2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 47
AETNA POS PROVIDERS
MEDICAL BENEFITS
Routine Newborn Care
(whether or not the newborn
is enrolled as a dependent)
Smoking Cessation
Plan Pays
Paid under the
mother’s
maternity
benefit
100% after
Copay
Covered Person
Pays
Paid under the
mother’s maternity
benefit
$20 Copay;
Deductible waived
NON POS PROVIDERS
(Subject to Usual &
Customary Charges)
Plan Pays
Covered Person
Pays
Paid under the
Paid under the
mother’s
mother’s maternity
maternity
benefit
benefit
No Coverage
N/A
Calendar Year Maximum
Benefit
1 program
Substance Use Disorders
Not Covered
Not Covered
Not Covered
Not Covered
90%
N/A
N/A
Transplants Performed at an
10% after
Aetna Institute of Excellence
Deductible
(IOE) Facility
The Institute of Excellence (IOE) is a facility that contracted with Aetna to furnish particular services and supplies
to you in connection with one or more highly specialized medical procedures. The maximum charge made by the
IOE for such services and supplies will be the amount agreed to between Aetna and the IOE. Your Participating
Provider should confirm if there is an Institute of Excellence (IOE) for your condition.
Transplants Performed at
any Other Facility (non-IOE
facility - including a
Participating Aetna Facility not
specified as an IOE facility)
Urgent Care Facility
N/A
N/A
70%
30% after
Deductible
100%
70%
Well Child Care (up to age 19)
100%
30% after
Deductible
N/A
Wig Due to Chemotherapy
90%
$20 Copay;
Deductible waived
$20 Copay;
Deductible waived
10% after
Deductible
Lifetime Maximum Benefit
All Other Eligible Expenses
1 wig
90%
10% after
Deductible
43
No Coverage
70%
1 wig
70%
30% after
Deductible
30% after
Deductible