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Human Energy. Yours.
TM
Chevron Open Enrollment
Your Action is Required
October 20 Through October 31, 2014
Your Health.
What’s Inside:
Page 3 Open Enrollment Checklist
Page 4 Do I Need to Do Anything?
Page 6 How to Enroll
Page 7
More Enrollment Resources
Page 8 How to Certify Your Tobacco Use Status
Page 10
Check Your Dependent’s Information
Page 11 Health Rewards Deadline
Page 12 2015 Medical Costs
Page 13 2015 Plan Changes
Page 27 Good to Know
Page 34 Legally Required Notices
This newsletter tells you how to enroll, how to certify your tobacco use status, outlines upcoming changes for
2015, and provides other important information about your benefits. The plan changes described in this newsletter
and any changes you make to your coverage during open enrollment become effective January 1, 2015. This
newsletter applies to U.S. payroll employees who work in the United States and U.S. payroll expatriates on rotational
assignment who are eligible for Chevron’s health and welfare benefits.
This newsletter serves as an official summary of material modification (SMM) for the plans referenced herein.
Please keep this information with your other plan documents for future reference. This communication
provides only certain highlights about changes of benefit provisions. It is not intended to be a complete
explanation. If there are any discrepancies between this communication and the legal plan documents, the
legal plan documents will prevail to the extent permitted by law. There are no vested rights with respect to
Chevron health care plans or any company contributions towards the cost of such health care plans. Rather,
Chevron Corporation reserves all rights, for any reason and at any time, to amend, change or terminate these
plans or to change or eliminate the company contribution toward the cost of such plans. Such amendments,
changes, terminations or eliminations may be applicable without regard to whether someone previously
terminated employment with Chevron or previously was subject to a grandfathering provision. Some benefit
plans and policies described in this document may be subject to collective bargaining and, therefore, may not
apply to union-represented employees.
2 | Open Enrollment October 2014
Open Enrollment Checklist
Open enrollment this year is very different; don’t ignore it. All employees (including employees on a leave
of absence who are not receiving coverage through COBRA) are required to certify your tobacco use status
during open enrollment, whether or not you use tobacco This means you must take action between
October 20 and October 31, even if you don’t typically make enrollment choices.
During open enrollment, you can decide to keep the coverage you currently have or make changes, such
as switching to another medical plan option or adding a dependent to your coverage. If you miss the open
enrollment deadline, you generally can’t make any changes until the next enrollment period in the fall of
2015. However, you can make changes to certain benefits outside of the open enrollment period if it’s within
the 31-day deadline after a qualifying life event, such as a marriage or birth.
 Make sure you have your Benefits Connection PIN if you plan to take action from outside the Chevron
network. (See Page 6.)
 Understand the tobacco use certification process and requirements. Remember, all employees are required
to certify. You must certify between October 20 and October 31, 2014. (See Page 8.)
 Check your dependent’s information. Chevron needs your spouse, domestic partner and children’s Social
Security Number if enrolled in a Chevron health plan. Learn why on Page 10.
 Understand what is changing with your benefits and what you need to do. There are some changes for 2015
that may affect you. It’s important to read this newsletter and review the resources posted at hr2.chevron.com
to understand what’s changing and if you need to take action. A few of the key changes include:
- The Medical PPO Plan – Option 3 plan choice will be discontinued. (See Page 20.)
- There is a new medical plan coming, the High Deductible Health Plan (HDHP). (See Page 21.)
- There are prescription drug, deductible and out-of-pocket maximum changes in the Medical PPO
Plan – Option 1 and Medical PPO Plan – Option 2. (See Page 18.)
- The monthly premium cost of Medical HMO Plans will increase. (See Page 12.)
 Decide if you want (or need) to make other changes. Your 2015 benefit choices and monthly cost for
coverage will be available online beginning October 13. Remember, you can’t make changes until October 20,
but you can preview the 2015 costs and your available options. The If You Don’t Make Changes section will show
what your 2015 coverage will be if you do not take action during open enrollment. On October 13, go to
hr2.chevron.com and click the Open Enrollment Preview link to get started.
- If you decide that you don’t want (or need) to make changes, you only need to certify your tobacco use status
and don’t need to do anything else to change your plans. But remember to look at the situations on Page 4
and make sure they don’t apply to you.
- If you decide that you do want to make changes, including updating your tobacco use status, you must take
action between October 20 and October 31.
 Verify your elections. Print your confirmation statement and review your elections and tobacco status
certification for accuracy. You’ll also receive a confirmation of your elections in the mail after October 31.
If any information is incorrect, call the HR Service Center within 10 days. Keep the statement for your records.
U.S. Pay and Benefits News | 3
Do I need to do anything?
All employees are required to take action this year
during open enrollment, October 20 through October 31, 2014.
If any of the situations below apply to you, you are required to take action starting October 20. See Page 6 for
general enrollment instructions and Page 8 for more information about how to certify your tobacco use status.
“I don’t use tobacco.”
All employees are required to certify your tobacco use status during open enrollment, October 20 through
October 31, 2014, whether or not you use tobacco. If you fail to certify your tobacco use status by the
deadline, you’ll be charged the higher monthly rates for medical and supplemental life insurance coverage
for all of 2015, whether or not you use tobacco. See Page 8 to learn more.
“I use tobacco.”
All employees are required to certify your tobacco use status during open enrollment, October 20 through
October 31, 2014. If you’ve been thinking about quitting the use of tobacco, there’s still time to commit. See
Page 8 to learn more.
“I’m not enrolled in Chevron’s health or life insurance benefits.”
Certify your tobacco use status anyway.
If you choose not to participate in Chevron health coverage next year, you’re still strongly encouraged to
certify your tobacco use during open enrollment. The tobacco surcharge won’t apply to you if you’re not
enrolled. But if you do not take action to certify your tobacco use status during open enrollment, you will
be automatically assigned to Tobacco User for all of 2015, whether or not you use tobacco. Your tobacco
use status on record as of January 1, 2015, will be used to determine your medical and supplemental life
insurance coverage rates for all of 2015 should you experience a life event and need to add coverage during
the year. You will not be able to change your tobacco use status until the next open enrollment, even if
you experience a life event and add coverage during the year. For this reason, you should still certify your
tobacco use status to ensure that you will be charged the most accurate rates if you need to enroll in the
future. (See Page 8 to learn more.)
“I’ve had a change to my dependents.”
If you need to add or remove a dependent from health coverage for 2015, you must make an election
during open enrollment.
“I want to start Chevron health coverage.”
If you want to start Chevron medical, dental or Vision Plus Program coverage for 2015, you must make
an election during open enrollment.
“I want to change my Chevron health coverage.”
If you want to change or stop Chevron medical, dental or Vision Plus Program coverage for 2015,
you must make an election during open enrollment.
4 | Open Enrollment October 2014
“I’m enrolled in the Medical PPO Plan – Option 3. What should I do?”
The Medical PPO – Option 3 plan choice will no longer be offered in 2015. That’s because this plan is being
replaced by the new HDHP option. If you don’t make an election to change plans during open enrollment, you
will be automatically enrolled in the HDHP for 2015. If you want to enroll in another Chevron medical plan or
stop participating, you must make an election during open enrollment. (See Page 20.)
“I’m enrolled in a flexible spending account this year.
I want to participate again in 2015.”
