Accidental Injury

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

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

Accidental Injury

Professional provider services in the emergency room, hospital outpatient department, including professional care, diagnostic studies, radiology services, laboratory tests, and pathology services, when billed by a professional provider

Standard Option - You Pay
Preferred: Nothing (no deductible)

Participating: Nothing (no deductible)

Non-participating: Nothing (no deductible)

Basic Option - You Pay
Preferred: Nothing

Participating: Nothing

Non-participating: Nothing

Benefit Description

Professional provider services in the provider's office, including diagnostic studies, radiology services, laboratory tests, and pathology services, when billed by a professional provider

Standard Option - You Pay
Preferred: Nothing (no deductible)

Participating: Nothing (no deductible)

Non-participating: Any difference between our allowance and the billed amount (no deductible)

Basic Option - You Pay
Regular benefit levels apply to covered services provided in this setting. See Sections 5(a) and 5(b).

Benefit Description

Outpatient hospital services and supplies, including professional provider services, diagnostic studies, radiology services, laboratory tests, and pathology services, when billed by the hospital

Standard Option - You Pay
Preferred: Nothing (no deductible)

Member: Nothing (no deductible)

Non-member: Nothing (no deductible)

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.

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.

Standard Option - You Pay
Preferred urgent care center: Nothing (no deductible)

Participating urgent care center: Nothing (no deductible)

Non-participating urgent care center: Nothing (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

Standard Option - You Pay
Preferred urgent care center: Nothing (no deductible)

Participating urgent care center: Nothing (no deductible)

Non-participating urgent care center: Any difference between our allowance and the billed amount (no deductible)

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

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

Benefit Description

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