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.
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:
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 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.
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.
If your situation is not urgent, consider these other sources of medical care:
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
Urgent calls are handled immediately. Education-related calls will be returned within an hour.