nafhealthplans.com DoD NAF Health Benefits Program Aetna Traditional Choice Plan 2020 Summary Plan Description Contents Welcome ............................................................................................................................................. 1 Understanding the Terms ................................................................................................................ 1 Amendment and Termination of the Plan ......................................................................................... 1 Plan Administration .......................................................................................................................... 1 Eligibility and Enrollment .................................................................................................................. 2 Who Is Eligible ................................................................................................................................. 2 Active Employees ........................................................................................................................ 2 Retired Employees ....................................................................................................................... 2 Dependents ................................................................................................................................. 3 How To Enroll .................................................................................................................................. 3 Newly Eligible Employees ............................................................................................................ 4 Open Enrollment .......................................................................................................................... 4 Retired Employees ....................................................................................................................... 5 Status Changes ........................................................................................................................... 5 When Coverage Begins ................................................................................................................... 7 Newly Eligible Employees ............................................................................................................ 7 Open Enrollment .......................................................................................................................... 7 Status Changes ........................................................................................................................... 7 Qualified Medical Child Support Order ......................................................................................... 7 How You Pay for Coverage ............................................................................................................. 7 Active Employees ........................................................................................................................ 7 Retired Employees ....................................................................................................................... 7 Your Medical ID Card....................................................................................................................... 8 Your Medical Plan at a Glance .......................................................................................................... 9 Summary of Benefits ....................................................................................................................... 9 Cost Sharing .............................................................................................................................. 11 Covered Services ....................................................................................................................... 12 How the Plan Works ........................................................................................................................ 21 Precertification ............................................................................................................................... 21 When You Need To Precertify Care ........................................................................................... 21 If You Don’t Precertify or If Precertification Is Denied ................................................................. 22 Coordination With Other Plans ....................................................................................................... 23 Effect of Another Plan on This Plan’s Benefits ............................................................................... 23 TRICARE ................................................................................................................................... 24 Coordination With Medicare ........................................................................................................... 25 Plan Options for Those Who Are Eligible for Medicare ............................................................... 25 Medicare Eligibility ..................................................................................................................... 25 When This Plan Is Primary ......................................................................................................... 25 When Medicare Is Primary ......................................................................................................... 26 Subrogation and Right of Recovery ............................................................................................... 27 Definitions .................................................................................................................................. 27 Right of Recovery ...................................................................................................................... 27 When You Accept Plan Benefits ................................................................................................ 28 What the Plan Covers ...................................................................................................................... 30 Preventive Care ............................................................................................................................. 30 Routine Physical Exams and Well Child Visits ........................................................................... 30 Routine Ob/Gynecological Exams .............................................................................................. 30 Routine Cancer Screenings ....................................................................................................... 30 Screening and Counseling Services........................................................................................... 31 Contents ii Proprietary Vision and Hearing Exams ............................................................................................................. 31 Routine Eye Exams ................................................................................................................... 31 Routine Hearing Exams ............................................................................................................. 31 Office Visits .................................................................................................................................... 32 Walk-In Clinics ........................................................................................................................... 32 Telehealth Physician Consultations – For Actives and Retirees Under 65 ................................. 32 Spinal Manipulation .................................................................................................................... 32 Outpatient Diagnostic Testing ........................................................................................................ 32 Diagnostic X-Ray and Laboratory Tests ..................................................................................... 32 MRI, PET Scan, and CAT Scan ................................................................................................. 32 Hospital Services ........................................................................................................................... 33 Urgent and Emergency Care ......................................................................................................... 33 Urgent Care ............................................................................................................................... 33 Emergency Care ........................................................................................................................ 33 Ambulance ................................................................................................................................. 33 Surgery and Anesthesia ................................................................................................................. 34 Pre-Operative Testing ................................................................................................................ 34 Oral Surgery .............................................................................................................................. 34 Outpatient Surgery ..................................................................................................................... 35 Reconstructive Surgery .............................................................................................................