Participation in the flexible spending accounts — Health Care Spending Account (HCSA) or Dependent Day
Care Spending Account (DCSA) — is the only benefit election that does not carry over from year to year.
Remember, you must re-enroll in the flexible spending accounts during open enrollment every year if you
want to participate. (See Page 28.)
“I want to try the new High Deductible Health Plan (HDHP) and a health savings account.”
If you decide to start participating in Chevron’s new HDHP, you must enroll during open enrollment. If you
enroll in the HDHP and you determine you’re also eligible to open and contribute to a health savings account
(HSA), you can open an account at any time with any financial institution that offers HSAs. Be sure to read
the HDHP and HSA materials mailed to you in early October or go to hr2.chevron.com to learn more. (See
Page 21.)
“I want additional vision coverage.”
The voluntary Vision Plus Program provides additional vision coverage beyond the basic vision coverage
already provided. If you want to start (or stop) participating in this program, you must make an election
during open enrollment. (See Page 31.)
“I want to change my Voluntary Group Accident Insurance coverage.”
If you contribute to this plan on a before-tax basis and you want to increase or decrease the amount of your
coverage, you must make an election during open enrollment.
“I want to change to after-tax health contributions.”
Your benefit contributions are automatically deducted from your paycheck on a before-tax basis. But you can
elect to have contributions deducted on an after-tax basis instead by calling the HR Service Center during
open enrollment. Read more about before-tax and after-tax contributions at hr2.chevron.com.
U.S. Pay and Benefits News | 5
How to Enroll
October 20 Through October 31, 2014
Online
The website will be open for you to certify your tobacco use status and make
other enrollment elections until midnight Pacific time on October 31.
• Go to hr2.chevron.com.
• Choose Open Enrollment to get started.
By phone
Customer Service Representatives can take your tobacco use status
certification and open enrollment elections by phone until 5 p.m., Pacific time
(7 p.m., Central time) on October 31.
HR Service Center
1-888-825-5247 (inside the U.S.)
610-669-8595 (outside the U.S.)
For quicker service, avoid peak call hours. Peak hours are all day Monday
and 9 a.m. to 10 a.m. Pacific time (11 a.m. to noon Central time) on other
weekdays.
Representatives Available
Monday through Friday
6 a.m. to 5 p.m. Pacific time
Do You Know Your Benefits Connection PIN?
If you access the enrollment website from the Chevron network, you can use the automatic sign-in feature and you
don’t need a PIN. But if you plan to certify your tobacco use status or make other open enrollment elections from
outside the Chevron network or by phone, you’ll need your PIN. A PIN reminder was mailed to you in September, but
if you still don’t know your PIN or can’t find it, you can request a new one online or by calling the HR Service Center.
It can take up to two weeks to receive your PIN in the mail, so take action right away if you need it.
Also, register for the Forgot your PIN feature if you haven’t already done so. This feature will allow you to access
your account by answering security questions. From the Benefits Connection home page, chose the Personal
Information tab, then Login and Site Preferences. If you don’t have this feature enabled, the only way to get a new
PIN is through the mail.
6 | Open Enrollment October 2014
More Enrollment Resources
The Open Enrollment section at hr2.chevron.com is the place to go to learn more about your benefits, learn more
about changes for next year, access links to other tools and resources, certify your tobacco use status and make
other enrollment choices online. You can go to this website at work or at home. Here are three resources available
at hr2.chevron.com that may be of special interest to you as you are thinking about your benefits for 2015.
Online Videos
Watch our new series of online videos, from home or work, on hr2.chevron.com to learn more about:
• A comparison of the three medical plan types now offered by Chevron.
• How flexible spending account plans work.
• Eight ways to be a smart health care shopper.
• The Patient Protection and Affordable Care Act, which is the law that’s known simply as Health Care Reform.
Summary of Benefits and Coverage (SBC)
SBCs provide summary information about your health plans, such as benefits, copayments, deductibles,
coinsurance and plan contact information. SBCs for 2015 health plans are available free of charge online at
hr2.chevron.com or by calling the HR Service Center at 1-888-825-5247 (inside the U.S.) or 610-669-8595
(outside the U.S.), and selecting option 2.
Summary Plan Description (SPD)
Your SPD provides specific details about your Chevron benefits, such as eligibility and covered services. You can get
your SPD in two ways:
• Online. Visit hr2.chevron.com and choose the Your Benefits tab.
• By phone. To request a printed copy by mail, contact the HR Service Center at 1-888-825-5247 (inside the
U.S.) or 610-669-8595 (outside the U.S.), and selecting option 2.
It’s not SPAM or Phishing
The HR Service Center manages the administration of your health and welfare benefits and maintains
enrollment records for Chevron. For this reason, Chevron may request the HR Service Center to provide
information that applies to your personal benefits enrollment situation directly to you at your Chevron email
address. The emails come from the Human Resources Service Center mailbox with the email address
[email protected]. These emails have been approved by Chevron’s benefits
department and can be considered safe. Please note this email box is an outgoing email box, so please don’t
send benefits questions to that address. If you have any question about the validity of an email you receive,
you’re always encouraged to call the Human Resources Service Center or send an email to the Chevron
benefits team at [email protected].
U.S. Pay and Benefits News | 7
How to Certify
Your Tobacco Use Status
All employees (including employees on a leave of absence who are
not receiving coverage through COBRA) are required to certify their
tobacco use status during open enrollment, October 20 through
October 31, 2014.
During this year’s open enrollment period, October 20 through October 31, 2014, all U.S.-payroll employees
who participate in Chevron medical or supplemental life insurance coverage will be required to certify
their tobacco use status. If you fail to follow the steps to certify your tobacco use status during open
enrollment, you’ll be charged the higher monthly rates for medical and supplemental life insurance
coverage for all of 2015, whether or not you use tobacco. You will not lose your coverage in these plans if
you fail to certify, but you will pay the higher rate. If you miss the deadline, you cannot change your tobacco
use status until next year’s open enrollment for 2016 benefits.
Note: COBRA participants are not required to certify their tobacco use status at this time.
Tobacco use can affect your health. And your health is important to your quality of life, your family, your career,
and the health of our business. That’s why Chevron announced an important change to medical and supplemental
life insurance coverage earlier this year. Starting January 1, 2015, Chevron will establish a tobacco surcharge
for medical and supplemental life insurance coverage. This means there will be different monthly rates for this
coverage for tobacco and non-tobacco users.
It matters to Chevron that you’re in good health at work and at home. That’s why we offer a variety of wellness
programs and resources to encourage and support better health. We hope our employees — tobacco and nontobacco users alike — take advantage of these opportunities, whether it’s to try to stop using tobacco, participate in
exercise programs, or take steps to protect your heart.
How to Certify
You can certify your tobacco use status by calling the HR Service Center (see Page 6) or by going online to Benefits
Connection, the same website you use to make open enrollment elections. If you access Benefits Connection, from
the Chevron network, you can use the automatic sign-in feature and you don’t need a PIN. But if you need to certify
your tobacco use status from outside the Chevron network or by phone, you’ll need your PIN. A PIN reminder was
mailed to you in September, but if you still don’t know your PIN or can’t find it, you can request a new one online
or by calling the HR Service Center. It can take up to two weeks to receive your PIN in the mail, so take action right
away if you need it.
• Go to hr2.chevron.com and click Open Enrollment, then the Certify Tobacco Status button.
