TRANSPLANT SCHEDULE OF BENEFITS Benefit Plan(s) 006 Transplant Services At A Designated Transplant Facility: Transplant Services: • Paid By Plan After Deductible 80% Travel And Housing: • Maximum Benefit Per Transplant $10,000 • Maximum Benefit Per Travel 1 Adult Patient And 1 Companion Or 1 Minor Patient With 2 Companions • Paid By Plan 100% (Deductible Waived) Travel And Housing At Designated Transplant Facility At Contract Effective Date/Pre-Transplant Evaluation And Up To One Year From Date Of Transplant. -30- 7670-00-413597