Benefits Handbook (SPD)
Health Care
Participation
Medical
Highlights of the Plan
Benefit Summary
Medical Necessity
Allowable Charge
Alliance Direct and Non-Direct Providers
Annual Deductible
Annual Out-of-Pocket Limits
Care Coordination
Centers of Expertise
Travel Benefit
Bundled Surgery Services
Eligible Expenses
Expenses That Are Not Eligible
Preauthorization, Concurrent Review, and Retrospective Review
Benefit Penalties
How to File a Claim
Definitions
Appendix A: Human Organ, Tissue, and Bone Marrow Transplant Services
Appendix B: Designated Procedures for Centers of Expertise
Appendix C: Services and Products That Require Preauthorization
Prescription Drug
Dental
Vision
Flexible Spending Accounts
Income Security
Retirement
Special Benefits
Policies

Appendix A: Human Organ, Tissue, and Bone Marrow Transplant Services

See “Eligible Expenses” for additional information about requirements for transplants to be covered by the Plan. For example, failure to obtain preauthorization will result in a 100% benefit penalty (in other words, the Plan will not cover any of the transplant expenses).

Definitions

The following definitions apply for the purpose of this appendix:

Bone Marrow Transplant - means a medical and/or surgical procedure composed of several steps or stages including:

  • The harvest of stem cells or progenitor cells, whether from the bone marrow or from the blood, from a third-party donor (allogeneic transplant) or from the patient (autologous transplant),
  • Processing and/or storage of the stem cells or progenitor cells after harvesting,
  • The administration of high-dose chemotherapy and/or high-dose radiation therapy, when this step is prescribed by the treating physician,
  • The infusion of the harvested stem cells or progenitor cells, and
  • Hospitalization, observation, and management of reasonably anticipated complications such as graft versus host disease, infections, bleeding, organ or system toxicities, and low blood counts.

The above definition of autologous bone marrow transplant specifically includes transplants wherein the transplant component is derived from circulating blood in lieu of, or in addition to, harvested directly from the bone marrow, a procedure commonly known as peripheral stem cell or progenitor cell transplant or rescue procedure. This definition further specifically includes all component parts of the procedure including, without limitation, the high-dose chemotherapy and/or high-dose radiation therapy.

High-Dose Chemotherapy - means a form of chemotherapy wherein the dose exceeds standard doses of chemotherapy to the extent that virtually all patients who receive high-dose chemotherapy sustain destruction of the bone marrow to the point that bone marrow or peripheral stem cells or progenitor cells must be implanted or infused to keep the patient alive.

High-Dose Radiation Therapy - means a form of radiation therapy wherein the dose exceeds standard doses of radiation therapy resulting in destruction of the bone marrow to the point that bone marrow or peripheral stem cells or progenitor cells must be implanted or infused to keep the patient alive.

Preauthorization - means certification from the Plan that, based upon the information submitted by your attending physician, benefits will be provided under the Plan. Preauthorization is subject to all conditions, exclusions, and limitations of the Plan. Preauthorization does not guarantee that all care and services you receive are eligible for benefits under the Plan.

Procurement Services - means the services provided to search for and match the human organ, tissue, bone marrow, peripheral stem cells, or progenitor cells donated to the transplant recipient, surgically remove the organ, tissue, bone marrow, peripheral stem cells, or progenitor cells from the donor and transport the organ, tissue, bone marrow, peripheral stem cells, or progenitor cells to the location of the recipient within 24 hours after the match is made.

Organ and Tissue Transplant Procedures

Subject to the exclusions, conditions, and limitations of the Plan, benefits will be provided for Allowable Charges rendered by a hospital, physician, or other provider for these approved human organ and tissue transplant procedures:

  • Musculoskeletal transplants
  • Parathyroid transplants
  • Cornea transplants
  • Heart-valve transplants
  • Kidney transplants

Specialized networks of transplant providers may be available in addition to providers in your local or primary network. Contact Member Services at (855) 979-5192 for more information.

Other Major Organ Transplant Procedures

Subject to the exclusions, conditions, and limitations of the Plan, benefits will be provided for Allowable Charges rendered by a hospital, physician, or other provider for the human organ and tissue transplant procedures set forth below.

