2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 69
(47) Occupational Therapy: Expenses for occupational therapy primarily for recreational or social interaction will
not be considered eligible.
(48) Operated by the Government: Expenses for treatment at a facility owned or operated by the government
will not be considered eligible, unless the Covered Person is legally obligated to pay. This does not apply to
Covered Expenses rendered by a Hospital owned or operated by the United States Veteran's Administration
when services are provided to a Covered Person for a non-service related Illness or Injury.
(49) Outside the United States (U.S.): Expenses for services or supplies if the Covered Person leaves the United
States, the U.S. Territories, or Canada for the express purpose of receiving medical treatment will not be
considered eligible.
(50) Over-the-Counter (OTC) Medication: Expenses for any over-the-counter medication will not be considered
eligible. Expenses for drugs and medicines not requiring a prescription by a licensed Physician and not
dispensed by a licensed pharmacist will not be considered eligible.
(51) Prior to Effective Date: Expenses which are Incurred prior to the effective date of your coverage under the
Medical Plan will not be considered eligible.
(52) Radioactive Contamination: Expenses Incurred as the result of radioactive contamination or the hazardous
properties of nuclear material will not be considered eligible.
(53) Recreational and Educational Therapy: Expenses for recreational and educational services; learning
disabilities; behavior modification services; vocational testing or training; any form of non-medical self- care
or self-help training, including any related diagnostic testing; music therapy; health club memberships; aquatic
or pool therapies; will not be considered eligible. Diabetic education is considered eligible as specified under
Eligible Medical Expenses. This exclusion will not apply to expenses related to the diagnosis, testing and
treatment of ADD, ADHD or autism.
(54) Refractive Errors: Expenses for radial keratotomy, Lasik Surgery or any Surgical Procedure, including after
cataract Surgery, to correct refractive errors of the eye will not be considered eligible.
(55) Self-Inflicted Injury: Expenses for Injury or Illness arising out of attempted suicide or an intentional selfinflicted Injury will not be considered eligible. This exclusion will not apply if self-inflicted Injuries result from a
medical condition (physical or mental) and the benefits for such Injuries are normally covered under the
Medical Plan.
(56) Sex Transformation: Expenses for care, services or treatment for non-congenital transsexualism, gender
dysphoria or sexual reassignment or change will not be considered eligible. This exclusion includes
medications, implants, hormone therapy, Surgery, medical or psychiatric treatment.
(57) Sexual Dysfunction: Expenses for services, supplies or drugs related to sexual dysfunction not related to
organic disease will not be considered eligible. Expenses for sex therapy will not be considered eligible.
(58) Sterilization: Expenses for elective sterilization or the reversal thereof will not be considered eligible.
(59) Substance Use Disorders: Inpatient and outpatient treatment and detoxification services for Substance Use
Disorder will not be considered eligible.
(60) Surrogate: Expenses relating to a surrogate pregnancy of any person who is not covered as an Employee or
as a Spouse under this Medical Plan, including but not limited to pre-pregnancy, conception, pre-natal,
childbirth and post-natal expenses, will not be considered eligible.
(61) Travel: Expenses for travel will not be considered eligible, except ambulance services as specified under
Eligible Medical Expenses.
(62) Usual and Customary Charge: Expenses in excess of the Usual and Customary Charge will not be
considered eligible.
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