27 Approved In-Network Provider All Other Providers Inpatient Facility Services • Precertification required No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible These charges will NOT apply to your Out- of-Pocket Limit. Inpatient Professional and Ancillary (non-Hospital) Services No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible These charges will NOT apply to your Out- of-Pocket Limit. Outpatient Facility Services • Precertification required No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible These charges will NOT apply to your Out- of-Pocket Limit. Outpatient Facility Professional and Ancillary (non-Hospital) Services No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible These charges will NOT apply to your Out- of-Pocket Limit. Travel Expenses • Transportation and Lodging Limit Covered, as approved by us, up to $10,000 per Benefit Period In- and Out-of-Network combined. Unrelated donor searches from an authorized, licensed registry for bone marrow/stem cell transplants for a Covered Human Organ or Tissue Transplant Procedure No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible These charges will NOT apply to your Out- of-Pocket Limit. • Donor Search Limit Covered, as approved by us, up to $30,000 per transplant In- and Out-of-Network combined. Live Donor Health Services • Inpatient Facility Services No Copayment, Deductible, or Coinsurance 50% Coinsurance after Deductible These charges will NOT apply to your Out- of-Pocket Limit.