Organ Transplant Benefits
UnitedHealthcare offers specialized case management services for individuals who have been recommended for an organ transplant, bone marrow transplant or tissue replacement, including CAR-T cell therapy for malignancies when ordered by a physician. UnitedHealthcare must be notified regarding any of these procedures. During the notification process, UnitedHealthcare may recommend that you receive transplant services at a facility that is nationally recognized as a center of excellence for specific organ transplant procedures.
Benefits are also available for cornea transplants. You are not required to obtain prior authorization of a cornea transplant nor is the cornea transplant required to be performed by a Designated Provider.
Each case must meet specific criteria. If treatment at a Designated Provider is recommended, covered charges in connection with the transplant procedure will be covered at 80% of the in-network benefit level. Reasonable and customary fee limits will not apply. In addition, you may qualify for reimbursement of travel and lodging expenses.
If treatment at a Designated Provider is recommended but you decide to have the transplant procedure performed elsewhere, the Plan will pay 60% of covered charges in connection with the transplant procedure. The 60% benefit level will apply even when the facility is considered in-network for other non-transplant procedures.
Benefits are available to the donor and the recipient when the recipient is covered under this plan. The transplant must meet the definition of a "covered health service" and cannot be experimental or investigational, or unproven. Examples of transplants for which benefits are available include but are not limited to:
Bone marrow (either from you or from a compatible donor) including CAR-T cell therapy for malignancies, and peripheral stem cell transplants, with or without high dose chemotherapy (Not all bone marrow transplants meet the definition of a covered health service.)
Transplantation of non-human organs is not covered.
Other Transplant Benefits
Charges for the following services are covered:
Preparation, acquisition, transportation and storage of human organs, bone marrow or human tissue
The Plan pays benefits for approved charges incurred by the organ donor and the transplant recipient when both are covered under Stryker's medical plan.
When the organ recipient is covered under Stryker's medical plan but the donor is not, the Plan pays benefits for approved charges incurred by the organ donor to the extent that those charges are not covered by any other source.
When only the organ donor is covered under Stryker's medical plan, the Plan covers any charges related to donor services up to a maximum benefit of $5,000. This benefit is payable only when the transplant recipient's plan does not cover donor services.
Prior Authorization Requirement
For out-of-network benefits you must obtain prior authorization from UnitedHealthcare as soon as the possibility of a transplant arises (and before the time a pre-transplantation evaluation is performed at a transplant center).