medical PPO plan
for U.S.-payroll employees

had a recent life event?

If you get married, have a baby, move or experience some other qualifying life event, you have 31 days to make changes to your benefits. If you miss this important deadline, you'll have to wait until the next open enrollment period to change your benefits.

the basics

The Medical PPO Plan is one of the self-insured medical plan choices offered to eligible U.S.-payroll employees.

When you enroll in the Medical PPO Plan, you are automatically enrolled in:

  • Medical coverage with Anthem Blue Cross (Anthem)
  • The Chevron Prescription Drug Program with Express Scripts
  • The Chevron Vision Program for basic vision coverage with VSP.
  • You are also automatically covered under the Chevron Mental Health and Substance Use Disorder (MHSUD) Plan with Beacon Health Options for behavioral health services.

The Medical PPO Plan is a preferred provider organization (PPO) health plan, so you can choose to see any provider you choose, network or out-of-network. A network is a group of independent medical providers that have agreed with your medical plan claims administrators to charge contracted fees for services provided to plan members. Learn more about networks in the How to at-a-glance section on this page.

When you enroll, you can choose your coverage level. Your monthly cost for coverage, your deductible amount, and your out-of-pocket maximum amount varies based on the coverage level you choose:

  • You Only
  • You + One Adult
  • You + Child(ren)
  • You + Family

Employees

  • You can enroll in the Medical PPO Plan if you're a U.S.-payroll employee and you're eligible for Chevron's health benefits. 

Dependents

  • You can also enroll your eligible dependents, just as you can with Chevron's other health plans. 

  • Eligible dependents generally include your spouse or domestic partner and children under the age of 26.

  • Special rules apply to dependents that are incapacitated or physically or mentally disabled. If you feel that your dependent may qualify to continue coverage beyond age 26 due to being incapacitated or physically or mentally disabled, contact the HR Service Center, in advance of your dependent turning age 26, for further assistance and instructions about how to certify your dependent to be eligible for coverage.

Dependent Verification Process

You are required to verify the eligibility of any new dependents you enroll in your Chevron health plans in a dependent verification process. You have up to 60 days to obtain and submit requested documentation that verifies your dependent(s) are eligible to participate in Chevron’s health benefits. If you don’t provide acceptable documentation by the deadline, your dependent(s) will be disenrolled from coverage. Learn more about this process.

Expatriates

To see the current year deductible amounts for this plan, reference the plan comparison or other plan documents posted on this page.

Your Chevron plan is structured into three cost sharing phases: deductible, coinsurance, and covered (when you reach your out-of-pocket maximum). At the beginning of the plan year, you are responsible for paying most costs until you satisfy the deductible, but as you move from phase to phase, your Chevron plan pays more of the costs.

deductible is the amount you must pay out-of-pocket for the covered care you receive before your plan begins to pay a share of costs through coinsurance or copayments. The Medical PPO Plan has two separate annual deductibles, one for medical services and the other for prescription drug costs. 

Medical Deductible

  • Your deductible amount depends on the coverage level you choose. 

  • In addition there are different deductible amounts for covered medical services depending on if you see a network or an out-of-network provider.

  • If you are covering dependents, each covered individual has a maximum deductible limit equal to the You Only network deductible amount.

Prescription Drug Deductible

  • Your deductible amount depends on the coverage level you choose. 

  • There is one deductible for network and of out-of-network costs.

  • Mail-order prescriptions are not subject to the annual deductible.

Mental Health and Substance Use Disorder

Learn More

  • You can review the plan's summary plan description, included in the Plan Documents section of this page, to understand more about how the deductible works and what services do or do not apply toward meeting your annual deductible.

To see the current year out-of-pocket maximum amounts for this plan, reference the comparison or other plan documents posted on this page.

Your Chevron plan is structured into three cost sharing phases: deductiblecoinsurance, and covered (when you reach your out-of-pocket maximum). At the beginning of the plan year, you are responsible for paying most costs until you satisfy the deductible, but as you move from phase to phase, your Chevron plan pays more of the costs. When you reach the out-of-pocket-maximum (OOP) your Chevron medical plan pays 100% of covered services for the remainder of the plan year. 

The Medical PPO Plan has two separate annual out-of-pocket maximums: 

  • One for prescription drug costs. 

  • The other is for medicalmental health and substance use disorder servicescombined. This means that your Medical PPO eligible out-of-pocket expenses and your Chevron Mental Health and Substance Use Disorder (MHSUD) Plan eligible out-of-pocket expenses are applied to one combined out-of-pocket maximum amount. 

