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Covered Services

Benefits are provided for the services listed in this section. All benefits are subject to the calendar year deductibles and the allowable charge, unless otherwise noted. Participants in Base Coverage or Select Coverage should refer to the Summaries of Benefits for coinsurance amounts. Benefits are provided for covered expenses incurred by a participant as a result of a non-occupational injury or non-occupational illness, only as expressly provided in this Plan.

Ambulance Medically necessary transportation by means of a specially designed and equipped vehicle used only for transporting the sick and injured:

From the place where the participant is injured or stricken by illness to the nearest appropriate hospital where treatment is to be given;

From a hospital where the participant is an inpatient to another hospital or freestanding facility to receive specialized diagnostic or therapeutic services not available at the hospital of origin and back to the hospital of origin after such services have been rendered, or;

From a hospital to another hospital when the discharging hospital has inadequate treatment facilities.

Ambulatory Surgical Facility Ambulatory surgical facility services are as follows:

  • Pre-operative laboratory procedures directly related to a surgical procedure.

  • Pre-operative preparation.

  • Use of facility (operating rooms, recovery rooms, and surgical equipment).

  • Anesthesia, drugs, and surgical supplies.

Cardiac Rehabilitation - Outpatient Benefits for outpatient cardiac rehabilitation are provided for patients with a clear medical need, referred by the attending physician. Prior approval must be obtained from Blue Cross & Blue Shield. The attending physician must submit a formal treatment plan to Blue & Cross Blue Shield (including number of visits, duration of therapy, and expected outcomes).

Participants must use a cardiac rehabilitation program that is certified by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR). Participants can contact Blue Cross & Blue Shield to locate a certified provider.


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