Noblesville Schools Medical Plan 54 Section 1: Covered Health Care Services Therapeutic Treatments - Outpatient Therapeutic treatments received on an outpatient basis at a Hospital or Alternate Facility or in a Physician's office, including: • Dialysis (both hemodialysis and peritoneal dialysis). • Intravenous chemotherapy or other intravenous infusion therapy. • Radiation oncology. Covered Health Care Services include medical education services that are provided on an outpatient basis at a Hospital or Alternate Facility by appropriately licensed or registered health care professionals. Benefits include: • The facility charge and the charge for related supplies and equipment. • Physician services for anesthesiologists, pathologists and radiologists. Benefits for other Physician services are described under Physician Fees for Surgical and Medical Services. Transplantation Services Organ and tissue transplants, including CAR-T cell therapy for malignancies, when ordered by a Physician. Benefits are available for transplants when the transplant meets the definition of a Covered Health Care Service, and is not an Experimental or Investigational or Unproven Service. Examples of transplants for which Benefits are available include: • Bone marrow, including CAR-T cell therapy for malignancies. • Heart. • Heart/lung. • Lung. • Kidney. • Kidney/pancreas. • Liver. • Liver/small intestine. • Pancreas. • Small intestine. • Cornea. Donor costs related to transplantation are Covered Health Care Services and are payable through the organ recipient's coverage under the Plan, limited to donor: • Identification. • Evaluation. • Organ removal. • Direct follow-up care. You can call the Claims Administrator at the telephone number on your ID card for information about the Claims Administrator's specific guidelines regarding Benefits for transplant services.