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HSA Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 750 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 1250 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

Must be medically necessary, not experimental or investigational: stem cell, kidney, liver, heart, lung, pancreas, small bowel or any combination are covered under the transplant benefits. Includes services related to organ procurement and donor expenses if not covered under another plan. Member must contact medical plan for arrangements. Travel, if approved, is limited to ten thousand dollars ($10,000) maximum per transplant.

  • Transplant Network: Includes travel and lodging allowance for recipient and their immediate family travel companion (younger than 19, both parents) if transplant facility is more than 50 miles from residence.
    • Lodging: Maximum lodging expenses shall not exceed the per diem rates as established annually by U.S. General Services Administration (GSA) for a specific city or county. Go to www.gsa.gov for per diem rates;
    • Travel: IRS standard medical mileage rates (same as flexible spending account (FSA) reimbursement); and
    • Meals: Not covered.
  • Non-network: Transplant benefits at a non-network facility. Travel, lodging and meals not covered.

Preauthorization by medical plan required.


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