• Login to Benefits Connection. Choose the Enroll Today button, then the Make Your Elections Now button.
• From the Make Coverage Elections screen, look for Tobacco Certification and choose Change.
• After you certify your tobacco use status, your Make Coverage Elections screen will be updated according
to your certification choice.
8 | Open Enrollment October 2014
Your Certification Choices
When you certify your tobacco use status, you’ll be asked to choose from the status options listed below. Here’s
what those choices are and what they mean.
Tobacco User
Tobacco use is a personal choice. It’s not our goal to intrude on your personal life and take away that choice. That’s
why if you currently use tobacco, you can continue using it. If you’re a tobacco user and don’t intend to stop using
tobacco, you’ll pay $25 more each month in 2015 for medical coverage than employees who are not tobacco users. If
you participate in Chevron’s Supplemental Life Insurance Plan, you’ll also pay 20 percent more each month in 2015
for that coverage. The higher rates will take effect on January 1, 2015. Your benefit plan and the level of coverage
you receive will be the same as non-tobacco users, the only difference will be that you pay a higher monthly cost for
your coverage.
Tobacco User, But Will Try to Quit
If you commit to try to stop using tobacco during 2015, we have support resources to help you, and you’ll pay the
lower monthly rate too. Go to hr2.chevron.com for resources.
Not a Tobacco User
If you don’t use tobacco you will not be subject to the higher medical and supplemental life insurance rates in 2015
as long as you certify your tobacco use status during open enrollment, October 20 through October 31. If you fail to
meet this deadline, you’ll be charged the higher monthly rates for medical and supplemental life insurance coverage
for all of 2015.
Decline to Disclose
You can choose to decline to disclose your tobacco use status, but you’ll be charged the higher monthly rates for
medical and supplemental life insurance coverage for all of 2015, whether or not you use tobacco.
What’s considered tobacco use?
You’ll be asked to indicate your tobacco use status only. You don’t have to certify the tobacco use status
of your spouse or domestic partner and other dependents for 2015. Any use, regardless of frequency or
location, is considered use. This includes daily, occasional or social use. It also includes if it’s used only at
your home. Use of the following since July 1, 2014, will be considered tobacco use:
• Tobacco (such as cigarette, pipe, cigar).
• Smokeless tobacco (such as snuff or chewing tobacco).
E-cigarettes do not contain tobacco, so at this time e-cigarettes are not included in the tobacco use
definition. However, the Federal Drug Administration is currently reviewing e-cigarettes. We continue to
monitor this review and may choose to include e-cigarettes in the tobacco use definition in the future.
U.S. Pay and Benefits News | 9
Check your dependent’s information.
Chevron needs your spouse, domestic partner and children’s Social
Security Number if enrolled in a Chevron health plan.
The Patient Protection and Affordable Care Act requires companies like Chevron to annually report Social Security
numbers (SSNs) for all dependents enrolled in one of Chevron’s health plans. This requirement starts in early
2016 for coverage effective in 2015. The HR Service Center has updated their systems to ensure we have the data
required to satisfy these government reporting requirements. As a result, if you have a life event in the future that
triggers a benefit change, you will be required to have all of your dependents’ Social Security numbers on file with
the HR Service Center. This includes life events like moving or adding a new dependent to your coverage. If SSNs
are missing for your dependent(s), your life event may not process correctly and you could experience a
disruption in your coverage.
What do I need to do?
While you’re certifying your tobacco use status or making other open enrollment elections, review your dependents
listed on Benefits Connection and be sure an SSN is listed for each of your dependents. For your reference this
includes all types of dependents, children, spouse and domestic partner. If an SSN is missing, please update your
dependent’s record as soon as possible. It’s a good idea to do this now so you don’t have a possible disruption
in your coverage during a future life event. You can update your dependent’s information either online from the
Personal Information – Dependents screen at the Benefits Connection enrollment website or by phone with the
HR Service Center. (See Page 6.) If your dependent does not have a social security number, please contact the HR
Service Center by telephone. Certain alternatives, such as Tax Identification Number, may also be entered into our
system to satisfy this request.
Your Right to Privacy
Please note that we respect your right to privacy. Chevron will only use the information collected to comply with
plan rules and these specific legal requirements. Chevron does not use or transmit any personal information
collected for the purpose of health plan administration except as described in the Notice of Privacy Practices For
Health Care Information available online at hr2.chevron.com.
10 | Open Enrollment October 2014
Health Rewards deadline
to qualify is October 31, 2014.
The choices you make every day about diet, exercise and tobacco matter. Earlier this year, Chevron announced a
new health reward opportunity to recognize your personal commitment to get and stay healthy this year. The deadline to qualify for the health reward is almost here.
Each time you choose a healthy lifestyle option and complete a qualifying wellness activity, you’ll earn points. Complete the health questionnaire and earn 250 points before October 31, 2014, to qualify for the health rewards. This
year, rewards include a $250 Wellness Credit. You’ll also be entered in a drawing for a chance to win free medical
premiums for all of 2015 for you and your eligible dependents.
It’s too late to start some of the long-term qualifying activities, but there may be others that you can still complete
before October 31 to receive points.
Go to hr2.chevron.com/wellness and choose the Health Rewards link to review full program details, eligibility
requirements, qualifying activities, frequently asked questions or to check your points balance.
How You’ll Receive Your Wellness Credit
If you are enrolled in the Chevron Medical PPO Plan, a Chevron Medical HMO Plan or have waived Chevron medical coverage, and you meet the requirements to qualify for health rewards, your Wellness Credit
will be deposited into your general purpose Health Care Spending Account (HCSA) on January 1, 2015,
as long as you’re still eligible. The Wellness Credit can be used for eligible health care expenses you incur
between January 1, 2015 and December 31, 2015. Your total HCSA balance, which includes your Wellness
Credit, will be available on and after January 1, 2015, on myuhc.com.
If you are enrolled in the Chevron High Deductible Health Plan (HDHP), and you meet the requirements to
qualify for health rewards, a Limited Purpose Health Care Spending Account (LHCSA) will automatically be
established for you. This is because you are not allowed to participate in the HCSA if you are enrolled in the
HDHP. Your Wellness Credit will be deposited into your LHCSA on January 1, 2015, as long as you’re still eligible. The LHCSA may only be used to pay for eligible dental and vision expenses you incur between January
1, 2015 and December 31, 2015. You’ll receive a separate special purpose debit card to use to pay for eligible
expenses along with more instructions later this year.
U.S. Pay and Benefits News | 11
Medical Coverage Costs
Your monthly cost for your 2015 benefit coverage will be available online beginning October 13.
Remember, you can’t make changes until October 20, but you can preview the 2015 costs and
your available options. To get started, click the Open Enrollment link at hr2.chevron.com (See
Page 6).
Medical PPO Plan Costs
As you know, Chevron currently shares the monthly cost of coverage — the premium — for your medical plans. The
total premium cost of a plan is determined, in part, by the actual health care expenses incurred by the plan in the
previous year. We’ve determined that costs in 2013, and in the first half of 2014, are actually better than estimated
for the Medical PPO Plans. Because the actual claims experience is better than expected, the Medical PPO (Option
1 and Option 2) will have an unusual decrease in the monthly premium for 2015. There are many reasons for the
improvement in the Medical PPO (Option 1 and Option 2) claims experience, including participants making an effort
to make healthy lifestyle choices and better manage healthcare expenses.
