30 Benefit Period, Covered Services will be covered as Inpatient Services, Outpatient Services, Home Visits, or Office Visits depending on where the service is performed. Inpatient Facility Services Precertification required No Copayment, Deductible, or Coinsurance 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 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 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 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 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
Plan 1 SPD 2025 Page 30 Page 32