for covered medical services

• To be eligible for reimbursement, the covered service must not be reasonably available to you from a network provider or facility within 100 miles of your home residence. For example, this might include – but is not limited to – when there are no network providers or facilities who offer the service in your area, or you cannot get an appointment within a reasonable time based on your health situation. 
• The health care you receive must be a covered medical service under the Medical PPO Plan, HDHP or HDHP Basic. If the related medical service is not covered or benefits are denied, travel expenses will not be covered. 
• To be eligible for reimbursement, the expense must be a covered, qualifying travel expense. 
• To be eligible for reimbursement, the expense must be incurred by an enrolled participant (the patient) and caregiver traveling with the patient, if any. A caregiver is a person who can give injections, medications, or other treatment required by the patient who is unable to travel alone to receive the covered service. In addition, the caregiver must travel with the patient on the same day(s) to and from the site where the service is provided. 
  • For adult patients, one caregiver will be covered.
  • If the patient is a dependent child, up to two caregivers will be covered.

For purposes of this plan provision, qualifying travel expenses are generally non-emergency Lodging and Transportation expenses for which you could have claimed a medical tax deduction on an itemized federal income tax return. Guidance for what constitutes such an expense may be found in IRS Publication 502 – Medical and Dental Expenses.

In general, qualifying transportation and/or lodging expenses must be essential to obtain a covered service and are incurred by an enrolled participant (the patient) and caregiver, if any.

General examples of qualifying travel expenses include but are not limited to:

• Mileage in your personal car to/from your home to the covered service provider or facility.
• Lodging not provided by a hospital or other institution for the patient and caregiver, subject to IRS per diem limits.
• Rental cars
• Gas
• Train or airline travel tickets
• Tolls
• Bus, shuttle, taxi and ride share services
• Long-term airport parking or other parking fees

Qualifying travel expenses do not include meals, personal use items (laundry, telephone calls, vehicle maintenance, etc.) or other travel expenses that relate to travel that is merely beneficial to general health and unrelated to a covered service, such as a vacation or personal trip. They also don’t include amounts you pay for the care of children, even if the expenses enable you, your spouse or domestic partner, or your dependent to receive a covered service.

Review IRS Publication 502 for complete details about what are and are not qualifying expenses.  

Under this provision, you are limited in the amount of reimbursement you can receive for qualifying transportation and lodging expenses. Amounts in excess of any applicable limits will not be reimbursed. Reimbursement is subject to the following limits:

• $2,000 per covered service maximum – whether the related covered medical service is received from a network or out-of-network provider or facility – for qualifying transportation and lodging expenses incurred by the plan participant receiving the covered service (the patient) and the eligible caregiver(s).
• A combined overall lifetime maximum of $10,000 per covered plan participant when traveling as the patient receiving the covered service. 
  • The same limit applies whether the related medical service is received from a network or out-of-network provider or facility.
  • The limit applies to qualifying transportation and lodging expenses incurred by the patient and the eligible caregiver(s), combined. 
  • This lifetime maximum benefit aggregates the qualifying travel expense reimbursements accumulated while you’re an eligible participant in the Chevron Medical PPO Plan, the Chevron High Deductible Health Plan (HDHP), the High Deductible Health Plan Basic (HDHP Basic), the Mental Health and Substance Use Disorder (MHSUD) Plan, or any combination thereof. 
• Qualifying charges for reasonable and necessary lodging expenses for the patient (while not confined) and caregiver are also subject to the current IRS per diem limit, as defined in IRS Publication 502. As of the writing of this publication, those limits are as follows:
• For covered adult patients, the per diem rate is up to $50 for one person or up to $100 per day for a patient and one caregiver, combined.
• If the patient is a covered dependent minor child, the transportation expenses of two caregivers will be covered, but lodging will be reimbursed up to the $100 per diem rate for the patient and both caregivers, combined. 

• You'll need to pay for the travel expense at the time of service and submit a request for reimbursement to Anthem. (See claims instructions later on this page.) You can’t be reimbursed for qualifying travel expenses in advance of receiving the medical service, even if you’ve prepaid for air or train tickets and lodging.
• The medical care you receive can be from a network or out-of-network provider or facility, as long as it's in the United States (or a territory). While you are strongly encouraged to use a network provider or facility whenever possible, there is no network requirement to receive reimbursement under this plan provision.
• There is no special pre-approval or pre-notification required to use the travel benefit. The plan rules for the medical care you receive will continue to apply as normal. Benefits for the covered medical service will continue to follow your plan's normal deductible, coinsurance and copayment schedule. In addition, normal pre-approval or pre-authorization rules for the covered medical service, if any, will continue to apply. 
• Reimbursement of travel expenses may be subject to your annual deductible, depending on your plan.
  • If you're enrolled in the Medical PPO travel reimbursement is not subject to the annual deductible.
  • If you're enrolled in the HDHP or HDHP Basic, travel reimbursement is subject to your combined annual deductible.