Chevron’s Maximum Contribution to Your 2015 Medical Coverage
The company makes a maximum monthly contribution for your medical coverage. The numbers in the chart below
show the maximum amounts Chevron will contribute to your medical coverage in 2015. This maximum contribution
is equal to 80 percent of the total premium of the Medical PPO Plan - Option 2. If the plan you select costs less
than that plan, Chevron will pay 80 percent of the cost of your plan. If the plan you select costs more, Chevron
will pay the maximum contribution (displayed below), and you will pay the difference. The total premium cost for
the Medical PPO Plan - Option 2 is decreasing, so this means Chevron’s maximum monthly contribution is also
decreasing in 2015.
Coverage Tier
Chevron’s Maximum Contribution Amount
You Only
$432/month (last year: $470)
You + One Adult
$865/month (last year: $940)
You + Child(ren)
$734/month (last year: $799)
You + Family
$1,166 /month (last year: $1,269)
Medical HMO Plan Costs
Most of the Medical HMO Plans will experience cost increases, as much as 35 percent, depending on the Medical
HMO Plan. HMO plans are products that Chevron purchases on behalf of our employees, and premiums are set
by the HMO Plans based on their specific claims experience. In addition, remember, the maximum company
contribution to medical coverage — including HMO plans — is equal to 80 percent of the total premium of the Medical
PPO - Option 2. Because the company contribution to Medical PPO - Option 2 is decreasing, the company may also
contribute less toward other medical plans in 2015, including your HMO Plan. If the HMO Plan you select costs less
than the Chevron Medical PPO Plan – Option 2, Chevron will pay 80 percent of the cost of your HMO Plan. If the
HMO Plan you select costs more than the Chevron Medical PPO Plan – Option 2, Chevron will pay the maximum
contribution (displayed above), and you will pay the difference.
12 | Open Enrollment October 2014
2015 Plan Changes
This section describes the changes to your health and
welfare benefits that take effect on January 1, 2015.
U.S. Pay and Benefits News | 13
Prescription Drug Changes
If you are enrolled in the Medical PPO Plan or the High Deductible Health Plan (HDHP), you automatically have
prescription drug coverage through the Prescription Drug Program with Express Scripts. The changes described
in this section take effect on January 1, 2015. For additional details, contact Express Scripts Member Services
at 1-800-987-8368, or review the documents and links available from hr2.chevron.com. Choose the Open
Enrollment link to get started.
14 | Open Enrollment October 2014
New National Preferred Formulary
A formulary is a list of drugs that are covered by your plan. It includes commonly prescribed medications that have
been selected based on their clinical effectiveness, safety and opportunities for savings. Effective January 1, 2015,
your plan will switch to the National Preferred Formulary. While many of the same drugs will continue to be covered,
there are approximately 65 drugs that will no longer be covered. See below for the list of drugs that will no longer be
covered. If you continue to use any of these drugs, you will pay the full retail price when you refill that prescription
starting January 1. If you are taking one of the drugs that will no longer be covered, Express Scripts will notify you
starting in October. You will receive a personalized list of alternatives that are available on the formulary, so you can
discuss them with your doctor and change your prescription in advance of January 1.
Excluded Medications and Products Effective January 1, 2015
Abbott (FreeStyle,
Precision)
Abstral
Alvesco
Apidra
Aranesp
Axert
Bayer (Breeze, Contour)
Beconase AQ
BenzaClin Gel Pump
Betaseron
Bravelle
Breo Ellipta
Cetraxal
Cimzia
Duexis
Edarbi/Edarbyclor
Epogen Euflexxa
Fentora
Flovent Diskus/HFA
Follistim AQ
Fortesta
Frova
Gel-One
Hyalgan
Incivek
Jentadueto
Kadian
Kazano
Levitra
Nesina
Nipro (TRUEtest,
TRUEtrack)
Novolin
NovoLog
Nutropin/Nutropin AQ
Omnaris
Omnitrope
Pancreaze
PegIntron
Pertzye
Proventil HFA
Roche (Accu-Chek)
Saizen
Simponi
Staxyn
Stendra
Subsys
Supartz
Tanzeum
Testim
Testosterone 1% Gel Teveten HCT
Tev-Tropin
Tradjenta
Ultresa
Veltin
Veramyst
Victoza
Vimovo
Vogelxo
Xeljanz
Xopenex HFA
Zetonna
Zioptan
Zohydro ER
Is My Prescription on the Formulary?
To determine at any time if a prescription drug is on the formulary you can:
• Call and ask a Patient Care Advocate at Express Scripts to check on the status of the medication.
• Register and login to www.express-scripts.com, click on the Manage Prescriptions tab
at the top of the page, then click on Price a Medication.
• Download the Express Scripts mobile app for free, register and then check status of
a medication.
U.S. Pay and Benefits News | 15
Breast Cancer Risk-Reducing Medications
In accordance with the Health Care Reform law, your plan will provide network coverage at 100 percent with no
deductible for certain breast cancer risk-reducing medication such as Tamoxifen and Raloxifene. You’re eligible for
the 100 percent coverage if you meet all of the following requirements:
• You are a woman age 35 or older.
• You do not have a prior history of a diagnosis of breast cancer, ductal carcinoma
in situ (DCIS), or lobular carcinoma in situ (LCIS).
• You are being prescribed tamoxifen or raloxifene for the purpose of primary
prevention of invasive breast cancer because you are deemed high risk.
• You are post-menopausal, if prescribed raloxifene (this does not apply to a woman
prescribed tamoxifen).
Breast cancer risk-reducing medications that are covered are:
• Generic tamoxifen
• Generic raloxifene
• Brand Soltamox (tamoxifen liquid*)
* Tamoxifen liquid will be covered at 100 percent with no deductible if the prescriber provides information that the patient
meets all other criteria and cannot swallow or has difficulty swallowing tamoxifen tablets
Coverage at 100 percent is not automatic. If you meet the eligibility criteria above, you or your provider must request
the $0 copayment/coinsurance within 30 days of the prescription being filled (pre- or post-fill). To request the $0
copayment/coinsurance, follow these steps:
• You or your prescriber contacts Express Scripts Customer Service at 1-800-987-8368.
• Customer service will explain the procedure for contacting the Coverage Review Department through mail,
fax, or a direct call transfer.
• You will submit your request through mail, fax or telephone.
• Your prescriber is contacted through a fax form to determine if you meet
the eligibility criteria.
• Copayment review decision is then made.
• You and your prescriber are notified of decision.
New Prior Authorizations
The Prescription Drug Program covers some drugs only if they’re prescribed for certain uses or only up to certain
quantity levels. For this reason, some medications must be approved in advance before you can receive plan benefits.
The following drugs will require prior authorization effective January 1, 2015:
• Lovaza
• Vescepa (fish oil)
16 | Open Enrollment October 2014
Compound Medications Not Covered Without Prior Authorization
According to the FDA, compounding is the practice in which a licensed pharmacist combines, mixes or alters
ingredients in response to a prescription to create a medication tailored to the medical needs of an individual
patient. Individual active ingredients within the compound might be FDA approved, but the FDA does not approve
the quality, safety and efficacy of a compound with multiple active ingredients. Express Scripts has identified 10
commonly used bulk powder ingredients (if submitted as the primary ingredient) that have limited or no medical
studies for topical use. These bulk powders are:
• Gabapentin
• Meloxicam
• Fluticasone
• Haluronic Acid
• Ketoprofen
• Flurbiprofen
• Ketamine
• Mometasone
• Diclofenac
• Nabumetone
Beginning January 1, 2015, if you are using a compound medication in which the primary ingredient is one
of the bulk powders listed above, the medication will no longer be covered without a Prior Authorization.
