Page 39 - QCS.19 SPD - HSA

Benefits include the facility charge and the charge for related supplies and equipment.
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 Service 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, double lung, kidney, kidney/pancreas, liver, liver/small intestine, pancreas,
bowel, small intestine and cornea.
Donor costs related to transplantation are Covered Health Care Services and are payable through the organ
recipient's coverage under the Policy, limited to donor:
· Identification.

· Evaluation.
· Organ removal.

· Direct follow-up care.
If you are required to receive transplantation services at a Designated Facility outside your geographic area, we
will provide travel and lodging in agreement with our guidelines.

There are specific Benefits for transplant services. Contact us at the telephone number on your ID card for
information about these guidelines.

Urgent Care Center Services

Covered Health Care Services received at an Urgent Care Center. When services to treat urgent health care
needs are provided in a Physician's office, Benefits are available as described under Physician's visit - Sickness
and Injury.

Voluntary Sterilization Procedures

We will also provide Benefits for voluntary sterilization procedures for you and for your Enrolled Dependent
Spouse. We will not provide benefits for your Enrolled Dependent child.

Page 34 Section 5- Additional Coverage Details
HSA - 2017