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Section 5 (d). Emergency
services/accidents
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Important things to 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.
The calendar year deductible is: PPO - $275 per person ($550 per family); Non-PPO - $500 per person
($1,000 per family). The calendar year deductible applies to almost all benefits in this Section. We
added “(No deductible)” to show when the calendar year deductible does not apply.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a
PPO provider. When no PPO provider is available, non-PPO benefits apply.
When you use a PPO hospital, keep in mind that the professionals who provide services to you in the
hospital, such as radiologists, emergency room physicians, anesthesiologists, and pathologists, may not
all be preferred providers. If they are not, they will be paid by this Plan as non-PPO providers.
However, if surgical services are rendered at a PPO hospital or a PPO freestanding ambulatory facility
by a PPO primary surgeon, we will pay the services of anesthesiologists who are not preferred
providers at the PPO rate, based on Plan allowance.
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 with Medicare.
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What is an accidental injury?
An accidental injury is a bodily injury sustained solely through violent,
external, and accidental means, such as broken bones, animal bites, and poisonings. |
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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. If you are unsure of the severity of a condition in terms of this benefit, the Plan recommends that you first
call its 24-hour nurse advisory service (888/993-0333) or your physician.
Note: If you use an emergency room for other than a recognized medical emergency, facility fees and supplies will not be covered.
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Benefit Description
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You Pay
After the calendar year deductible… |
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NOTE: The calendar year deductible applies to almost all
benefits in this Section. We say "(No deductible)" when it does not apply. |
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Accidental injury
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If you receive care for your accidental injury within 24 hours, we cover:
- Physician services and supplies
- Related outpatient hospital services
- Professional ambulance service
- Air ambulance if medically necessary for transport to the closest
appropriate facility for treatment
Note: We pay Hospital benefits if you are admitted.
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PPO: Nothing (No deductible)
Non-PPO: Only the difference between
our allowance and the billed amount
(No deductible) |
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Accidental injury (continued)
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You Pay |
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If you receive care for your accidental injury after 24 hours, we cover:
- Physician services and supplies
Note: We pay Hospital benefits if you are admitted.
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PPO: $18 copayment (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between
our allowance and the billed amount |
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Medical emergency
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You pay
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Outpatient facility charges in an Urgent Care Center
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PPO: $40 copayment (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed
amount
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Outpatient medical or surgical services and supplies, other than an Urgent Care
Center
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PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed
amount
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Ambulance
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- Professional ambulance service within 24 hours of a medical injury
- Air ambulance if medically necessary for transport to the closest appropriate facility for
treatment within 24 hours of a medical emergency
Note: See Section 5(c) for non-emergency service.
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PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance and the billed
amount
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