2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 43
AETNA POS PROVIDERS
MEDICAL BENEFITS
Substance Use Disorders
Plan Pays
Not Covered
Covered Person
Pays
Not Covered
NON POS PROVIDERS
(Subject to Usual &
Customary Charges)
Plan Pays
Covered Person
Pays
Not Covered
Not Covered
80%
N/A
N/A
Transplants Performed at an
20% after
Deductible
Aetna Institute of Excellence
(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
60%
40% after
Deductible
100%
60%
Well Child Care (up to age 19)
100%
40% after
Deductible
N/A
Wig Due to Chemotherapy
Lifetime Maximum Benefit
All Other Eligible Expenses
80%
1 wig
80%
$25 Copay;
Deductible waived
$25 Copay;
Deductible waived
20% after
Deductible
20% after
Deductible
39
No Coverage
60%
1 wig
60%
40% after Deductible
40% after Deductible