2025 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(d). Emergency Services/Accidents
Page 93
Section 5(d). Emergency Services/Accidents
Page 93
Benefit Description
Medical Emergency (cont.)
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
Medical Emergency (cont.)
- 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
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
- 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
Not covered: Emergency room professional charges for shift differentials
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Benefit Description
Ambulance
See Section 5(c) for complete ambulance benefit and coverage information.
Standard Option - You Pay
See Section 5(c)
Basic Option - You Pay
See Section 5(c)
Ambulance
See Section 5(c) for complete ambulance benefit and coverage information.
Standard Option - You Pay
See Section 5(c)
Basic Option - You Pay
See Section 5(c)