Medical and MHSUD Combined Out-of-pocket Maximum

  • Your OOP amount depends on the coverage level you choose. 

  • In addition there are different OOP amounts for covered medical services depending on if you see a network or an out-of-network provider.

  • If you are covering dependents, each covered individual has a maximum OOP limit equal to the You Only network OOP amount.

Prescription Drug Out-of-pocket Maximum

  • Your OOP amount depends on the coverage level you choose.

  • There is one OOP for network and of out-of-network costs.

Learn More
  • You can review the plan's summary plan description, included in the Plan Documents section of this page, to understand more about how the out-of-pocket maximum works and what services do or do not apply toward meeting your annual out-of-pocket maximum.

All of Chevron’s medical plans offer access to one of two tax-advantaged accounts that permit you to contribute money so you can later use the money in your account to help pay for certain out-of-pocket health care costs. 

  • When you enroll in the Chevron Medical PPO Plan, you are eligible to participate in Chevron's health flexible spending account plan, the Health Care Spending Account (HCSA) with payroll contributions. Chevron does not contribute to this account.

  • This plan is not compatible with a health savings account (HSA). 

The Medical PPO PlanHDHP and the HDHP Basic generally provide the same 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, infertility services, and rehabilitative services. The monthly premium, deductible, copayment and coinsurance amounts are different between the three plans. Coverage features to note 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. Learn more about preventive care.

  • Access to online health visits (also referred to as telehealth) as part of your benefit coverage. Learn about virtual health visits.

  • Coverage for Family Planning and Fertility Services as part of your benefit coverage.

  • Access to a medical travel benefit to help cover the cost of travel for those who cannot access the care they need where they live.

  • Covered immunizations can be received from your doctor under your medical coverage, but with the Medical PPO Plan, you have the added flexibility to receive a covered immunization, like the flu shot or COVID-19 vaccine, from a network pharmacy or an out-of-network pharmacy through your Express Scripts coverage. 

  • At-home COVID-19 tests make it easy to test anytime, anywhere. Your Chevron prescription drug coverage with Express Scripts provides three ways to help you keep a supply of COVID-19 tests on-hand for you and your family. 

  • You must seek a second opinion through the Health Decision Support Program administrator prior to receiving knee, hip, back or spine surgery (on a non-emergency basis) to avoid an additional $400 added to your total claim cost for the procedure. See the How To At-a-Glance section below for more information.

The Medical PPO Plan also includes special features or services that are offered only to plan participants including:

  • Anthem Future Moms is a program that can answer your questions about pregnancy, help you make good choices and follow your health care provider’s plan of care. And it can help you have a safe delivery and a healthy child. Sign up as soon as you know you’re pregnant.

  • Know your health costs with Engage. You can see what's covered by your medical plan, compare the cost of services, see where you've spent your medical care dollars and determine your progress through your plan's cost sharing phases.

  • Opportunity to receive up to $750 off your annual medical plan premium when you participate in Chevron Health Rewards. Learn more about how to qualify for reduced premiums.

  • A temporary special provision is available for plan participants who maintain a permanent home address in one any of the specified zip codes in the Permian Basin. Learn about the special provision.

medical plan by-the-numbers

plan documents

The summary plan descriptions (SPD) provides specific details about your benefits, such as eligibility, covered services and participation rules. If there recent updates to the SPD since the last publication date, look for the summary of material modification (SMM) included in the very front of the book.

The documents listed below are called a summary of material modification (SMM). An SMM explains recent updates to your plan that are not yet captured or updated in your summary plan description (SPD) since the last publication date. Be sure to review the SMM for an understanding of important plan updates.

Medical Coverage Changes

Prescription Drug Program Changes

Deductible Changes

Permian Basin Participants
Other General Plan Changes
Review the Summary of Benefits and Coverage (SBC) to understand basic information about your plan, such as benefits, copayments, deductibles, and coinsurance. 
Chevron is legally required to provide certain notices to plan participants. These notices are posted on this website for your reference

how to at-a-glance

If you're eligible to participate, enroll:

 

Tip: When you enroll in health benefits on the BenefitConnect website or through the HR Service Center, know that your election is not immediate with each of the claims administrators. You must wait until your coverage is activated with the claims administrators before ID cards can be generated and for your coverage to display in the plan administrator's system.

