2026 CODAC Benefit Summaries and Carrier Flyers

Note: This Plan will pay travel and housing benefits for a non-covered living donor only after any other coverage that the living donor has is exhausted.

TRANSPLANT EXCLUSIONS

In addition to the items listed in the General Exclusions section of this SPD, benefits will NOT be provided for any of the following:

• Expenses if a Covered Person donates an organ and/or tissue and the recipient is not a Covered Person under this Plan.

• Expenses for Organ and Tissue Acquisition/Procurement and storage of cord blood, stem cells, or bone marrow, unless the Covered Person has been diagnosed with a condition for which there would be Approved Transplant Services.

• Expenses for any post-transplant complications of the donor, if the donor is not a Covered Person under this Plan.

• Transplants considered Experimental, Investigational, or Unproven unless covered under a Qualifying Clinical Trial.

• Solid organ transplantation, autologous transplant (bone marrow or peripheral stem cell), or allogeneic transplant (bone marrow or peripheral stem cell) for conditions that are not considered to be Medically Necessary and/or are not appropriate, based on the National Comprehensive Cancer Network (NCCN) and/or Transplant Review Guidelines.

Expenses related to, or for, the purchase of any organ.

•

-71-

7670-00-412271