Summary Plan Description

Transplants

90% Network and 80% Non-Network
Services and Supplies Must Be Precertified Unless the Patient Is A Medicare-Eligible Retiree

Benefits are provided for the services and supplies of a covered transplant at an approved transplant facility as described below. Authorization is based on the patient's medical condition, the qualifications of the providers, appropriate medical indications for the transplant, and appropriate, proven medical procedures for the type of condition (in other words, not experimental in nature and within the standards of generally accepted medical practice as determined in the sole and absolute discretion of the Board of Trustees). All approved transplants must be performed at a Medicare-approved transplant center or within a Joint Commission On Accreditation of Hospitals (JCAHO) hospital with a Medicare-approved transplant program. Only facilities designated for Aetna's Institutes of Excellence Transplant Network are considered network providers.

Waiting Period

A transplant recipient must have at least 12 months of eligibility under the Carpenters Health and Security Plan of Western Washington in the past 24 months to be eligible for any benefits related to a transplant. The waiting period is waived for newborn children who have been continuously eligible under this plan from birth. If the transplant recipient has not been continuously eligible from birth but is an eligible natural child less than 24 months old, eligibility is based on the participant's ability to satisfy the required waiting period. Prior medical coverage does not count toward this waiting period.

Cord Blood Stem Cells

Transplantation of cord blood stem cells from related or unrelated donors is considered medically necessary when the recipient is a child, adolescent or young adult with an appropriate indication for allogeneic bone marrow transplant but without a hematopoietic stem-cell donor. Collection and storage of cord blood from a neonate is considered medically necessary when an allogeneic transplant is imminent in an identified recipient with a diagnosis that is consistent with the possible need for allogeneic transplant.

Prophylactic collection and storage of cord blood from a neonate is not considered medically necessary when proposed for unspecified future use as an autologous stem cell transplant in the original donor, or for unspecified use as an allogeneic stem cell transplant in a related or unrelated donor.

Donor Benefits

Donor procurement costs are available if the transplant recipient is covered for the transplant under this plan. Donor procurement benefits are limited to selection, removal of the organ or tissue, storage, transportation of the surgical harvesting team and the organ or tissue, and such other medically necessary procurement costs as determined by this plan. Donor benefits are not provided when they are available through another health care plan, when the donor is eligible under this plan and the recipient is not, or for donor and procurement services and costs incurred outside the United States, unless specifically approved by Carpenters Trusts.

Institutes of Excellence Transplant Network

The Institutes of Excellence (IOE) Transplant Network is Aetna's national participating network for transplants and transplant-related services, including evaluation and follow-up care. It is a facility and physician network. Only facilities designated for the IOE Transplant Network are considered network providers for transplant-related services.

If the IOE facility is more than 100 miles from the patient's residence, certain travel and lodging expenses for the patient and one companion may be reimbursed if precertified. Travel is reimbursed between the patient's home and the IOE for round trip (air, train or bus) transportation costs (coach class only). If traveling by auto to the IOE, mileage, parking and toll costs are reimbursed.

  • Lodging reimbursed at a rate of $50 per night per person (maximum $100 per night).
  • Overall travel and lodging reimbursement limited to $10,000 for any one procedure treatment or type.

No other travel expenses will be reimbursed.

Limitations and Exclusions

Benefits are not provided for:

  1. Transplants not provided in a Medicare-approved transplant center or within a JCAHO hospital with a Medicare approved transplant program.
  2. Nonhuman, artificial or mechanical transplants.
  3. Experimental or investigational services or supplies as defined by this plan.
  4. Services in a facility not approved by this plan.
  5. Stem cell support and high dose chemotherapy associated with stem cell support, except as specified by this plan.
  6. Services and supplies for the donor when the donor benefits are available through other group coverage.
  7. Expenses when government funding of any kind is provided.
  8. Expenses when the recipient is not covered under this plan.
  9. Donor and procurement services and costs incurred outside the United States.
  10. Any services, supplies, drugs, or immunosuppressive therapy relating to the transplant if furnished before the recipient has met the transplant waiting period described above.
  11. More than one retransplant if the transplant was not successful.