Emergency care and urgent care

For emergency services, all three medical options (PPO, EPO, and HDHP) pay 80 percent of covered charges after the deductible is met. In all instances, you are responsible for paying your deductible and coinsurance. If it’s not an emergency, using an urgent care center instead of the hospital emergency room can save you time and money.

Emergency care

​Hospital emergency rooms (ERs) are the most prepared and best-equipped facilities to handle serious, potentially life-threatening health needs. If you need emergency care:

  1. Call 911 and get the care you need from the nearest provider or hospital ER, regardless of whether it is a network facility or which medical option you have.
  2. Within 48 hours of an inpatient emergency admission — for an illness or injury or for behavioral health or substance use disorder treatment — call the toll-free number on your medical ID card to certify your stay and maximize your benefits.

If you go to an ER and are admitted to an out-of-network hospital or other facility, once the emergency is addressed, you may need to transfer to a network provider to continue to receive the network level of benefits.

Note: Admissions to behavioral care and substance use disorder programs and facilities must be precertified.

Urgent care

Urgent care centers are for health issues that can’t wait until you can see your primary care doctor but don’t require a trip to the ER; for example, earaches, minor cuts that may need stitches, sore throats, or back pain.

  • Urgent care centers are free-standing facilities staffed with doctors and nurses, many with onsite labs and X-ray equipment.
  • No appointment is necessary, and some allow online check-in.
  • Most are open in the evening, as well as on weekends and holidays.

If you’re enrolled in the PPO or EPO, you pay a flat dollar copay for each network urgent care visit: ($45 if you’re in the PPO or $60 if you’re in the EPO).

If you’re enrolled in the HDHP and go to a network urgent care center, you are responsible for the entire cost of the visit until you’ve paid the annual deductible, after which you pay 20 percent of the cost, until you reach the total out-of-pocket maximum amount. Although you must pay the deductible, the cost of an urgent care visit is usually much less than a visit to the ER. You also can use funds in a health savings account to pay for the visit.

Other alternatives to the ER

If your situation is not urgent, consider these other sources of medical care:

  • your primary care physician
  • the Teladoc telemedicine benefit (800-835-2362)
  • retail medical clinics (typically in a pharmacy and staffed by certified nurse practitioners)

24-hour nurse line

If you aren’t sure if you need to get medical care or where is the most appropriate place to go, call the 24-hour nurse line listed on your medical ID card.

Nurses are available through Highmark Blue Cross Blue Shield 24 hours a day, seven days a week to answer health-related questions. This service is part of your medical benefits; there is no cost to you.

In addition to helping you determine whether you should seek medical care, the nurse line can help if you

  • need information about a medication, test, or medical procedure;
  • want reliable information about a health condition;
  • aren't sure what questions you should ask your doctor; or
  • have questions about how you or your family can stay healthy.

Urgent calls are handled immediately. Education-related calls will be returned within an hour.