29 Approved In - Network Provider All Other Providers Inpatient Facility Services • Precertification required 10% Coinsurance after Deductible Not Covered Inpatient Professional and Ancillary (non - Hospital) Services 10% Coinsurance after Deductible Not Covered Outpatient Facility Services • Precertification required 10% Coinsurance after Deductible Not Covered Outpatient Facility Professional and Ancillary (non - Hospital) Services 10% Coinsurance after Deductible Not Covered Travel Expenses • Transportation and Lodging Limit (Deductible applies) Covered, as approved by us, up to $10,000 per Benefit Period In - Network only. Benefits are not available Out - of - Network . • Lodging maximum $50 per day for double occupancy Not Covered Unrelated donor searches from an authorized, licensed registry for bone marrow/stem cell transplants for a Covered Human Organ or Tissue Transplant Procedure 10% Coinsurance after Deductible Not Covered • Donor Search Limit Covered, as approved by us, up to $30,000 per transplant In - Network only. Benefits are not available Out - of - Network . Live Donor Health Services • Inpatient Facility Services 10% Coinsurance after Deductible Not Covered • Outpatient Facility Services 10% Coinsurance after Deductible Not Covered Donor Health Service Limit For Human Organ and Tissue Transplants, Medically Necessary charges for getting an organ from a live donor are covered up to our Maximum Allowed Amount, including complications from the donor procedure for up to six weeks from the date of procurement.