Summary Plan Description

Ambulance Transportation

90% Network and Non-Network

Benefits are provided for services and supplies for licensed ambulance transportation to the nearest hospital or Medicare-approved skilled nursing facility which has the appropriate facilities to treat the patient's condition when the patient requires immediate medical intervention as a result of a severe, life threatening or potentially disabling condition, and only if any other means of transportation would seriously endanger the patient's life. Licensed ambulance transportation is also provided in the following situations:

  • Ambulance service is from one hospital to another, including return, but only in situations where evidence clearly establishes that the institution to which the patient is being transferred is the nearest one having appropriate facilities, equipment or staff physicians to treat the patient's condition or to obtain medically necessary diagnostic or therapeutic services not available at the patient's hospital or skilled nursing facility.
  • Licensed air ambulance but only to the nearest medical facility that can provide the needed medical treatment. Air ambulance services are covered only when the point of pickup is inaccessible by land, or great distances or other obstacles are involved in getting the patient to the nearest appropriate facility, and speedy admission is essential. If it is determined that a ground ambulance would have sufficed, this plan pays only the amount it would have paid for a ground ambulance. Air transports must be precertified.

If the patient is transported beyond the nearest appropriate facility, benefits are prorated accordingly.

Benefits are not provided for:

  1. Ambulance use to or from a place of residence and a physician's office.
  2. Ambulance use from a hospital back to a place of residence.
  3. Ambulance service to or from any facility for the effective treatment or assessment of chemical dependency.
  4. Cabulance services or any other commercial transportation.
  5. Transportation for the patient's or provider's convenience.