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Chevron Mental Health & Substance Abuse PlanGlobal Choice (U.S.-Payroll Expatriates) Participants (012) Coverage Period: 01/01/2014 – 12/31/2014Summary of Benefits and Coverage:What this Plan Covers & What it CostsCoverage for: You Only | You and One Adult | You and Child(ren) | You and FamilyPlan Type: PPOCommonMedical EventServices You May NeedMental/Behavioral healthoutpatient servicesYour Cost If You Use aU.S. Network or Non-U.S. Provider10% coinsuranceYour Cost If YouUse anOut-of-networkU.S. Provider20% coinsurancebased on allowedchargesLimitations & ExceptionsAll services must meet medicalnecessity.If you have mentalhealth, behavioralhealth, or substanceabuse needsMental/Behavioral healthinpatient servicesSubstance use disorder outpatientservices10% coinsurance10% coinsurance20% coinsurancebased on allowedcharges withnotification; 40%coinsurance basedon allowed chargeswithout notification.20% coinsurancebased on allowedchargesAll services must meet medicalnecessity. All inpatient servicesrequire notification to ValueOptionswithin 2 days of admission.All services must meet medicalnecessity.Substance use disorder inpatientservicesNo coinsurance for the first$5,000; 10% coinsuranceafter first $5,000.20% coinsurancebased on allowedcharges withnotification; 40% ofallowed chargeswithout notification.All services must meet medicalnecessity. Employees must notifyEAP-WorkLife Services within twobusiness days of admission.Dependents must notifyValueOptions within two businessdays of admission.If you are pregnantPrenatal and postnatal care Not covered Not coveredDelivery and all inpatient services Not covered Not coveredCheck with your medical plan forcoverage information.Questions: Call 1-888-825-5247 (inside the U.S.) or 610-669-8595 (outside the U.S.) or visit us at hr2.chevron.com.If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossaryat www.dol.gov/ebsa/healthreform or call 1-888-825-5247 (610-669-8595 outside the U.S.) to request a copy.7 of 12CHV-1412-2014-ENG-XXXX