| Section 5(d):
Emergency Services/Accidents In This Section: What Is An Accidental Injury? What Is A Medical Emergency? Basic Option Benefits For Emergency Care Accidental Injury Benefits Medical Emergency Benefits Ambulance Benefits IMPORTANT Here are some important things you should keep in mind about these benefits: • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary. • Under Standard Option, the calendar year deductible is $250 per person ($500 per family). The calendar year deductible applies to almost all Standard Option benefits in this Section. We added "(No deductible)" to show when the calendar year deductible does not apply. • Under Basic Option, there is no calendar year deductible. • Under Basic Option, you must use Preferred providers in order to receive benefits, except in cases of medical emergency or accidental injury. Refer to the guidelines appearing below for additional information. • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including Medicare. • You should be aware that some PPO hospitals may have non-PPO professional providers on staff. • PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.
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|  | | WHAT IS AN ACCIDENTAL INJURY? | |
An accidental injury is an injury caused by an external force or element such as a blow or fall and which requires immediate medical attention, including animal bites and poisonings. (See Section 5(h) for dental care for accidental injury.)
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| | | WHAT IS A MEDICAL EMERGENCY? | |
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.
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| | | BASIC OPTION BENEFITS FOR EMERGENCY CARE | |
Under Basic Option, you are encouraged to seek care from Preferred providers in cases of accidental injury or medical emergency. However, if you need care immediately and cannot access a Preferred provider, we will provide benefits for the initial treatment provided in the emergency room of any hospital – even if the hospital is not a Preferred facility. We will also provide benefits if you are admitted directly to the hospital from the emergency room until your condition has been stabilized. In addition, we will provide benefits for emergency ambulance transportation provided by Preferred or Non-preferred ambulance providers if the transport is due to a medical emergency or accidental injury.
We provide emergency benefits when you have acute symptoms of sufficient severity – including severe pain – such that a prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the person's health, or with respect to a pregnant woman, the health of the woman and her unborn child.
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| | | BENEFIT DESCRIPTION |
| YOU PAY | | | NOTE: The calendar year deductible applies to almost all Standard Option benefits in this Section. We say "No deductible" when the Standard Option deductible does not apply. There is no calendar year deductible under Basic Option. | | | | Accidental Injury |
| You Pay
Standard Option |
| You Pay
Basic Option | | |
• Physician services in the hospital outpatient department, urgent care center, or physician's office, including X-rays, MRIs, laboratory and pathology services, and machine diagnostic tests
• Related outpatient hospital services and supplies, including X-rays, MRIs, laboratory and pathology services, and machine diagnostic tests
Note: We pay Inpatient hospital benefits if you are admitted [see Sections 5(a), 5(b), and 5(c)].
Note: See Section 5(h) for dental benefits for accidental injuries.
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Preferred: Nothing (No deductible)
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Preferred emergency room: $50 copayment per visit
| Participating/
Member: Nothing (No deductible)
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| Participating/
Member emergency room: $50 copayment per visit
| Non-participating/
Non-member: Any difference between the Plan allowance and the billed amount (No deductible)
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| Non-participating/
Non-member emergency room: $50 copayment per visit
| Note: These benefit levels apply only if you receive care in connection with, and within 72 hours after, an accidental injury. For services received after 72 hours, regular medical and outpatient hospital benefits apply. See Section 5(a), Medical services and supplies, Section 5(b), Surgical procedures, and Section 5(c), Outpatient hospital, for the benefits we provide.
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| Note: You are responsible for the applicable copayment as shown above. If you use a Non-preferred provider, you may also be responsible for any difference between our allowance and the billed amount.
Note: If you are admitted directly to the hospital from the emergency room, you do not have to pay the $50 emergency room copayment. However, the $100 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.
For the following places of service, you must receive care from a Preferred provider:
Preferred urgent care center: $30 copayment per visit
Preferred primary care provider or other health care professional's office: $20 copayment per visit
Preferred specialist's office: $30 copayment per visit
Participating/
Member (for other than emergency room): You pay all charges
Non-participating/
Non-member (for other than emergency room): You pay all charges
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NOT COVERED:
• Oral surgery except as shown in Section 5(b)
• Injury to the teeth while eating
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| | | Medical Emergency |
| You Pay
Standard Option |
| You Pay
Basic Option | | |
• Physician services in the hospital outpatient department, urgent care center, or physician's office, including X-rays, MRIs, laboratory and pathology services, and machine diagnostic tests
• Related outpatient hospital services and supplies, including X-rays, MRIs, laboratory and pathology services, and machine diagnostic tests
Note: We pay Inpatient hospital benefits if you are admitted as a result of a medical emergency [see Sections 5(a), 5(b), and 5(c)].
Note: Please refer to Section 3 for information about precertifying emergency hospital admissions.
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Preferred: 10% of the Plan allowance
Note: If you receive services in a Preferred physician's office, you pay a $15 copayment (No deductible) for the office visit, and 10% of the Plan allowance for all other services (deductible applies).
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Preferred emergency room: $50 copayment per visit
| Participating/
Member: 25% of the Plan allowance
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| Participating/
Member emergency room: $50 copayment per visit
| Non-participating/
Non-member: 25% of the Plan allowance, plus any difference between our allowance and the billed amount
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| Non-participating/
Non-member emergency room: $50 copayment per visit
| Note: These benefit levels do not apply if you receive care in connection with, and within 72 hours after, an accidental injury. See Accidental Injury benefits above for the benefits we provide.
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| Note: You are responsible for the applicable copayment as shown above. If you use a Non-preferred provider, you may also be responsible for any difference between our allowance and the billed amount.
Note: If you are admitted directly to the hospital from the emergency room, you do not have to pay the $50 emergency room copayment. However, the $100 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.
For the following places of service, you must receive care from a Preferred provider:
Preferred urgent care center: $30 copayment per visit
Preferred primary care provider or other health care professional's office: $20 copayment per visit
Preferred specialist's office: $30 copayment per visit
Participating/
Member (for other than emergency room): You pay all charges
Non-participating/
Non-member (for other than emergency room): You pay all charges
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| | | Ambulance |
| You Pay
Standard Option |
| You Pay
Basic Option | | |
Local professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically appropriate, and:
• Associated with covered hospital inpatient care
• Related to medical emergency
• Associated with covered hospice care
Note: See Section 5(c) for non-emergency ambulance services.
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Preferred: 10% of the Plan allowance (no deductible)
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Preferred: $50 copayment per trip
| Participating/
Member: 10% of the Plan allowance (no deductible)
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| Participating/
Member: $50 copayment per trip
| Non-participating/
Non-member: 10% of the Plan allowance, plus any difference between our allowance and the billed amount (no deductible)
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| Non-participating/
Non-member: $50 copayment per trip
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Local professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically appropriate, and when related to accidental injury
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Preferred: Nothing (No deductible)
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Preferred: $50 copayment per trip
| Participating/
Member: Nothing (No deductible)
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| Participating/
Member: $50 copayment per trip
| Non-participating/
Non-member: Any difference between the Plan Allowance and the billed amount (No deductible)
Note: These benefit levels apply only if you receive care in connection with, and within 72 hours after, an accidental injury. For services received after 72 hours, see above.
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| Non-participating/
Non-member: $50 copayment per trip
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