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Summary Plan Description MEDICAL PLAN …

Summary plan DescriptionMEDICAL plan ANTHEM BLUE CROSS BlueCard PPO Network 201501/01/2010 Your MEDICAL plan OptionsThe MEDICAL plan offers eligible participants the following coverage options. Aetna Basic Option A Point of Service (POS) health plan that covers carereceived from in-network or out-of-network providers with no physician referral. Refer to theseparate Summary plan Description for plan details, including deductibles, coinsurance levelsfor in-network and out-of-network care and out-of-pocket limits. Aetna HealthFund Option A high deductible POS health plan compatible with HealthSavings Accounts (HSAs).

Summary Plan Description MEDICAL PLAN – ANTHEM BLUE CROSS BlueCard PPO Network 2015

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Transcription of Summary Plan Description MEDICAL PLAN …

1 Summary plan DescriptionMEDICAL plan ANTHEM BLUE CROSS BlueCard PPO Network 201501/01/2010 Your MEDICAL plan OptionsThe MEDICAL plan offers eligible participants the following coverage options. Aetna Basic Option A Point of Service (POS) health plan that covers carereceived from in-network or out-of-network providers with no physician referral. Refer to theseparate Summary plan Description for plan details, including deductibles, coinsurance levelsfor in-network and out-of-network care and out-of-pocket limits. Aetna HealthFund Option A high deductible POS health plan compatible with HealthSavings Accounts (HSAs).

2 HSAs allow you to save money for current or future medicalexpenses (or other retirement expenses after age 65) on a tax-advantaged basis. Refer to theseparate Summary plan Description for plan details including deductibles, coinsurance levelsfor in-network and out-of-network care, out-of-pocket limits and HSA contribution limits. Anthem Blue Cross Option A Preferred Provider Organization (PPO) health plan whichprovides access to a nationwide network and out-of-network coverage with no physicianreferral. Refer to this Summary plan Description for plan details, including fixed-dollar officevisits, deductibles, coinsurance levels for in-network and out-of-network care and out-of-pocket limits.

3 Regionally Available HMO Options AHealth Maintenance Organization (HMO) is a planin which you must receive MEDICAL treatment or services from participating providers, andservices received outside the network may not be covered except in the case of a benefits, limitations and exclusions for the regional options are listed in their respectivemember brochures and contracts. Upon request, the OxyLink Employee Service Center willprovide written materials that describe the regionally available options, their respectivecovered and non-covered benefits, plan copayments/coinsurance, procedures to be followed inobtaining benefits, and the circumstances under which benefits may be may elect a regional plan option if you live in the applicable geographic area.

4 If you enrollin a regional plan and move out of the applicable geographic area, you must make a newmedical coverage election within 31 days after the date of your move. To make a new election,you must notify OxyLink and complete and return any appropriate forms within the eligibility and participation requirements described in this booklet apply to all Anthem Blue CrossiiiTable of ContentsBenefits at a Glance .. 1 For Help and Information .. 6 Eligibility and 8 Eligibility .. 9 Changing Your Elections .. 11 Using the plan .. 12 Anthem Blue Cross PPO 12 Anthem BlueCard Provider 12 Out-of-Area Benefits.

5 13 Prescription Drug 14 What the Prescription Drug Benefit Covers .. 17 What the Prescription Drug Benefit Does Not 18 Claims and Benefit 19 When You Disagree With a Claim Decision .. 20 When Coverage 22 When Employee Coverage Ends .. 22 Death .. 22 When Dependent Coverage Ends .. 23 Certificate of Group Health Coverage .. 23 Continuation of Coverage .. 24 During Illness or 24 During Approved Leaves of 24 During Military Leave .. 24 Under 25 General 28 Privacy Notice for Health 28 Your Rights as a plan Participant .. 2801/01/2011 Anthem Blue CrossivPlan Documents.

6 30 Discretionary Authority of plan Administrator and Claims 31No Guarantee of Employment .. 31 Future of the plan and plan Amendment .. 31 plan Administration .. 32 Glossary .. 34 Anthem Blue Cross BlueCard PPO to subsequent issues ofBenefits Newsfor any material changes to thePlan made after the date of this Anthem Blue Cross1 BENEFITS AT A GLANCEThe plan is designed to provide financial protection when you or a covered familymember needs MEDICAL care. It provides MEDICAL coverage you need when an illness orinjury strikes, certain preventive care, and access to special programs that focus onimproving your health or helping you stay MEDICAL benefits described in this booklet are offered to Occidental PetroleumCorporation and/or affiliated company employees, as defined in theEligibility andEnrollmentsection.

7 This information, along with the booklet provided by Anthem BlueCross, serves as your Summary plan Description (SPD). You should keep and refer to itwhen you have questions about your MEDICAL benefits. Any capitalized term or phrase notdefined in the Glossary of this supplement has the meaning ascribed to it in the bookletthat plan is administered by Anthem Blue Cross (referred to as Anthem ) and MedcoHealth Solutions ( Medco ). The MEDICAL and pharmacy benefits described in thisbooklet are not insured with Anthem or Medco or any of their affiliates and are paid fromOccidental Petroleum Corporation s general are some important points to remember about your MEDICAL benefits:When you need care, you have a choice.

8 You can select a doctor or facility that belongsto Anthem s BlueCard PPO network (a Network Provider) or one that does not belong(an Out-of-Network Provider). Through the BlueCard PPO provider network, you willhave access to about 84 percent of doctors and 94 percent of hospitals in the UnitedStates. With the BlueCard Worldwide Program, you have international access tohospitals and physicians in 200 prescription drugs, if you purchase prescriptions from a Medco network retail or mailorder pharmacy, you will pay a copayment as described in the section entitledPrescription Drug you are a retiree, refer to the separate SPD for a Description of your medicalbenefits.

9 If you are an LTD beneficiary, refer to the separate supplement foreligibility and enrollment of BenefitsThe charts in this section show the deductibles, copayments or coinsurance for majortypes of covered expenses, and out-of-pocket maximums under the Anthem PPO later in this SPD include more detail about coverage for specific services andsupplies as well as information about prescription drug Anthem Blue Cross2 All coverage levels apply to covered expenses after the applicable deductible is metunless otherwise noted. Benefit payments are based on the amount of the provider scharge that Anthem Blue Cross recognizes for payment of benefits.

10 The allowed amountmay vary depending upon the type of provider and where services are received. Priorauthorization for certain services is required. See the section entitled Your MedicalBenefits How Covered Expense is Determined in the attached Anthem Blue Crossbooklet for additional plan InformationAnnual DeductibleIndividualFamilyNetwork$300$60 0 Out-of-Network$600$1,200 Deductible does not apply to retail or mail order prescription Out-of-Pocket Maximum(includes your deductible)IndividualFamilyNetwork$1,500 $3,000 Out-of-Network$2,500$5,000 The following do not apply to the calendar year deductible or out-of-pocket maximum.


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