Health & Security Retiree Health Plan > SPD > Transplants

Summary Plan Description

Transplants—90%

Services and Supplies Must Be Precertified With the Medical Review Agency (non-Medicare Patients)
Benefits are provided for the services and supplies of a covered transplant at an approved transplant facility as described below. All transplants must be preauthorized with the medical review agency (non-Medicare patients). 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 an approved transplant center.

Waiting Period

A transplant recipient must have at least 12 months of eligibility under the Carpenters Health and Security Plan – For Retired Carpenters (includes the SecureHorizons Medicare Advantage Plan for retirees) to be eligible for any benefits related to a transplant. Coverage under another group health plan, Medicare Advantage Plan, Medicare Supplemental Insurance (Medigap), or COBRA Continuation Coverage does not entitle you or your dependents to credit toward the 12-month waiting period under the Retiree Health Plan's transplant benefit.

There are two exceptions to this rule:

  • If the transplant is received within the first 12 months of coverage under the Retiree Health Plan and the transplant recipient had continuous coverage between the Employee Health Plan and the Retiree Health Plan, the transplant recipient must have 12 months of eligibility under the Employee Health Plan and Retiree Health Plan in the past 24 months to be eligible.
  • If the transplant is received within the first 12 months of coverage under the Retiree Health Plan and the transplant recipient is the retiree's natural child with continuous eligibility under the Retiree Health Plan from birth, the 12-month waiting period is waived.

Medicare Note

Prescription drugs used in immunosuppressive therapy are covered by Medicare Part B if the drugs are prescribed following a kidney, heart, liver, bone marrow/stem cell, lung, heart/lung, or whole organ pancreas (simultaneous with or subsequent to a kidney transplant for diabetic nephropathy) transplant which met Medicare coverage criteria in effect at the time (e.g., approved facility for kidney, heart, liver, lung, or heart/ lung transplant; national or local medical necessity criteria; etc.). Contact Medicare for additional information.

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 allogenic 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.

Key Point

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 the Trust Office.

Donor Benefits

Donor procurement costs are available up to a maximum of $25,000 per transplant if the transplant recipient is covered for the transplant under this plan. If procurement expenses exceed this $25,000 per transplant procurement maximum, this plan will not pay the additional costs. 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 charged against the recipient's annual plan maximum. 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 the Trust Office.

Benefits are not provided for:

  1. Nonhuman, artificial, or mechanical transplants.
  2. Experimental or investigational services or supplies as defined by this plan.
  3. Services in a facility not approved by this plan.
  4. Stem cell support and high dose chemotherapy associated with stem cell support, except as specified by this plan.
  5. Services and supplies for the donor when the donor benefits are available through other group coverage.
  6. Expenses when government funding of any kind is provided.
  7. Expenses when the recipient is not covered under this plan.
  8. Lodging, food, or transportation costs, unless specifically provided under this plan.
  9. Donor and procurement services and costs incurred outside the United States, unless specifically approved by the Trust Office.
  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 (subject to the limits specified above) if the transplant was not successful.