Approval for a Prior Authorization will require clinically sound studies proving the efficacy of the medication.
Express Scripts recommends that you contact your physician to try a commercially available, FDA-approved
alternative. For a few of the powders, there are commercially available products that don’t require a compounded
product. Only your medical provider and you can determine a suitable alternative since it is often difficult to
determine the condition for which a compounded medication is being prescribed. If you continue to use the affected
compounded medications without an approved Prior Authorization, you will pay the full retail price if you refill that
prescription starting January 1. Express Scripts will continue to monitor this class of medications closely.
Preferred Step Therapy Program Updates
Certain drugs are covered by the Prescription Drug Program only if preferred drugs — which include generics — are
tried first. This is called Preferred Step Therapy (PST). The following are new additions to PST that will require you,
when clinically appropriate, to try the preferred drug before Express Scripts will authorize coverage for the use of
non-preferred drugs:
• Gabapentin (anticonvulsant and analgesic - pain relief - drugs): Lyrica, Horizant, Neurontin, Gralise
• HMG (statin drugs/cholesterol lowering drugs): Altoprev, Caduet, Lescol/Lescol XL, Lipitor, Livalo, Mevacor,
Pravachol, Zocor
• Beta Blockers (blood pressure drugs): Bystolic, Sectral, Tenormin, Kerlone, Zebeta, Coreg, Coreg CR,
Trandate, Lopressor, Toprol XL, Corgard, Levatol, Inderal, Inderal LA, InnoPran XL, Tenoretic, Ziac, Lopressor
HCT, Corzide, Inderide, Dutoprol
U.S. Pay and Benefits News | 17
Medical PPO — Option 1 and Option 2
Option 1 Deductibles*
Medical
You Only
$300
You + One Adult
$600
You + Child(ren)
$600
You + Family
$900
Prescription Drugs
You Only
$150
You + Family
$300
Mental Health and Substance Abuse (MHSA) Plan
$0 There is no deductible for covered mental health and
substance abuse services.
Option 2 Deductibles*
Medical
You Only
$600
You + One Adult
$1,200
You + Child(ren)
$1,200
You + Family
$1,800
Prescription Drugs
You Only
$150
You + Family
$300
Mental Health and Substance Abuse (MHSA) Plan
$0 There is no deductible for covered mental health and
substance abuse services.
* For Option 1 and Option 2, each covered individual has a maximum deductible equal to the You Only deductible amount. For the
You + One Adult, You + Child(ren) and You + Family coverage category levels, there is an overall maximum deductible amount for
all covered participants that corresponds to the coverage category elected. No more than the You Only deductible amount can be
applied toward the family deductible for any one person to satisfy the You + One Adult, You + Child(ren) or You + Family deductible.
18 | Open Enrollment October 2014
Option 1 Out-of-Pocket Maximum**
Medical and Mental Health, Combined †
You Only
$2,300
You + One Adult
$4,600
You + Child(ren)
$4,600
You + Family
$6,900
Prescription Drugs
You Only
” $1,800
You + Family
” $3,600
Option 2 Out-of-Pocket Maximum**
Medical and Mental Health, Combined
” $3,000
You Only
You + One Adult
” $6,000
You + Child(ren)
” $6,000
You + Family
” $9,000
Prescription Drugs
You Only
” $1,800
You + Family
” $3,600
** Generally includes your annual deductibles, copayments and coinsurance.
† The medical and mental health out-of-pocket maximums listed for Option 1 represent an increase for 2015 with respect to
mental health services.
U.S. Pay and Benefits News | 19
Medical PPO — Option 3
The Medical PPO — Option 3 plan choice will no longer be offered in 2015. That’s because this plan is being
replaced by the new Chevron High Deductible Health Plan (HDHP) option. The Medical PPO — Option 1 and
Medical PPO — Option 2 will continue to be offered to eligible employees in 2015. If you are currently enrolled in the
Medical PPO — Option 3, you will be automatically enrolled in the new Chevron High Deductible Health Plan starting
January 1, 2015. If you would rather choose another plan, you must make an election during open enrollment,
October 20 through October 31, 2014. Open enrollment is your only opportunity to change your 2015 medical
coverage, unless you experience a qualifying life event later during the year.
The new HDHP plan generally covers the same services as your current Medical PPO — Option 3 plan; however, there
are important differences between your current plan and the HDHP that change how you will pay for your medical,
prescription drug and mental health benefits in 2015. It’s important that you pay attention to the differences
and take the time to learn about the HDHP to ensure it’s the right choice for you. Open enrollment is your only
opportunity to change your 2015 medical coverage, unless you experience a qualifying life event later during the
year. Be sure you don’t miss this opportunity to learn, decide and act. See Page 21 to learn more about the HDHP.
20 | Open Enrollment October 2014
High Deductible Health Plan (HDHP)
New Plan Choice Starting January 1, 2015
The Chevron HDHP is a new plan choice that will be offered in 2015. You can enroll in the HDHP if you’re a U.S.payroll employee and you’re eligible for Chevron’s health benefits. You can also enroll your eligible dependents,
just as you can with Chevron’s other health plans. The HDHP is a preferred provider organization (PPO) health
plan that includes medical coverage with UnitedHealthcare, prescription drug coverage with Express Scripts, and
Mental Health Substance Abuse coverage with Value Options. In addition, if you enroll in the HDHP, you’re also
automatically enrolled in the Vision Program for basic vision coverage with VSP. You can choose to see any provider
you want; however, higher benefits are paid when you go to a network provider.
With this plan you pay a low monthly premium in exchange for a high deductible. Participants enrolled in the HDHP
may also be eligible to open and contribute to a health savings account (HSA).
U.S. Pay and Benefits News | 21
How the HDHP is Similar to Other Choices
Just like your other medical plan options, Chevron currently shares the monthly cost of coverage – the premium –
with you. This plan offers comprehensive coverage for the same major medical services you’d expect, including
office visits, emergency services, hospital care, lab services, outpatient care, pregnancy and newborn care and
rehabilitative services. It also includes 100 percent coverage with no deductible for certain preventive care
services as specified by the Affordable Care Act when you see a network provider (100 percent of allowable
charges for an out-of-network provider). Additional preventive screenings and services may be covered, depending
on factors such as your age and gender. If you are enrolled in the HDHP, you automatically have prescription drug
coverage through the Prescription Drug Program with Express Scripts. (See Page 14 for information about 2015
changes to the Prescription Drug Program.) For additional summary information about the new HDHP, such as
benefits, copayments, deductibles, coinsurance and plan contact information, review the plan’s
Summary of Benefits and Coverage. (See Page 7.)
Go to the Benefits Connection website to see the 2015 monthly premium costs for this and the other health
plans that are available to you.
22 | Open Enrollment October 2014
One Combined Deductible
Chevron’s other medical plan choices typically require you to satisfy two deductibles before the plan pays its share
of benefits: one for medical services and one for prescription drugs. The HDHP has only one combined deductible
for medical, prescription drugs (both retail and mail-order), and mental health and substance abuse. And, it’s a
much higher deductible than your other Chevron medical plan choices. This means you’ll have to pay the full cost for
covered services and supplies until you reach the deductible for the year.
