Benefits are payable for the following transplant types: • Kidney. • Kidney/pancreas. • Pancreas, if the transplant meets the criteria determined by care management. • Liver. • Heart. • Heart/lung. • Lung. • Bone marrow or Stem Cell Transplant (allogeneic and autologous), which may include chimeric antigen receptor T-cell therapy (CAR-T) for certain conditions. • Small bowel. SECOND OPINION The Plan will notify the Covered Person if a second opinion is required at any time during the determination of benefits period. If a Covered Person is denied a transplant procedure by the transplant facility, the Plan will allow him or her to go to a second Designated Transplant Facility for evaluation. If the second facility determines, for any reason, that the Covered Person is an unacceptable candidate for the transplant procedure, benefits will not be paid for further transplant-related services or supplies, even if a third Designated Transplant Facility accepts the Covered Person for the procedure. ADDITIONAL PROVISIONS (Applies to a Designated Transplant Facility Only) TRAVEL EXPENSES (Applies to a Covered Person who is a recipient or to a covered or non-covered donor if the recipient is a Covered Person under this Plan) If the Covered Person or non-covered living donor lives more than 75 miles from the transplant facility, the Plan will pay for travel and housing related to the transplant, up to the maximum listed on the Schedule of Benefits. Expenses will be paid for the Covered Person and: • One or two parents of the Covered Person (if the Covered Person is a Dependent Child, as defined in this Plan); or • An adult to accompany the Covered Person. Covered travel and housing expenses include the following: • Transportation to and from the transplant facility, including: ➢ Airfare. ➢ Tolls and parking fees. ➢ Gas/mileage. • Lodging at or near the transplant facility, including: ➢ Apartment rental. ➢ Hotel rental. ➢ Applicable tax. Lodging for purposes of this Plan does not include private residences. Lodging reimbursement that is greater than $50 per person per day may be subject to IRS codes for taxable income. Benefits will be payable for up to one year from the date of the transplant while the Covered Person is receiving services at the transplant facility. Note: This Plan will pay travel and housing benefits for a non-covered living donor only after any other coverage that the living donor has is exhausted. -73- 7670-00-413597