medical PPO plan Find a provider medical PPO option 1 no longer offered New monthly premium cost prescription drug program

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1 medical PPO plan Aside from the switch to a new claims administrator Anthem Blue Cross this section provides more detail about other changes to the Chevron Medical PPO Plan that will be offered to pre 65 eligible retirees and their pre 65 eligible dependents effective January 1, New monthly premium cost Chevron will currently continue to share the monthly cost of coverage the premium with you. The HR Service Center will mail a personalized open enrollment worksheet to you under separate cover in early October. The worksheet includes the 2017 cost for coverage for pre 65 eligible participants. Chevron s company contribution to retiree medical coverage for all non-medicare medical plans for 2017 will remain the same amount as for prescription drug program If you are enrolled in the Medical PPO Plan, you automatically have prescription drug coverage through the Prescription Drug Program with Express Scripts. See Page 14 for information about the 2017 Prescription Drug Program. medical PPO option 1 no longer offered The Chevron Medical PPO Plan will be streamlined. The Medical PPO Option 1 will no longer be offered effective January 1, The current Medical PPO Option 2 will still be offered at this time, but it will just be referred to as the Chevron Medical PPO Plan. You ll continue to have the flexibility to see whichever provider you d like network or out-of-network. If you are currently enrolled in the Medical PPO Plan Option 1, you will be automatically enrolled in the Medical PPO Plan effective January 1, You do not have to make an enrollment election during open enrollment, unless you want to make a change to your coverage or choose another plan. If you are currently enrolled in the Medical PPO Plan Option 2, you will automatically continue to be enrolled in the Medical PPO Plan effective January 1, You do not have to make an enrollment election during open enrollment, unless you want to make a change to your coverage or choose another plan. Find a provider Go to hr2.chevron.com/retiree and click on 2017 Benefit Changes to access special links that make it easier to research your provider options. October

2 new annual deductibles The Medical PPO Plan has separate deductibles, one for medical services and the other for prescription drug costs. There is no deductible for mental health and substance abuse services. Effective January 1, 2017, the following changes to the Medical PPO deductibles will take effect. Covered medical services There are now different deductible amounts for covered medical services depending on if you see a network or an out-of-network provider. The medical deductibles will increase in 2017 for this plan. Amounts paid for covered medical services provided by a network provider also count toward the out-of-network annual deductible. Amounts paid for covered medical services provided by an out-of-network provider also count toward the network annual deductible. Coverage Category Network Out-of-Network You only $1,000 $2,000 You + One adult $2,000 $4,000 You + Child(ren) $2,000 $4,000 You + Family $3,000 $6,000 Each covered individual has a maximum deductible equal to the You only amount. Covered prescription drugs The prescription drug deductible will change in 2017, and the deductible amount is the same whether you use a network or out-of-network provider. Deductible does not apply to mail-order prescriptions. Coverage Category You only $400 You + One adult $800 You + Child(ren) $800 You + Family $800 Each covered individual has a maximum deductible equal to the You only amount. Covered mental health and substance abuse services If you and any of your covered dependents are enrolled in the Medical PPO Plan, you are also automatically enrolled in the Chevron Mental Health and Substance Abuse (MHSA) Plan, so long as you aren t eligible for Medicare. The deductible does not apply to mental health and substance abuse services, network or out-of-network. U.S. Retiree Benefit News 16

3 new out-of-pocket maximums The Medical PPO has separate out-of-pocket maximums, one for prescription drug costs and the other for medical, mental health and substance abuse services, combined. Covered prescription drugs The prescription drug out-of-pocket maximum will not change in 2017, and the amount is the same whether you use a network or out-of-network provider. Individual $1,800 Family $3,600 Each covered individual has an out-of-pocket maximum equal to the You only amount. Covered medical, mental health and substance abuse services, combined There are different out-of-pocket maximums for medical, mental health and substance abuse services combined, depending on if you see a network provider or an out-of-network provider. These out-of-pocket amounts will increase in 2017 for this plan. Note: While covered mental health and substance abuse services will apply to the combined out-of-pocket maximum, know that, depending on your usage, you may actually reach the MHSA Plan s out-of-pocket maximum for covered mental health and substance abuse services before you reach the Medical PPO Plan s combined annual out-of-pocket maximum amount. See Page 30 for more information about the MHSA out-of-pocket maximum amount. Amounts paid for covered services provided by a network provider also count toward the out-of-network maximum. Amounts paid for covered services provided by an out-of-network provider also count toward the network maximum. + Coverage Category Network Out-of-Network You only $5,000 $10,000 You + One adult $10,000 $20,000 You + Child(ren) $10,000 $20,000 You + Family $10,000 $20,000 Each covered individual has an out-of-pocket maximum equal to the You only amount. lifetime maximum This plan has a lifetime maximum for the following four services: family planning services, transportation and lodging incurred by a transplant recipient and companion(s), nutritional counseling covered by the plan, and temporomandibular joint (TMJ) disorder. Any amounts incurred by the plan participant that count toward the lifetime maximum while UnitedHealthcare was the claims administrator will carry over and also apply toward the lifetime maximum while Anthem Blue Cross is the claims administrator. October

