2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(d). Emergency Services/Accidents
Page 86
 
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
 
Benefit Description

Ambulance
See page 83 for complete ambulance benefit and coverage information.