Human Energy. Yours. TM Chevron Global Choice Plan (U.S.-Payroll Expatriates) (008) Summary of Benefits and Coverage What This Plan Covers and What it Costs Coverage Period January 1, 2015 December 31, 2015! This is not a policy or a summary plan description. Benefits described here are for comparison purposes only. Please refer to this plan s summary plan description (SPD) and/or the Cigna International Certificate of Coverage for U.S.-Payroll Expatriates for a detailed list of benefits and exclusions. If there are any discrepancies between the information in this benefit summary and the Certificate of Coverage and/or plan documents, the Certificate of Coverage and/or plan documents prevail. You can review the Certificate of Coverage and SPD online at hr2.chevron.com or request a copy by calling the HR Service Center at 1-888-825-5247 (toll-free) or 610-669-8595 (toll). Quick Reference Highlights Plan Name Chevron Global Choice Plan (U.S.-Payroll Expatriates) Claims Administrator or Insurer Networks Medical Claims Cigna Global Health (Cigna) (Group Number is 05721A) Prescription Drug Claims Cigna for prescription drugs obtained outside the U.S. (Group Number is 05721A) Express Scripts for prescription drugs obtained inside the U.S. (Group Number is CT1839) Cigna (medical and prescription drugs outside the U.S.) Express Scripts (prescription drugs inside the U.S.) Human Resources Service Center Contact the HR Service Center for general questions about this benefit, such as eligibility, to enroll, to review your current coverage or to make changes. Contact the insurer(s) directly for all other needs related to this benefit. By Phone 610-669-8595 (from outside the U.S.) 1-888-825-5247 (toll-free) 6 a.m. to 5 p.m. Pacific time, Monday - Friday Benefits Connection website hr2.chevron.com This plan provides global coverage. In the U.S. there is a network and out-of-network benefit. There is no network outside the U.S., but your benefit is not reduced for services received outside the U.S. Outside the U.S., individual providers (such as a doctor) and outpatient hospital facilities will generally require payment at the time services are delivered, so you ll need to submit a claim to Cigna to be reimbursed. Cigna does have a direct settlement agreement with many international hospitals, but you still need to notify Cigna that you are going into the hospital, and you need to provide your member ID card when you visit. Contact Cigna for more information regarding direct settlement procedures. Chevron Global Choice Plan (U.S.-Payroll Expatriates) (008) Summary of Benefits and Coverage Page 1
Out-of-Pocket Maximums* Medical, Mental Health and Substance Abuse, and Prescription Drugs Obtained Outside the U.S. $2,300 You Only $4,600 You and One Adult $4,600 You and Child(ren) $6,900 You and Family Prescription Drugs Obtained Inside the U.S. $1,800 You Only $3,600 You and Family (2 or more) * Copayments (fixed dollar amounts), coinsurance (your share of the costs of a covered service, calculated as a percent) and deductibles (the amount before this plan begins to pay for covered services) are included in out-of-pocket maximums. Medical Coverage (Cigna) Cigna can be reached toll free at 1-800-828-5822 or 1-302-797-3871. You can use Cigna s website at www.cignaenvoy.com to submit claims, search for a doctor in the U.S. OA Plus network, and find providers outside the U.S. Deductible $300 You Only $600 You and One Adult $600 You and Child(ren) $900 You and Family Preventive Care Physical Exam Well-Baby Outpatient Care Office Visits Surgery 3 Lab/X-Ray Inpatient Hospital Expenses 3 Room Surgery Lab/X-Ray Maternity Care Office Visit Hospital and Nursery Services Outside the U.S. 1 and Network Coverage in the U.S. Out-of-Network Coverage in the U.S. 2 Chevron Global Choice Plan (U.S.-Payroll Expatriates) (008) Summary of Benefits and Coverage Page 2