4 new coinsurance and copayment amounts for covered medical services The Medical PPO Plan currently has different coinsurance and copayment amounts for covered medical services depending on if you see a network or an out-of-network provider. That structure won t change in It s still your choice to use any provider you want, but starting in 2017, it s important to know that using a network provider will save you money. That s because your share of copayment and coinsurance amounts for most covered medical services and office visits will increase in The Medical PPO Plan will continue to include 100 percent coverage with no copayment, coinsurance or deductible for certain preventive care services, as specified by the Affordable Care Act, when you see a network provider. If you see an out-of-network provider you ll pay 40 percent of maximum allowable amounts and the annual medical deductible will apply. If you visit a network provider, you ll pay 20 percent of maximum allowable amounts, and the plan will pay 80 percent, after you ve met your annual deductible for medical services, unless otherwise stated. If you visit an out-of-network provider, you ll pay 40 percent of maximum allowable amounts, and the plan will pay 60 percent, after you ve met your annual deductible for medical services, unless otherwise stated. There are specific procedures and services for which you re required to notify the claims administrator in accordance with timelines identified in plan rules. Starting in 2017, if you fail to meet the Medical PPO Plan s notification requirements for these procedures and services, then you will pay 40 percent of maximum allowable amounts, network or out-of-network, after you ve met your annual deductible for covered medical services, unless otherwise stated. For emergency room visits, you ll pay a $250 copayment, not subject to the deductible, network or out ofnetwork. Anthem defines a primary care provider as any of the following: Family Practice, General Practitioner, Pediatrician, Internal Medicine, OB/GYNs, GYNs, Certified Nurse Midwife, Nurse Practitioner, Physician Assistant, and Clinical/Multi Specialty Group. All other professional providers are considered specialists. If you see a network primary care provider, you ll pay a $25 copayment for the office visit, not subject to the deductible, unless otherwise stated. If see an out-of-network primary care provider, you ll pay 40 percent of maximum allowable amounts for the office visit, after you ve met your annual deductible, unless otherwise stated. If you see a network specialist, you ll pay a $40 copayment for the office visit, not subject to the deductible, unless otherwise stated. If you see an out-of-network specialist, you ll pay 40 percent of maximum allowable amounts for the office visit, after you ve met your annual deductible, unless otherwise stated. U.S. Retiree Benefit News 18

5 change to bereavement counseling benefit Currently, for hospice patients, bereavement counseling is available under the Medical PPO Plan for the patient s immediate family members (who are covered by the Medical PPO) from a licensed social worker or a licensed pastoral counselor within six months after the patient s death. Effective January 1, 2017, this bereavement counseling benefit will no longer be available under the Medical PPO Plan; however, it will remain available through the Mental Health and Substance Abuse Plan. That s because the benefit under the MHSA Plan has always been and continues to be better than the same benefit in the Medical PPO. Note that counseling services related to hospice care are not intended to address mental or nervous disorders. October

6 prescription drug program If you are enrolled in the Medical PPO Plan, the High Deductible Health Plan (HDHP) or the new High Deductible Health Plan Basic (HDHP Basic), you automatically have prescription drug coverage through the Prescription Drug Program with Express Scripts. The Prescription Drug Program currently has prior authorization, preferred step therapy and drug quantity management programs in place, but these programs will be expanding in This is an administrative change only; you don t need to do anything as a result of this change. 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 will require your prescribing doctor to provide additional clinical information so that use of the medication can be approved in advance before you can receive Prescription Drug Program benefits. This is called prior authorization. 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. If your medication is subject to Preferred Step Therapy, this means that you will be required, when clinically appropriate, to try a preferred drug before Express Scripts will authorize coverage for the use of non-preferred drugs. Drug Quantity Management is a program included in the Prescription Drug Program that s designed to make the use of prescription drugs safer and more affordable. It provides you with medicines you need for your good health and the health of your covered dependents, while making sure you receive them in the amount or quantity considered safe and most cost effective. You ll be notified by Express Scripts if your medication is subject to any of these programs in 2017, including what you need to do, if anything. Starting October 17, 2016, to find out if your prescription drug is subject to prior authorization, Preferred Step Therapy and Drug Quantity Management programs, contact Express Scripts Member Services at , or review the documents and links available from hr2.chevron.com/retiree. Click the 2017 Benefit Changes link to get started. U.S. Retiree Benefit News 14