| HMO | Transplants |
| Aetna US Healthcare | Covers: Non-experimental transplants, including the medical and surgical expenses of a live donor, to the extent these services are not covered by another plan or program. A transplant is non-experimental when HMO determines that the majority of physicians who are board certified in the appropriate specialty consider the procedure appropriate for the specific condition of the member. Also covers travel and lodging expenses for the member and for the parent or guardian when accompanying a minor for a transplant procedure outside the service area.
Limits: Transplant must be ordered in writing by HMO in advance of surgery, and performed at hospitals specifically approved and designated by HMO to perform these procedures. Excludes: Experimental or investigational transplants. |
| Blue Cross Blue Shield | Covers: Organ, tissue, and bone marrow transplants. This includes heart, combined heart and lung, lung (single and bilateral), simultaneous pancreas and kidney, liver, small bowel, kidney, cornea, simultaneous small bowel and liver, high dose chemotherapy with bone marrow or peripheral blood stem cell transplants.
Limits: Prior approval is required. Not all participating facilities are approved transplant centers. Cost Sharing: Subject to applicable copayments and/or coinsurance based on the type and location of the service. Donor expenses: Covers donor expenses, including expenses to locate a donor and/or diagnostic and pre-transplant care for the donor. Limit of $10,000 for donor expenses. BCBS will coordinate coverage for donor expenses with the donor’s health insurance ("coordination of benefits"). |
| CIGNA / Healthsource | Covers: medically necessary organ, bone marrow or stem cell transplants.
Limits: Services must be approved by CHCNC and performed in an approved transplant center. Not all participating facilities are approved transplant centers. Donor expenses: Covers donor expenses, including expenses to locate a donor and/or diagnostic and pre-transplant care for the donor. Limit of $10,000 for donor expenses. This limit does not include transportation, lodging or meal expenses. CHCNC will coordinate coverage for donor expenses with the donor’s health insurance ("coordination of benefits"). |
| Doctors Health Plan | Covers: Organ or bone marrow transplants including liver, heart, corneal, bone marrow, lung, heart-lung, pancreas and kidney that meet the coverage criteria (see definition section for description of coverage criteria).
Limits: Requires precertification. Services must be provided by a facility approved by Doctors for transplant. Not all participating facilities are approved transplant centers. |
| Generations | Covers: Heart, lung, heart-lung, kidney, liver, pancreas, cornea, bone marrow and other non-experimental transplants deemed medically necessary. Also covers donor’s costs if the recipient is a member (the donor’s costs are charged to the recipient’s benefits). Travel and lodging for plan-authorized organ and bone marrow transplants are also covered.
Limits: Transplants must be authorized by PCP and approved in writing in advance by Generations Medical Management Department. Services must be provided in an approved institution. Excludes: Donor-related costs when the donor is a member but the recipient is not. |
| Optimum Choice | Covers: Kidney, cornea, all non-experimental bone marrow transplants, and liver transplants in children under the age of 18 with biliary atresia. Also covers harvesting of the organ from a non-member donor.
Donor expenses: Covers all approved physician and hospital charges for organ transplants and any complications when the organ recipient and donor are both members or when the recipient alone is a member. Costs related to the screening of organ donors will be covered for the actual donor only. Limits: Transplants must be approved by OCCI and performed at a facility approved by OCCI. Transplant evaluations will not be covered if the member does not meet basic screening criteria (e.g. age, weight) for a facility. The use of non-participating facilities must be pre-approved by OCCI. Excludes:
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| PARTNERS | Covers: Heart, heart/lung, cornea, pediatric and neonatal heart, kidney, bone marrow, liver, lung, and pancreas transplants. Coverage includes: preoperative care (including prophylactic dental care), transplant care, facility and professional fees, organ procurement fees (including organ donor fees), and post transplant care (including immunosuppressant when included in outpatient prescription rider). Expenses for the member’s reasonable travel, meals and lodging are covered with prior approval for transplants outside of the plan’s service area at a plan-designated facility.
Limits: Transplants must be approved in advance by the plan. Partners reserves the right to choose the transplant center. Excludes: Combined kidney and liver transplants, and transplants which are determined by the plan to be experimental or investigational. |
| Coventry/Principal Health Care of the Carolinas | Covers: Kidney, cornea, heart, liver, and bone marrow, when determined that medically necessary and specific criteria are met.
Limits: Transplants must be approved by Coventry/Principal and performed at a facility approved by Coventry/Principal. Donor expenses: Professional and facility costs for donor are covered if other sources of reimbursement are unavailable, regardless of membership. Organ preparation and transportation are also covered. Excludes: The cost of any care arising from an organ donation by a member when the recipient is not a member. Also, excludes any transplant procedure that is performed in a facility that has not been designated by the Medical Director as an approved transplant facility. |
| QualChoice | Covers: Medically necessary transplant services that meet Qual Choice’s transplant criteria. Coverage includes up to 5 days of preoperative care in a hospital, and up to one year of post-operative care.
Limits: Pre-authorization is required for all transplants. Organ Procurement: Covers tissue typing, surgical procedure, storage expense and transportation costs directly related to the donation of an organ or other human tissue used in a covered transplant procedure. Excludes: Artificial organs, organs from non-human donors, or services related to transplants involving artificial organs or organs from non-human donors. |
| The Wellness Plan of North Carolina, Inc. | Covers: All organ and tissue transplants.
Limits: Transplants and all related charges are covered when approved in advance. Donor expenses: Covered when both the donor and the recipient are members of TWP-NC and the expenses are authorized in advance. Excludes: Any transplant considered or classified as experimental by FDA. |
| United HealthCare | Covers: Inpatient hospital and related services, including room and board, travel expenses, related services and supplies provided in a designated transplant facility. High dose chemotherapy with autologous or allogenic bone marrow is covered only for the following diseases: non-Hodgkin’s lymphoma, Hodgkin’s disease, Neuroblastoma if older than one year of age, acute lymphocytic leukemia, and acute non-lymphocytic leukemia. Also covers travel expense to out-of-area transplant facilities if approved in advance by UHC.
Limits: Services must be ordered, provided or arranged under the direction of a participating physician and authorized in advance by United HealthCare of North Carolina. There is a lifetime limit of one high dose chemotherapy with bone marrow transplant (rescue), whether rescue is by autologous or allogenic bone marrow transplant or by peripheral stem cell transfusion. Excludes: Organ transplants otherwise covered under the plan which is performed as a treatment for cancer, or transplants of two or more organs simultaneously. However, kidney/pancreas and heart/lung are covered. Also excludes expenses related to the removal of an organ for transplant purposes and expenses involving transplants or mechanical or animal organs. |
| WellPath | Covers: Non-experimental transplants, including corneal, liver, kidney, kidney-pancreas, heart, lung, heart-lung, bone marrow and peripheral stem cell transplants.
Limits: Covered if approved by a participating Center of Excellence and it is not experimental or investigational, as determined by WellPath. Cost Sharing: Copayments may apply. Excludes: Mechanical organ replacement devices, such as artificial hearts or left ventricular assist devices or any cross-species transplants. The plan does not cover any expenses relating to the donation of organs, tissues, bone marrow, or peripheral stem cells unless the donor is also a member of a WellPath plan. Also, the plan does not cover any other donor expenses, including transportation costs. |