2026 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5(d). Emergency Services/Accidents
Page 93

 

Benefit Description

Accidental Injury (cont.)

Note: If you are treated by a non-PPO professional provider in a PPO facility, you will only be responsible for your cost-share and will not owe any difference between our allowance and the billed amount. (See Section 4.)

Note: We pay inpatient benefits if you are admitted. See Sections 5(a), 5(b), and 5(c) for those benefits.

Note: See Section 5(g) for dental benefits for accidental injuries.


Standard Option - You Pay
Note: The benefits previously described apply only if you receive care in connection with, and within 72 hours after, an accidental injury. For services received after 72 hours, regular benefits apply. See Sections 5(a), 5(b), and 5(c) for the benefits we provide.

Note: For drugs, services, supplies, and/or durable medical equipment billed by a provider other than a hospital, urgent care center, or physician, see Sections 5(a) and 5(f) for the benefit levels that apply.

Basic Option - You Pay
Note: All follow-up care must be performed and billed for by Preferred providers to be eligible for benefits.

 

Benefit Description

Not covered:
 
  • Oral surgery except as shown in Section 5(b)
     
  • Injury to the teeth while eating
     
  • Emergency room professional charges for shift differentials


Standard Option - You Pay
All charges

Basic Option - You Pay
All charges

 

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: $425 copayment per day per facility

Member emergency room: $425 copayment per day per facility

Non-member emergency room: $425 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 $425 emergency room copayment. However, the $425 per day copayment ($2,975 limit) 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.

 

Medical Emergency - continued on next page