2020 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Page 83
 
Benefit Description

Ambulance

Professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically necessary, and:

 
  • Associated with covered hospital inpatient care
     
  • Related to medical emergency
     
  • Associated with covered hospice care

Notes:
 
  • We also cover medically necessary emergency care provided at the scene when transport services are not required.
     
  • Prior approval is required for all non-emergent air ambulance transport.

You Pay
30% of the Plan allowance
 
Benefit Description

Professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically necessary, and when related to accidental injury care for your accidental injury.

Notes:

 
  • We also cover medically necessary emergency care provided at the scene when transport services are not required.
     
  • Prior approval is required for all non-emergent air ambulance transport.

You Pay
Nothing (no deductible)

Note: These benefit levels apply only if you receive care in connection with, and within 72 hours after, an accidental injury. For services received after 72 hours, see above.
 
Benefit Description

Medically necessary emergency ground, air and sea ambulance transport services to the nearest hospital equipped to adequately treat your condition if you travel outside the United States, Puerto Rico and the U.S. Virgin Islands

Note: If you are traveling overseas and need assistance with emergency evacuation services to the nearest facility equipped to adequately treat your condition, please contact the Overseas Assistance Center (provided by GMMI, Inc.) by calling the center collect at 804-673-1678. See page 109 for more information.

You Pay
30% of the Plan allowance
 
Benefit Description
Not covered:

 
  • Wheelchair van services and gurney van services
     
  • Ambulance and any other modes of transportation to or from services including but not limited to physician appointments, dialysis, or diagnostic tests not associated with covered inpatient hospital care
     
  • Ambulance transport that is requested, beyond the nearest facility adequately equipped to treat the member’s condition, by patient or physician for continuity of care or other reason
     
  • Commercial air flights
     
  • Repatriation from an international location back to the United States. See definition of repatriation in Section 10. Members traveling overseas should consider purchasing a travel insurance policy that covers repatriation to your home country.
     
  • Costs associated with overseas air or sea transportation to other than the closest hospital equipped to adequately treat your condition

You Pay
All charges