  • If you enroll during open enrollment, your ID cards will be generated in December, and your coverage fully activated on January 1 of the new year.

  • If you enroll mid-year as a new hire or due to a qualifying life event, please allow at least 7 business days for BenefitConnect/HR Service Center to process your enrollment election with the claims administrators. Know that this could take slightly less or slightly more days, depending on when you enrolled. If you have questions about your election, contact the HR Service Center. (Choose the option for Benefits, then Health coverage.)

After you enroll, there are two opportunities to change your coverage ongoing:

Open Enrollment

Open enrollment is your annual opportunity to review and make changes to your coverage for the next plan year.  Any changes you make to your benefits coverage during open enrollment become effective January 1 of the new year. If you miss the open enrollment deadline, you must wait until the next open enrollment period or if you experience a qualifying life event. You'll receive information each year about the dates of the open enrollment period and instructions for reviewing your coverage and making any desired changes.

Life Event

If you get married, have a baby, move or experience some other qualifying life event, you have 31 days to make changes to your benefits, if permitted by the event. If you miss this deadline, you'll have to wait until the next open enrollment period to change your benefits. To report a life event and understand what changes you may be eligible to make:

  • Go to the BenefitConnect website and click the Report a Life Event link just under the main banner on the home page.

  • Call the HR Service Center. Choose the option for Benefits, then Health coverage.

You are required to verify the eligibility of any new dependents you enroll in your Chevron health plans. You have up to 60 days to obtain and submit requested documentation that verifies your dependent(s) are eligible to participate in Chevron’s health benefits. If you don’t provide acceptable documentation by the deadline, your dependent(s) will be disenrolled from coverage. Learn more about this process.

If you enroll in the Medical PPO Plan for the first time, you will receive the ID cards listed below. You may also receive a new ID card periodically; always destroy your old card and be sure to present your new card to your provider at your next visit.  

  • You will receive an ID card in the mail from Anthem for medical services. You can also download a digital ID card from your account on the Anthem website or mobile app

  • You will receive an ID card in the mail from Express Scripts for prescription drugs. You must present this ID card for retail pharmacy benefits in the U.S. You can also download a digital ID card from your account on the Express Scripts website or the mobile app.

  • You will not receive an ID card from VSP for basic vision coverage. You do not need an ID card to receive care, simply tell your provider that you have coverage under VSP. 


Tip: When you enroll in health benefits on the BenefitConnect website or through the HR Service Center, know that your election is not immediate with each of the claims administrators. You must wait until your coverage is activated with the claims administrators before ID cards can be generated and for your coverage to display in the plan administrator's system.

  • If you enroll during open enrollment, your ID cards will be generated in December, and your coverage fully activated on January 1 of the new year.

  • If you enroll mid-year as a new hire or due to a qualifying life event, please allow at least 7 business days for BenefitConnect/HR Service Center to process your enrollment election with the claims administrators. Know that this could take slightly less or slightly more days, depending on when you enrolled. If you have questions about your election, contact the HR Service Center. (Choose the option for Benefits, then Health coverage.)

A network is a group of independent medical providers that have agreed with your medical plan claims administrators to charge contracted fees for services provided to plan members. With the Medical PPO, you can see any provider you choose, but using a network provider saves you money directly by reducing your out-of-pocket costs.

  • There are different deductible amounts for covered medical services depending on if you see a network or an out-of-network provider

  • There are different out-of-pocket maximums depending on if you see a network provider or an out-of-network provider. 


What happens when I use an out-of-network provider?
If you visit an out-of-network provider, you may be responsible for paying the full amount and submitting a claim to the claims administrator after the visit. Your services will be subject to the out-of-network annual deductible and your coinsurance amounts will be higher, so your out-of-pocket costs will be higher. In addition, out-of-network providers may balance bill you for the difference between the plan allowance and their usual fee for services. Learn more about going out-of-network.


Temporary Special Provision for Permian Basin Participants
The Temporary Special Provision for Permian Basin Participants under the Chevron Medical PPO Plan (Medical PPO) applies to certain out-of-network services for plan participants who maintain a permanent home address in one any of the specified zip codes in the Permian Basin.

How to Find a Network Provider

If you visit a network provider, your provider will usually handle all claims and paperwork for you. If you visit an out-of-network provider you may have to pay the cost out-of-pocket and/or be billed directly from the provider. To be reimbursed for covered services, you’ll have to file a claim form with the claims administrator. 

