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Section 5(d). Emergency services/accidents |
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Important things you should keep in mind about these benefits:
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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.
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The calendar year deductible is: $250 per person ($500 per family) under the High Option and $300 per person ($600 per family) under the Standard Option. 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.
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The non-PPO benefits are the regular benefits of this Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.
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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. See Section 5(g) for dental care for accidental injury.
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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 |
High Option
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Standard Option
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If you receive care for your accidental injury within 72 hours, we cover:
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All medically necessary physician services and supplies
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Related hospital services
Note: Services received after 72 hours are considered the same as any other illness and regular Plan benefits will apply.
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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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PPO: Nothing (No deductible)
Non-PPO: Only the difference between our allowance and the billed amount. (No deductible)
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Medical emergency |
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Medical emergencies are considered the same as any other illness and regular Plan benefits apply.
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Regular Plan benefits apply
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Regular Plan benefits apply
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Ambulance |
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For accidental injury only --
Professional ambulance service, including medically necessary air ambulance
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We pay 100% when services are rendered within 72 hours of your accidental injury.
Note: See 5(c) for non-emergency service.
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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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PPO: Nothing (No deductible)
Non-PPO: Only the difference between our allowance and the billed amount. (No deductible)
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