by a provider other than the urgent care center are stated in Section 5(a), pages 55-56.

You Pay
Preferred urgent care center: $25 copayment per visit (no deductible)

Non-preferred (Participating/Non-participating): You pay all charges
 
Benefit Description
Not covered: Emergency room professional charges for shift differentials

You Pay
All charges
 

List Item:

emergency
accidents
outpatient
medical
hospital
room
diagnostic
radiology
laboratory
pathology
follow-up
preferred
non-ppo
ppo
non-preferred
crutches
splints
braces
urgent
care