Medical Services with Anthem

Prescription Drugs with Express Scripts

  • Express Scripts claim form 
  • You can also submit a claim online from the Express Scripts website or the mobile app.
  • To ensure timely payment, you should file your claim as soon as you can. If you don’t file a claim within 365 days from the date on which you incur a covered charge, no plan benefits will be payable for that covered charge.  

Reimbursement for Medical Travel

Basic Vision with VSP

We request that you seek a second opinion through 2nd.MD — the Health Decision Support Program administrator — prior to receiving any of the four medical procedures (on a non-emergency basis) listed below. If you decline to use the service for these four procedures, that's your choice. But by doing so, you will be responsible for an additional $400 added to your total claim cost for the procedure, whether or not you've met the deductible.

  • Knee surgery
  • Hip surgery
  • Back surgery
  • Spine surgery
The second medical opinion service is free to eligible employees enrolled in a Chevron medical plan. It's always your decision whether to follow the second opinion, or stay the course on your original treatment plan. We're simply asking that you seek a second opinion through the 2nd.MD service to help you make informed decisions about your care before your knee, hip, back or spine procedure. This requirement currently only applies to eligible employees enrolled in the Chevron Medical PPO Plan, the Chevron HDHP and the Chevron HDHP Basic.

If you’re enrolled in the Medical PPO Plan, you’ll be covered until the last day of the month in which your employment ends. 

  • You can elect COBRA coverage for you and your covered dependents for this plan. If  you timely elect COBRA coverage, your medical coverage will be retroactive to the date your active employee coverage ended. If you wish to continue medical coverage, you must make an election to continue it.

  • Medical coverage is available to eligible retirees. If you're eligible for retiree health benefits, there are different decisions and actions required of you. 

    • See if you're eligible for retiree health benefits on BenefitConnect. Go to I need to… on the top navigation, then choose Retiree medical eligibility.

    • Learn about health benefits available to eligible pre-65 retirees here.

    • Learn about health benefits available to eligible post-65 retirees here.

    • Go to the Leaving Chevron resource on this website for more information about the things you need to do and the choices you need to make. 

Continuity of Care generally, applies to hospitalization, pregnancy, and treatment for a serious and complex condition. Anthem's Transition Assistance is a process that allows continued care for participants when certain situations occur, such as: your primary provider is terminated from the participating provider network; you're a new enrollee in an Anthem plan and your primary provider is not part of the network; your continuity of care is at risk for reasons over which you have no control.

supplement your health coverage

Supplement your medical coverage with a variety of optional benefits such as:

special services from your plan

virtual doctor visits

With a virtual health visit service (also referred to telehealth), you can receive care for minor issues, right from home.

know your costs

With Engage, you can see what's covered by your medical plan, compare the cost of services, and review your cost sharing status with your plan.

get a second opinion

Get a second opinion from expert specialists on a surgery or any diagnosis you may be facing without the travel, paperwork or costs. And remember, for certain surgeries, your Anthem medical plan may require you to seek a second opinion to avoid paying $400 more in claim costs.

travel reimbursement

Your Anthem coverage includes an expanded travel benefit to help with the cost of travel when you cannot access a covered medical service where you live.

reduced medical premiums

You have the opportunity to receive up to $750 off your annual medical plan premium when you participate in Chevron Health Rewards.

contacts

The HR Service Center manages your enrollment in and eligibility for this benefit plan. For all other questions regarding your coverage, contact the claims administrator. A claims administrator manages the administration of your plan — for example, claims, account balances, ID cards, what's covered and what's not, provider networks, phone numbers, the administrator's website or mobile app, and more. 

medical coverage

prescription drug program

chevron vision program
  • Eligibility  U.S. Payroll Employees, U.S. Payroll Expatriates, Expatriates in the U.S.
  • Enrollment  Enrollment is automatic when you enroll in the Medical PPO, HDHP, HDHP Basic or Global Choice Plans
  • Claims Administrator  VSP Vision Care (VSP) 
  • Group Number  30021085
  • Network name  VSP Choice
  • Phone (Inside U.S.) 1-800-877-7195 
  • Phone (Outside U.S.) 1-916-851-5000 (Press '0' for operator assistance)
  • Website  www.vsp.com
  • Mobile App   VSP Vision Care app from the Apple App Store or Google Play
  • Claim Form  Forms Library
  • Address  Vision Service Plan │ Attention: Claims Services │ P.O. Box 385018 │ Birmingham, AL 35238-5018

This web page 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.