After you meet the deductible, coinsurance or copayments will apply. This means you will pay the full cost for these
covered services (and other covered services) until you meet your annual deductible:
• Retail prescriptions.
• Mail-order prescriptions.
• Visits to a mental health practitioner.
• Office visits to your doctor (except for certain
preventive care as specified by the Affordable
Care Act).
• Treatment for substance abuse.
Annual Deductible*
Medical, Prescription Drug, Mental Health Combined
You Only
$2,650
You + One Adult
$5,300
You + Child(ren)
$5,300
You + Family
$7,950
* Each covered individual has a maximum deductible equal to the You Only deductible amount. For the You + One Adult, You
+ Child(ren) and You + Family coverage category levels, there is an overall maximum deductible amount for all covered
participants that corresponds to the coverage category elected. No more than the You Only deductible amount can be applied
toward the family deductible for any one person to satisfy the You + One Adult, You + Child(ren) or You + Family deductible.
Understand how the combined annual deductible works.
If you choose the HDHP, you must be ready to pay the full amount of the higher deductible up front before
the HDHP pays any benefits (except for certain preventive care as specified by the Affordable Care Act).
You might already be familiar with this process if you’re enrolled in the Medical PPO Plan because that
plan works the same way. However, with the HDHP there are services that are now subject to the
deductible which are typically excluded under the Medical PPO Plan. This difference could surprise
you, so we wanted to point them out in the event you use these services often. First, you’ll pay full cost for
retail and now also mail-order prescription drugs until you reach the single combined annual deductible.
And under the current Medical PPO, mental health and substance abuse services are not subject to the
deductible, so the Medical PPO shares the costs of those services right away. With the HDHP, mental
health and substance abuse services are subject to the deductible, so you’ll pay full cost for those covered
services until you reach the single combined annual deductible.
U.S. Pay and Benefits News | 23
One Combined Out-of-Pocket Maximum
The HDHP has only one combined out-of-pocket maximum for medical, prescription drugs, mental health and
substance abuse. The out-of-pocket maximum is the most you will have to pay out-of-pocket for the year for covered
services and supplies. When you reach this limit, the HDHP begins to pay 100 percent of the allowed amount for
covered services and supplies.
Out-of-Pocket Maximum*
Medical, Prescription Drug, Mental Health Combined
You Only
$5,000
You + One Adult
$9,000
You + Child(ren)
$9,000
You + Family
$12,900
* Generally includes your annual deductible, copayments and coinsurance.
24 | Open Enrollment October 2014
Health Savings Account (HSA) Compatible
If you enroll in the HDHP, you may also be eligible to open and contribute to a health savings account (HSA).
An HSA is like a savings plan for health care. It works like a regular bank account, but you don’t currently pay
federal income taxes on money you deposit. And, under current IRS rules, when you use your money to pay
for qualified health care expenses, you won’t pay federal income taxes on the money either. Your savings grow
from year to year. There is no use it or lose it rule. And you can take your money with you if you change medical
plans. You can use an HSA to pay for qualified medical expenses this year, three years from now or at any point
in the future — even in retirement.
It’s your responsibility to learn about the strict eligibility rules and restrictions imposed by the IRS and
determine if you meet the requirements to open and contribute to an HSA. Eligible employees enrolled in
Chevron’s HDHP may be able to make contributions to the BenefitWallet Health Savings Account (HSA) though
payroll deductions. Links to more information about the BenefitWallet HSA are available on hr2.chevron.com.
But you can choose from HSAs offered by any financial institution that offers them, including the Chevron
Federal Credit Union. It’s up to you to find the one that meets your needs. In addition, you’ll be responsible for
understanding how an HSA works and making contributions.
Participating in an HSA is a voluntary choice. Chevron does not provide an HSA, and Chevron cannot offer
counsel about HSAs. You should consult your tax advisor and read about the requirements in IRS Publication
969, Health Savings Accounts and Other Tax-Favored Health Plans available at www.irs.gov.
U.S. Pay and Benefits News | 25
On the Job Accident Insurance Plan
On-the-Job Accident insurance provides a level of income protection for you and your family members due to
death or a covered loss resulting from an on the job accident. Currently, this coverage is automatically provided
at no additional cost to eligible employees. The following additional benefits are provided under the plan for
covered accidents that occur on and after July 1, 2014:
• Seatbelt/Airbag Benefit: If you die as the result of a covered accident while wearing a properly
fastened, original, factory-installed seatbelt, the plan will pay $25,000 to your beneficiary. The plan will
pay an additional airbag benefit of $10,000 if the seatbelt benefit is payable and you are positioned in a
seat protected by a properly functioning, original, factory-installed supplemental restraint system that
inflates on impact. Verification of the actual use of the seat belt and verification that the supplemental
restraint system inflated properly upon impact at the time of a covered accident must be provided in
accordance with the plan’s requirements.
• Coma Benefit: If you are injured as a result of a covered accident, the plan will pay a monthly benefit of
one percent of your principal sum if:
- You are injured and become comatose within 31 days of the date of the covered accident; and
- The coma continues for a period of 31 consecutive days.
The plan pays monthly benefits for as long as you remain comatose due to the injury, up to 11 straight
months. Benefits stop at the end of the month during which the earliest of the following occurs:
- You cease to be comatose due to that injury; or
- You die.
• Brain Damage Benefit: The plan will pay a benefit equal to 100 percent of the principal sum if as a
result of a covered accident:
- Brain damage begins within 30 days of a covered accident;
- You are hospitalized for at least five days within the first 30 days following the covered accident;
- Brain damage continues for 12 consecutive months; or
- A physician determines the brain damage is permanent, complete and irreversible at the end of
the 12-consecutive-month period.
Brain damage means physical damage to the brain which cause the complete inability to perform all the
substantial and material functions and activities normal to everyday life.
The amount payable under this benefit will be made in one lump sum during the 12th month following
the date of the accident if brain damage continues longer than 12 consecutive months.
• Home Alteration and Vehicle Modification Benefit: If you suffered an accidental dismemberment for
which benefits are payable under the plan and, as a direct result, require the use of a wheelchair to be
ambulatory, the plan will pay up to $25,000 for alterations to your residence and modifications to your
vehicle to make them wheelchair accessible. Such expenses must be incurred incurred within one year
after the date of the accident causing such loss.
• Rehabilitation Benefit: If you suffer an accidental loss for which benefits are payable under the plan,
the plan will reimburse you up to $25,000 for covered rehabilitative expenses that are incurred within
two years after the date of the covered accident.
26 | Open Enrollment October 2014
Good to Know.
Benefit facts and reminders you might want
to know as you make enrollment choices.
U.S. Pay and Benefits News | 27
Flexible Spending Accounts Help
With Health and Day Care Expenses
You must re-enroll in flexible spending accounts every year; coverage is not automatic. If you want to
participate in 2015, you must enroll during open enrollment, even if you’re already participating this year. If
you don’t make an election during open enrollment, you will not have coverage during 2015.