Heart Transplants

Benefits will be provided for a heart transplant, provided you:

  • Have terminal heart disease with a life expectancy of 18 months or less,
  • Have normal liver and kidney function,
  • Have no concurrent malignancy, HIV (human immunodeficiency virus) infection, or AIDS (acquired immunodeficiency syndrome), and
  • Are psychologically stable and have a supportive social environment.

Single Lung, Double Lung, and Heart/Lung Transplants

Benefits will be provided for a single lung, double lung, or heart/lung transplant, provided you:

  • Have end-stage cardiopulmonary or pulmonary disease with a life expectancy of 18 months or less,
  • Have no concurrent malignancy, HIV infection, or AIDS,
  • Have normal liver and kidney function, and
  • Are psychologically stable and have a supportive social environment.

Liver Transplants

Benefits will be provided for a liver transplant, provided you:

  • Have end-stage liver disease with a life expectancy of 18 months or less due to any of the following conditions:
    • Extrahepatic biliary atresia
    • Primary biliary cirrhosis
    • Primary sclerosing cholangitis
    • Antigen-negative hepatitis B, antigen-negative or antigen-positive hepatitis C
    • Hepatic vein thrombosis (Budd-Chiari syndrome)
    • Certain inborn errors of metabolism (such as Alpha-1-antitrypsin deficiency, Wilson's disease and primary hemochromatosis)
    • Primary hepatocellular carcinoma
    • Primary autoimmune hepatitis
  • Have normal kidney function,
  • Have no concurrent extrahepatic malignancy (including extrahepatic extension or primary hepatocellular carcinoma), HIV infection, or AIDS, and
  • Are psychologically stable and have a supportive social environment.

No benefits will be provided to you for end-stage liver disease as a result of viral hepatitis where you remain antigen positive (except for hepatitis C), or whose primary cause of liver damage is secondary to alcohol abuse, unless it can be demonstrated that you have abstained from alcohol for a period of no less than 12 months.

Intestinal Transplants

Benefits will be provided for a small bowel transplant using a cadaveric intestine for adult and pediatric patients with short-bowel syndrome who have established long-term dependency on total parenteral nutrition and who have developed severe complications due to parenteral nutrition, provided you:

  • Have no concurrent malignancy, HIV infection, or AIDS, and
  • Are psychologically stable and have a supportive social environment.

Benefits will be provided for a small bowel/liver transplant or multivisceral transplant for adult and pediatric patients with short bowel syndrome who have been managed with long-term parenteral nutrition and who have developed evidence of impending end-stage liver failure, provided you:

  • Have no concurrent malignancy, HIV infection, or AIDS, and
  • Are psychologically stable and have a supportive social environment.

Pancreas Transplants

  • Benefits will be provided for a combined pancreas/kidney transplant for diabetic patients with uremia, provided you have no concurrent malignancy, HIV infection, or AIDS, and are psychologically stable and have a supportive social environment.
  • Benefits will be provided for a pancreas transplant after a prior kidney transplant for patients with insulin dependent diabetes mellitus, provided you have no concurrent malignancy, HIV infection, or AIDS, and are psychologically stable and have a supportive social environment.
  • Benefits will be provided for a pancreas transplant alone for patients with severely disabling and potentially life-threatening complications due to hypoglycemia unawareness and labile diabetes that persists in spite of optimal medical management, provided you have no concurrent malignancy, HIV infection, or AIDS, and are psychologically stable and have a supportive social environment.

Islet Cell Transplants

Benefits will be provided for an autologous islet cell transplant for patients undergoing total or near total pancreatectomy for intractable pain due to chronic pancreatitis.

Bone Marrow Transplants

Not all autologous or allogeneic bone marrow transplants or stem cell or progenitor cell support procedures, whether performed as independent procedures or in combination with other therapies, e.g., high-dose chemotherapy and/or high-dose radiation therapy, are covered. Benefits for bone marrow transplants are not available for treatment of all conditions, or at all stages of a condition, even if the provider may recommend such treatment. Benefits will be provided for Allowable Charges rendered by a hospital, physician, or other provider for bone marrow transplants in accordance with the Plan's medical criteria for coverage of such transplant. If it is determined by the Plan that the transplant is not medically necessary for you, is experimental or investigational, or is otherwise excluded from coverage, benefits will be denied. Medical research regarding the effectiveness of bone marrow transplant procedures is ongoing. The Plan periodically reviews conditions to determine eligibility for benefits. You or the treating provider may obtain information regarding whether a specific type of bone marrow transplant will be eligible for coverage upon request to Member Services.