Medical Coverage (Cigna) (Continued) Services Outside the U.S. 1 and Network Coverage in the U.S. Out-of-Network Coverage in the U.S. 2 Emergency Room Services 3 Chiropractic Care 4 Office Visit Treatment in Outpatient Facility Physical Therapy 5 Office Visit Treatment in Outpatient Facility Home Health Care 3 (Up to 60 visits per year) 70%, after deductible Skilled Nursing Facility 6 Vision Program Coverage (VSP) Claims Insurer: Vision Service Plan (VSP) Plan Group Number: 30021085 Network: VSP Choice VSP Contact Information: 1-916-851-5000 (press 0 for operator assistance) from outside the U.S. 1-800-877-7195 from inside the U.S. VSP Website: www.vsp.com/go/chevron WellVision Exam Network Coverage in the U.S. 100% comprehensive eye exam, including dilation as needed, once per calendar year. (Network coverage only available in the U.S.) Outside the U.S. and Out-of-Network Coverage in the U.S. Up to $45 maximum, once per calendar year, for a comprehensive eye exam, including dilation as needed. Chevron Global Choice Plan (U.S.-Payroll Expatriates) (008) Summary of Benefits and Coverage Page 3
Prescription Drugs Obtained Outside U.S. (Cigna) Contact Cigna if you need assistance locating a place to purchase prescription drugs outside the U.S. Cigna can be reached toll free at 1-800-828-5811 or 1-302-797-3871. Retail 1 90%, no deductible, for drugs obtained outside the U.S. Prescription drugs obtained outside the U.S. are paid by Cigna International and reimbursement is based on billed charges. Prescription Drugs Obtained in the U.S. (Express Scripts) Contact Express Scripts for prescription drugs obtained inside the U.S. or mail order at 1-800-987-8368 or go to Express-Scripts.com. Deductible Retail $150 You Only Retail $300 You and Family (2 or more) No deductible for mail order Network Coverage in the U.S. Out-of-Network Coverage in the U.S. 2 Retail 2,7 Mail Order 7 After separate deductible: Generics: $5 copayment Preferred Brand-Name: 80% ($15 minimum copayment) Non-Preferred Brand-Name: 70% ($30 minimum copayment) Members may receive a 365-day supply; however, minimum copayments apply to each 31-day supply. No deductible. Generics: $15 copayment Preferred Brand-Name: 85% ($35 minimum copayment) Non-Preferred Brand-Name: 75% ($75 minimum copayment) Members may receive a 365-day supply; however, minimum copayments apply to each 92-day supply. Drugs can be mailed only to addresses within the U.S. Same as in-network. However, in addition you will pay the cost of the difference between the innetwork price of the drug and the out-of-network price of the drug. You will also be required to submit a paper claim form. Does not apply. Note: Certain items identified by the Prescription Drug Plan as preventive care are covered in full and not subject to the copay or deductible amounts indicated in the chart above. 1 Reimbursement for services obtained outside the U.S. is based on billed charges. 2 Reimbursement for out-of-network services in the U.S. is based on the allowable charge as defined in the Plan document. You may be responsible for any difference between the billed amount and the allowable charges. The plan will pay 100% of covered charges when you reach the annual out-of-pocket maximum. 3 Certain services require notification to the health plan. Chevron Global Choice Plan (U.S.-Payroll Expatriates) (008) Summary of Benefits and Coverage Page 4
4 Up to 20 visits per calendar year (network and out-of-network combined). 5 Up to 90 visits per calendar year for physical, speech and occupational therapy combined (network and out-of-network combined). 6 Up to 120 days per calendar year (network and out-of-network combined). 7 For brand name medications purchased in the U.S. via retail or mail order, when a generic equivalent is available, you will pay the generic copayment plus the difference between the brand drug and the generic drug, even if the doctor writes "Dispense as Written" on the prescription. Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Chevron Global Choice Plan (U.S.-Payroll Expatriates) (008) Summary of Benefits and Coverage Page 5
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