The Health Care Spending Account (HCSA) and Dependent Day Care Spending Account (DCSA) are Chevron’s
flexible spending account plans. These plans are voluntary options that allow you to pay for certain eligible
expenses with before-tax dollars. Each month, you contribute a set amount to your account(s) through before-tax
payroll deductions. Then you use the funds in your account(s) to pay for eligible expenses. More information about
the HCSA and DCSA plans is available online. You can also watch our video online to learn more about these plans
and how they can help you. Go to hr2.chevron.com and choose Open Enrollment to get started.
Health Care Spending Account (HCSA)
You can use the HCSA to pay for your (and your eligible dependents’) out-of-pocket health care expenses — like
deductibles, office copayments, prescription drug copayments, and contact lens supplies. If you enroll in the new
High Deductible Health Plan (HDHP), you are not eligible to enroll in the HCSA. (See Page 21.)
The contribution limit for the HCSA for 2015 will remain at $2,250. If you qualify for the Wellness Credit by
completing the health questionnaire and earning 250 points before October 31, 2014, Chevron will contribute an
additional $250. This will bring your total maximum Health Care Spending Account balance for 2015 to $2,500. See
Page 11 for more information about the Wellness Credit deadline and eligibility requirements.
Dependent Day Care Spending Account (DCSA)
You can use the DCSA to pay for eligible dependent day care expenses for a qualified dependent — like after-school
child care, a licensed child care provider, or school tuition up to kindergarten — so you and your spouse can go
to work. The contribution limit for the DCSA is generally $5,000 ($2,500 if married and filing a separate return),
subject to other IRS limitations. If you enroll in the new High Deductible Health Plan (HDHP), you can still enroll in
the DCSA.
Plan Your Contributions Carefully
If you enroll in the HCSA, DCSA or both for 2015, your account(s) will reimburse eligible expenses you incur from
January 1 through December 31, 2015. If you do not use all of your account funds to pay for eligible expenses during
this period, money left unspent or unclaimed in your account will be forfeited.
You have until June 30, 2016, to file a claim to be reimbursed for eligible expenses you incurred in 2015. Note
that HCSA funds cannot be used for Dependent Day Care Spending Account expenses and DCSA funds cannot be
used for Health Care Spending Account expenses. It’s your responsibility to meet the December 31 and June 30
deadlines; be sure to add a reminder to your calendar to help you remember.
28 | Open Enrollment October 2014
A Word About Wellness Credits
If you qualify for a Wellness Credit by meeting the program requirements by the October 31, 2014, deadline,
you don’t need to do anything. (See Page 11 for more details.) Your $250 Wellness Credit will automatically be
applied to your HCSA account on January 1 (for use between January 1 and December 31, 2015). You are not
required to enroll in the HCSA Plan during open enrollment to receive your Wellness Credit. However, if you want
to contribute additional money to the HCSA, you must make an election during open enrollment. Please note you
must be a current employee on January 1, 2015, to receive the Wellness Credit. Learn more about the Wellness
Credit opportunity on Page 11.
Note: If you enroll in the new High Deductible Health Plan (HDHP) and qualify for a Wellness Credit, please see Page
11 for more information about how you’ll receive your Wellness Credit.
Is the HCSA the same as a health savings account?
No, the Health Care Spending Account (HCSA) — a flexible spending account — and a health savings account
(HSA) are two very different types of health accounts. While they are similar in some ways, the differences
are important to understand.
• The HCSA is a benefit plan offered as part of your total Chevron benefits package. An HSA is a
personal account separate from your Chevron benefits.
• If you are enrolled in the Chevron High Deductible Health Plan (HDHP), you can’t enroll in the HCSA.
However, to open and contribute to an HSA, you must be enrolled in a high deductible health plan.
• There are strict eligibility rules and restrictions to open and contribute to an HSA; not everyone will be
eligible. If you are eligible for Chevron’s health benefits, you’re eligible to participate in the HCSA (as
long as you aren’t enrolled in the HDHP or another high deductible health plan.)
• Any money you contribute to an HSA is yours. It rolls over from year to year and you can use it to pay
for qualified medical expenses now or at any time in the future. And if you retire or leave Chevron to
work for another employer, you can take your HSA with you. With a health flexible spending account,
like Chevron’s HCSA, the money you contribute must be spent by December 31 and you have until
June 30 of the following year to submit claims for qualified expenses. After that, any unspent and
unclaimed money will be forfeited. If you retire or leave Chevron, your HCSA will not go with you.
U.S. Pay and Benefits News | 29
Medical and Dental HMO Plans
An HMO option may be available to you in your area. The Benefits Connection website will list the HMOs available to
you next year (if any). All existing HMO plans will continue to be offered in 2015.
• Your provider or other plan features, like monthly premiums, copayments or prescription drug
coverage could still change. See your plan’s Summary of Benefits and Coverage (SBC) for more information
about your plan’s features or contact the HMO directly.
• Even if your current HMO will be available in 2015, that doesn’t guarantee that it is still available to
you. Each year, the HMOs review the ZIP codes and counties in which they have providers. An HMO may
choose to discontinue coverage to residents of certain areas.
• Your HMO provider may have changed. Remember that HMOs require you to use doctors, dentists and
hospitals that are part of their provider network. Contact your medical or dental HMO directly to find out if
your current providers continue to be in the network. If they are not, you will need to change providers or
choose a new plan to ensure that your medical and dental services continue to be covered.
• Copayment and other changes in your current HMO coverage may apply because of state filings,
compliance with the Health Care Reform law provisions, or to make them more closely align with Chevron’s
standard benefit design. You’ll be able to view more information about HMO plan changes, if any, in the 2015
Evidence of Coverage document available for each HMO plan. Contact the HMO directly to request a copy.
• If you are enrolled in a Chevron Medical HMO Plan, you have the choice to use the mental health
and substance abuse benefits provided by your HMO Plan, or to use the benefits provided under the
MHSA Plan administered by ValueOptions. However, you cannot make a claim to both your HMO Plan and
ValueOptions for the same service. If you are enrolled in a Chevron Medical HMO Plan and you choose to
use your ValueOptions MHSA benefit, remember you must use a ValueOptions network provider to receive
benefits. Out-of-network provider services are covered for emergencies only.
30 | Open Enrollment October 2014
An Eye on Your
Chevron Vision Coverage
Basic Vision Coverage
If you’re enrolled in the Medical PPO Plan or the HDHP you are automatically enrolled in the Vision Program for
basic vision coverage. VSP is the insurer for the Vision Program and administers your annual eye exam coverage.
If you’re enrolled in a Chevron Medical HMO Plan, your HMO Plan may also provide vision coverage. To learn more
about the vision coverage available through your HMO plan, contact the HMO directly. Go to hr2.chevron.com for a
listing of phone numbers and websites
Vision Plus Program
The Vision Plus Program is a voluntary coverage option that provides prescription eyewear coverage for an
additional payroll deduction. This is additional coverage for prescription eyewear that goes beyond your basic vision
coverage. Any U.S.-payroll employee eligible for Chevron’s health plans can enroll, and you can enroll even if you
waive Chevron health coverage. VSP is the insurer for the Vision Plus Program.
• If you are currently enrolled, your coverage will automatically continue in 2015.
• If you want to start (or stop) coverage, you must make an election during open enrollment.
• Go to hr2.chevron.com and click Open Enrollment to review more information about this benefit and
what it covers.
Chevron’s basic vision coverage includes 100 percent coverage for an annual comprehensive eye exam, including
dilation as needed, from a network provider. Contact your plan to understand what’s available.
