2024 Blue Cross and Blue Shield Service Benefit Plan - Standard and Basic Option
Section 5. Benefits
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Ambulance
Section 5. Benefits
Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services
Ambulance
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
Ambulance
Professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically necessary, and:
Note: We also cover medically necessary emergency care provided at the scene when transport services are not required.
Standard Option - You Pay
$100 copayment per day for ground ambulance transport services (no deductible)
$150 copayment per day for air or sea ambulance transport services
Basic Option - You Pay
$100 copayment per day for ground ambulance transport services
$150 copayment per day for air or sea ambulance transport services
Benefit Description
Ambulance
Professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically necessary, and:
- Associated with covered hospital inpatient care
- Related to medical emergency
- Associated with covered hospice care
Note: We also cover medically necessary emergency care provided at the scene when transport services are not required.
Standard Option - You Pay
$100 copayment per day for ground ambulance transport services (no deductible)
$150 copayment per day for air or sea ambulance transport services
Basic Option - You Pay
$100 copayment per day for ground ambulance transport services
$150 copayment per day for air or sea ambulance transport services
Benefit Description
Professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically necessary, and when related to accidental injury
Note: We also cover medically necessary emergency care provided at the scene when transport services are not required.
Note: Prior approval is required for all non-emergent air ambulance transport.
Standard Option - You Pay
Nothing (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.
Basic Option - You Pay
$100 copayment per day for ground ambulance transport services
$150 copayment per day for air or sea ambulance transport services
Professional ambulance transport services to or from the nearest hospital equipped to adequately treat your condition, when medically necessary, and when related to accidental injury
Note: We also cover medically necessary emergency care provided at the scene when transport services are not required.
Note: Prior approval is required for all non-emergent air ambulance transport.
Standard Option - You Pay
Nothing (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.
Basic Option - You Pay
$100 copayment per day for ground ambulance transport services
$150 copayment per day for air or sea ambulance transport services
Benefit Description
Medically necessary emergency ground, air and sea ambulance transport services to the nearest hospital equipped to adequately treat your condition if you travel outside the United States, Puerto Rico and the U.S. Virgin Islands
Note: If you are traveling overseas and need assistance with emergency evacuation services to the nearest facility equipped to adequately treat your condition, please contact the Overseas Assistance Center (provided by GeoBlue) by calling 804-673-1678.
Standard Option - You Pay
$100 copayment per day for ground ambulance transport services (no deductible)
$150 copayment per day for air or sea ambulance transport services
Basic Option - You Pay
$100 copayment per day for ground ambulance transport services
$150 copayment per day for air or sea ambulance transport services
Medically necessary emergency ground, air and sea ambulance transport services to the nearest hospital equipped to adequately treat your condition if you travel outside the United States, Puerto Rico and the U.S. Virgin Islands
Note: If you are traveling overseas and need assistance with emergency evacuation services to the nearest facility equipped to adequately treat your condition, please contact the Overseas Assistance Center (provided by GeoBlue) by calling 804-673-1678.
Standard Option - You Pay
$100 copayment per day for ground ambulance transport services (no deductible)
$150 copayment per day for air or sea ambulance transport services
Basic Option - You Pay
$100 copayment per day for ground ambulance transport services
$150 copayment per day for air or sea ambulance transport services
Benefit Description
Not covered:
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges
Not covered:
- Wheelchair van services and gurney van services
- Ambulance and any other modes of transportation to or from services including but not limited to physician appointments, dialysis, or diagnostic tests not associated with covered inpatient hospital care
- Ambulance transport that is requested, beyond the nearest facility adequately equipped to treat the member’s condition, by patient or physician for continuity of care or other reason
- Commercial air flights
- Repatriation from an international location back to the United States. See definition of repatriation in Section 10. Members traveling overseas should consider purchasing a travel insurance policy that covers repatriation to your home country.
- Costs associated with overseas air or sea transportation to other than the closest hospital equipped to adequately treat your condition.
Standard Option - You Pay
All charges
Basic Option - You Pay
All charges