Exclusions and Limitations Applicable to Organ/Tissue/Bone Marrow Transplants

In addition to the exclusions set forth elsewhere in this Plan, no benefits will be provided for the following organ or tissue transplants, or bone marrow transplants, or related services:

  • Adrenal to brain transplants
  • Allogeneic islet cell transplants
  • High-dose chemotherapy or high-dose radiation therapy if the associated autologous or allogeneic bone marrow transplant, stem cell, or progenitor cell treatment or rescue is not an eligible expense
  • Autologous or allogeneic bone marrow transplant and/or stem cell or progenitor cell treatment or rescue with or without high-dose chemotherapy or high-dose radiation therapy for breast cancer patients with stage I, II, or III disease, or with refractory stage IV disease
  • Tandem transplants for autologous or allogeneic bone marrow or stem cell or progenitor cell treatment or rescue, with or without high-dose chemotherapy and/or high-dose radiation therapy, except for a tandem transplant for autologous bone marrow or stem cell or progenitor cell treatment or rescue with high-dose chemotherapy to treat newly diagnosed or responsive multiple myeloma only
  • Small bowel transplants using a living donor
  • Liver transplant for a patient with end-stage liver disease as a result of viral hepatitis where you remain antigen positive (except for hepatitis C), or whose primary cause of liver damage is secondary to alcohol abuse, unless it can be demonstrated that you have abstained from alcohol for a period of no less than 12 months
  • More than one organ of the same type, with the exception of a double-lung transplant done at one time. A heart-only, lung-only, or heart/lung transplant will be considered the same type organ
  • Any organ or tissue transplant or bone marrow transplant from a non-human donor or for the use of non-human organs for extracorporeal support and/or maintenance
  • Any artificial device for transplantation/implantation
  • Any organ or tissue transplant or bone marrow transplant procedure which the Plan considers to be experimental or investigational in nature
  • Expenses related to the purchase, evaluation, procurement services, or transplant procedure if the organ or tissue or bone marrow or stem cells or progenitor cells are sold rather than donated to you
  • All services, provided directly for or relative to any organ or tissue transplant, or bone marrow transplant procedure which is not specifically listed as an eligible expense in this appendix

The transplant must meet the criteria established by the Plan for assessing and performing organ or tissue transplants, or bone marrow transplant procedures. The transplant must be performed in a facility and by a provider that meet the criteria established by the Plan for assessing and selecting providers in the performance of organ or tissue transplants, or bone marrow transplant procedures.

Donor Benefits

If a human organ, tissue, or bone marrow transplant is provided from a living donor to a human transplant recipient:

  • When both the recipient and the living donor are covered by the Plan, each is entitled to the benefits of the Plan.
  • When only the recipient is covered by the Plan, both the donor and the recipient are entitled to the benefits of the Plan. The donor benefits are limited to only those not provided or available to the donor from any other source. This includes, but is not limited to, other insurance coverage or any government program. Benefits provided to the donor will be charged against the recipient's coverage under the Plan.
  • When only the living donor is covered by the Plan, the donor is entitled to the benefits of the Plan. The benefits are limited to only those not provided or available to the donor from any other source. This includes, but is not limited to, other insurance coverage or any government program available to the recipient. There are no eligible expenses for the non-covered transplant recipient.
  • If any organ or tissue or bone marrow or stem cells or progenitor cells are sold rather than donated to you, no reimbursement will be provided for the purchase price, evaluation, procurement services, or procedure.
  • The Plan is not liable for transplant expenses incurred by donors, except as specifically provided.

Research - Urgent Bone Marrow Transplant Benefits Within National Institutes of Health Clinical Trials Only

Bone marrow transplants that are otherwise excluded by this Plan as experimental or investigational (see definitions and exclusions) are eligible for benefits if the bone marrow transplant meets all of the following criteria:

  • It is therapeutic (not diagnostic or supportive) treatment used to directly improve health outcomes for a condition that is life-threatening and that has a poor prognosis with the most effective conventional treatment. For purposes of this provision, a condition is considered life-threatening if it has a substantial probability of causing premature death and all other conventional treatments have failed, or are not medically appropriate;
  • The bone marrow transplant is available to you and will be provided within a clinical trial conducted or approved by the National Institutes of Health;
  • The bone marrow transplant is not available free or at a reduced rate; and
  • The bone marrow transplant is not excluded by another provision of this Plan.