2025 Blue Cross and Blue Shield Service Benefit Plan - FEP Blue Focus
Section 5(d). Emergency Services/Accidents
Page 78
Section 5(d). Emergency Services/Accidents
Page 78
Benefit Description
Accidental Injury (cont.)
Urgent care centers, not licensed as or permitted to provide emergency services and supplies, including professional providers’ services, diagnostic studies, radiology services, laboratory tests and pathology services, when billed by the provider.
You Pay
Preferred urgent care center: Nothing (no deductible)
Non-preferred (Participating and Non-participating): You pay all charges
Accidental Injury (cont.)
Urgent care centers, not licensed as or permitted to provide emergency services and supplies, including professional providers’ services, diagnostic studies, radiology services, laboratory tests and pathology services, when billed by the provider.
You Pay
Preferred urgent care center: Nothing (no deductible)
Non-preferred (Participating and Non-participating): You pay all charges
Benefit Description
Not covered:
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
You Pay
All charges
Benefit Description
Medical Emergency
Outpatient medical or surgical services and supplies related to a medical emergency to include:
Notes:
You Pay
Preferred: 30% of the Plan allowance (deductible applies)
Non-preferred professional providers (Participating and Non-participating):
Non-preferred facilities (Member/Non-member):
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 your liability for the difference between our allowance and the billed amount may be limited under the NSA. See Section 4 for more information.
- 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 (deductible applies)
Non-preferred professional providers (Participating and Non-participating):
- Participating: 30% of the Plan allowance (deductible applies)
- Non-participating: 30% of the Plan allowance (deductible applies)
Non-preferred facilities (Member/Non-member):
- Member: 30% of the Plan allowance (deductible applies)
- Non-member: 30% of the Plan allowance (deductible applies)
Benefit Description
Notes:
You Pay
$25 copayment per visit (no deductible)
- Urgent care centers, licensed as and permitted to provide emergency services and supplies, including professional providers’ services, diagnostic studies, radiology services, laboratory tests and pathology services, when billed by the provider regardless of the providers network status
Notes:
- The urgent care center must be licensed as and permitted to provide emergency services in order to receive protections under the NSA. See Section 4 for more information.
- Benefits for crutches, splints, braces, etc. when billed by a provider other than the urgent care center are stated in Section 5(a), DME.
You Pay
$25 copayment per visit (no deductible)
Benefit Description
Note: Benefits for crutches, splints, braces, etc. when billed by a provider other than the urgent care center are stated in Section 5(a), DME.
You Pay
Preferred urgent care center: $25 copayment per visit (no deductible)
Non-preferred (Participating/Non-participating): You pay all charges
- Urgent care centers, not licensed as or permitted to provide emergency services and supplies, including professional providers’ services, diagnostic studies, radiology services, laboratory tests and pathology services, when billed by the 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), DME.
You Pay
Preferred urgent care center: $25 copayment per visit (no deductible)
Non-preferred (Participating/Non-participating): You pay all charges
Medical Emergency - continued on next page