Prescription for additional pharmacy information. Transplants Transplant services, including heart, heart-lung, single lung, Hospital - Inpatient: After Deductible, Enrollee double lung, kidney, pancreas, cornea, intestinal/multi- pays $250 Copayment per day up to $1,250 per visceral, liver transplants, and bone marrow and stem cell admission support (obtained from allogeneic or autologous peripheral blood or marrow) with associated high dose chemotherapy. Hospital - Outpatient: After Deductible, Enrollee pays $200 Copayment Services are limited to the following: • Inpatient and outpatient medical expenses for evaluation Outpatient Services: After Deductible, Enrollee testing to determine recipient candidacy, donor matching pays $30 primary care provider services Copayment tests, hospital charges, procurement center fees, or $50 specialty care provider services Copayment professional fees, travel costs for a surgical team and excision fees. Donor costs for a covered organ recipient are limited to procurement center fees, travel costs for a surgical team and excision fees. • Follow-up services for specialty visits • Rehospitalization • Maintenance medications during an inpatient stay Organ Transplant Recipient: All services and supplies related to the organ transplant, including transportation to and from the KFHPWA Facilities (beyond the distance the Enrollee would normally be required to travel for most hospital services), are covered in accordance with the transplant benefit language, provided the Enrollee is accepted into the treating facility’s transplant program and continues to follow that program’s prescribed protocol. Organ Transplant Donor: The costs related to organ removal, as well as the cost of treating complications directly resulting from surgery, are covered, provided the organ recipient is an Enrollee under this Agreement, and provided the donor is not eligible for coverage under any other health care plan or government-funded program. Donor search costs for up to 15 searches only for allogeneic bone marrow transplants. Transplant services must be provided through locally and nationally contracted or approved transplant centers. All transplant services require Preauthorization. Contact Member Services for Preauthorization. Exclusions: Donor costs to the extent that they are reimbursable by the organ donor’s insurance; living expenses except as covered under Section II.K. Utilization Management; transportation expenses except as covered above; costs for searches for non-allogeneic bone marrow donors PEBB_VA_2024 45