2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(d). Emergency Services/Accidents
Medical Emergency

 

Note: For Standard Option, we state whether or not the calendar year deductible applies for each benefit listed in this Section. There is no calendar year deductible under Basic Option.

Benefit Description

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
 
  • 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: $350 copayment per day per facility

Member emergency room: $350 copayment per day per facility

Non-member emergency room: $350 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 $350 emergency room copayment. However, the $350 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.

 

Benefit Description
 
  • 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

    Note: 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.

    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.


Standard Option - You Pay
Preferred urgent care center: $30 copayment per visit (no deductible)

Participating urgent care center: $30 copayment per visit (no deductible)

Non-participating urgent care center: $30 copayment per visit (no deductible)

Basic Option - You Pay
Preferred urgent care center: $50 copayment per visit

Participating/Non-participating urgent care center: $50 copayment per visit

 

Benefit Description
 
  • 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.


Standard Option - You Pay
Preferred urgent care center: $30 copayment per visit (no deductible)

Participating urgent care center: 35% of the Plan allowance (deductible applies)

Non-participating urgent care center: 35% of the Plan allowance (deductible applies), plus any difference between our allowance and the billed amount

Basic Option - You Pay
Preferred urgent care center: $50 copayment per visit

Participating/Non-participating urgent care center: You pay all charges

 

Benefit Description

Not covered: Emergency room professional charges for shift differentials


Standard Option - You Pay
All charges

Basic Option - You Pay
All charges