About VSP
The VSP Preferred Provider network is made up of primarily private-practice vision providers across the
United States. All VSP private-practice doctors provide exams and have materials, such as glasses and
contacts, available in their office. You still have the option to see an out-of-network provider for exams or
to purchase materials if you desire. But note that the out-of-network benefit will apply and you’ll generally
have to submit a claim to VSP for reimbursement. VSP also offers Retail Chain Affiliate Providers for added
convenience and additional retail locations. These providers are network providers, so network benefits will
apply. Retail Chain Affiliate Providers include Visionworks, WisconsinVision, HeartlandVision, Rx Optical and
Cohen’s.
We know many employees use Costco for their prescription eyewear. Costco is an out-of-network provider, so
out-of-network benefits will apply. Unlike other out-of-network providers, however, Costco can submit your
claim to VSP. In addition, out-of-network coverage with Costco includes standard progressive lenses fully
covered after a $40 copayment.
If you have questions about your vision coverage, contact VSP at 1-800-877-7195, or go to
www.vsp.com/go/chevron.
U.S. Pay and Benefits News | 31
Maintain Your Emotional Health
Mental Health and Substance Abuse (MHSA) Plan
The MHSA plan, administered by ValueOptions, provides confidential support for a wide range of personal issues
— from everyday challenges to more serious problems. You and your covered dependents have access to support
services 24 hours a day for a variety of concerns such as:
• Depression
• Stress and anxiety
• Parenting and family problems
• Relationship difficulties or problems at work
32 | Open Enrollment October 2014
MHSA Basics
• You do not need to enroll. This benefit is automatically provided to you, as long as you’re eligible
to participate. And you’re still covered by this plan even if you are not enrolled in a medical plan offered
by Chevron.
• Your eligible dependents are covered, if they are enrolled in a medical plan to which Chevron contributes,
such as the Medical PPO, the HDHP or a Medical HMO.
• You do not pay a monthly cost for this coverage. Chevron currently pays the full monthly cost for this
coverage. However, you do share a portion of the costs if you receive benefits under the plan.
• If you’re enrolled in the Medical PPO Plan, a Chevron Medical HMO Plan or a medical plan with another
employer, there is no deductible to satisfy.
• If you’re enrolled in the Chevron HDHP, your combined deductible applies to mental health and substance
abuse services. This means you must satisfy your deductible before the HDHP shares the cost of mental
health or substance abuse services.
• If you are enrolled in a Chevron Medical HMO Plan, you have the choice to use the mental health and
substance abuse benefits provided by your HMO Plan, or to use the benefits provided under the MHSA
Plan administered by ValueOptions. However, you cannot make a claim to both your HMO Plan and
ValueOptions for the same service. If you choose to use the ValueOptions MHSA benefit, you must use a
ValueOptions network provider to receive benefits. Out-of-network benefits are not covered, except for
emergency services.
If you need assistance, you can talk to either ValueOptions, Chevron’s Employee Assistance and WorkLife
Services, or both. Contact ValueOptions at 1-800-847-2438. Contact Chevron’s Employee Assistance WorkLife
Services at 1-800-860-8205 (CTN 842-3333).
U.S. Pay and Benefits News | 33
Legally Required Notices
No action required by you.
Women’s Health and Cancer Rights Notice
To comply with the Women’s Health and Cancer Rights Act of 1998, Chevron reminds you that all medical plans
the company offers cover medically necessary mastectomy and related breast reconstructive surgery, including
reconstruction of the breast on which the mastectomy is performed; surgery and reconstruction of the other breast
to produce a symmetrical appearance; prostheses; and treatment remedies for physical complications during all
stages of the mastectomy, including lymphedema.
Free or Low-Cost Health Coverage to Children and Families
To comply with the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Chevron reminds
you that if you are eligible for health coverage from Chevron or another employer, but are unable to afford the
monthly premiums, you may qualify for a premium assistance program that some states offer to help pay for your
coverage. These states use funds from their Medicaid or Children’s Health Insurance Program (CHIP) programs to
help people who are eligible for employer-sponsored health coverage but need assistance with paying their health
premiums. This typically applies to households with an annual income under $44,100 for a family of four. For a list of
states that participate in premium assistance, go to hr2.chevron.com.
• If you or your dependents are already enrolled in Medicaid or CHIP, and you live in a participating state,
contact your state’s Medicaid or CHIP office to find out if premium assistance is available.
• If you or your dependents are not currently enrolled in Medicaid or CHIP but you think you or your
dependents might be eligible for either program, contact your state’s Medicaid or CHIP office. You can also
call 1-877-Kids-Now or visit www.insurekidsnow.gov to learn how to apply. If you qualify, ask your state if it
has a program that might help you pay the premiums for an employer-sponsored plan.
Special Enrollment Opportunity
If it’s determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, Chevron
is required to allow you and your dependents to enroll in a company-offered plan. To qualify for this special
enrollment opportunity, you must be eligible for Chevron coverage but not already enrolled. In addition, you must
contact the HR Service Center and request Chevron health coverage within 60 days of being determined eligible for
Medicaid or CHIP premium assistance. If you enroll within the 60-day time limit, Medicaid or CHIP will subsidize, or
pay for, a portion of the Chevron health plan premium cost.
34 | Open Enrollment October 2014
Mental Health and Substance Abuse Plan (MHSA) is a Grandfathered
Health Plan Under the Patient Protection and Affordable Care Act
Chevron Corporation believes the Chevron Corporation Mental Health and Substance Abuse Plan (the MHSA Plan)
is a grandfathered health plan under the Patient Protection and Affordable Care Act (the Affordable Care Act).
As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage
that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may
not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the
requirement for the provision of preventive health services without any cost sharing. However, grandfathered health
plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination
of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and
what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator
at 1-888-825-5247 (610-669-8595 outside the U.S.). You may also contact the Employee Benefits Security
Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/healthreform. This website
has a table summarizing which protections do and do not apply to grandfathered health plans.
Please note: This newsletter applies to U.S. payroll employees who work in the United States and U.S. payroll expatriates on rotational assignment who are
eligible for Chevron’s health and welfare benefits.
This newsletter serves as an official summary of material modification (SMM) for the plans referenced herein. Please keep this information with your
other plan documents for future reference. This communication provides only certain highlights about changes of benefit provisions. It is not intended
to be a complete explanation. If there are any discrepancies between this communication and the legal plan documents, the legal plan documents will
prevail to the extent permitted by law. There are no vested rights with respect to Chevron health care plans or any company contributions towards the
cost of such health care plans. Rather, Chevron Corporation reserves all rights, for any reason and at any time, to amend, change or terminate these
plans or to change or eliminate the company contribution toward the cost of such plans. Such amendments, changes, terminations or eliminations may be
applicable without regard to whether someone previously terminated employment with Chevron or previously was subject to a grandfathering provision.
Some benefit plans and policies described in this document may be subject to collective bargaining and, therefore, may not apply to union-represented
employees.
U.S. Pay and Benefits News | 35
Chevron Human Resources Service Center
P.O. Box 199708
Dallas, TX 75219-9708
Address Service Requested
Chevron Open Enrollment and Tobacco Certification Information.
Read and Take Action October 20 - October 31, 2014.
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Chevron Human Resources Service Center
P.O. Box 199708
Dallas, TX 75219-9708
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U.S. Pay and Benefits News is published by
Human Resources Communications,
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