SCHLUMBERGER RETIREE MEDICAL PLAN

Transcription

SCHLUMBERGER
RETIREE MEDICAL
PLAN
Summary Plan Description
TABLE OF CONTENTS
Eligibility and Enrollment
Eligibility
Enrollment
Enrollment Elections
Qualified Medical Child Support Orders (QMSCO)
Contributions
Discontinuing Contributions
CIGNA Open Access Plus (OAP) Coverage
Benefit Summary
Availability of the CIGNA OAP Network
Claims Incurred Outside the CIGNA OAP Network
Managed Care Provisions
Claims Review Award
Alternatives to Long-term Hospitalization
Covered Services, Expenses and Supplies
Preventive Care Benefits under the Open Access Plus
Mental Health Benefits under the Open Access Plus
Vision Care under the Open Access Plus
Prescription Drug Benefits under the Open Access Plus
Wellness Benefits under the Open Access Plus
Exclusions
CIGNA Indemnity Coverage
Benefit Summary
Claims Incurred outside the US
Covered Services, Expenses and Supplies
Preventive Care Benefits under CIGNA Indemnity Coverage
Vision Care under CIGNA Indemnity Coverage
Prescription Drug Benefits under CIGNA Indemnity Coverage
Wellness Benefits under CIGNA Indemnity Coverage
Exclusions
Preventive Care Benefits
Periodic Physical Exam
Comprehensive Physical Exam
Mental Health Benefits (participants enrolled in CIGNA OAP Coverage)
Pre-certification Requirements for Mental Health Benefits under the OAP
Continuing Certification of Treatment under the OAP
Mental Health Benefit Claims under the OAP
Mental Health Exclusions under the OAP
Mental Health Benefits (participants enrolled in CIGNA Indemnity Coverage)
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Mental Health Exclusions under CIGNA Indemnity Coverage
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Vision Care Benefits
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Prescription Drug Benefits
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Prescription Drug Supplies for a 30-day Supply
Prescription Drug Supplies for More than a 30-day Supply
Covered Prescription Drugs
Prescription Drug Exclusions
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Wellness Benefits and Services
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Lifetime Maximum
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Coverage Begins
Identification Cards
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Death of a Retiree
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Maintenance of Benefits
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Coordination of Benefits
Benefit Determination Rules
General Retiree Medical Plan Limitations
Subrogation and Right of Recovery
Automobile Insurance
Other Retiree Medical Plan Considerations
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Claims Administrator
When Coverage Ends
Forfeiture of Benefits, effective March 1, 2006
Supplemental Information
Plan Document Governs
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Appendix 1 − Terms to Know
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Appendix 2 − Special Rules for Retiree Medical Coverage
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Appendix 3 – Administrative and ERISA Information
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Appendix 4 – Claims Procedure
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Appendix 5 – COBRA Continuation of Coverage
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Appendix 6 – Statement of Rights under the Newborns’ and Mothers’
Health Protection Act
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RETIREE MEDICAL PLAN
This Summary Plan Description (“SPD”) is intended to provide a summary of the medical benefits provided
under the Schlumberger Group Welfare Benefits Plan (the “Group Plan”). For simplicity, the benefit program
under the Group Plan that provides medical benefits is referred to as the “Plan” or the “Retiree Medical Plan”
in this SPD.
The Schlumberger Retiree Medical Plan provides healthcare benefits to former employees and their eligible
Dependents who leave the Company after having met certain minimum age and service requirements. The
coverage available to you is designed to complement the coverage available through Medicare Parts A and
B while supporting Schlumberger’s basic retiree health care philosophy, which emphasizes:
• Protection against the major expenses of serious accidents or health problems
• Cost-sharing between you and the Company.
The healthcare coverage you are eligible to receive is based on your age:
• Retirees and / or eligible Dependents under age 65 – Open Access Plus (OAP) Coverage
Under the OAP, you and your family may use the services of any eligible provider at any time, without
referral by a Primary Care Physician. However, when you choose a provider who participates in
CIGNA’s OAP network, the Plan pays 80% of Negotiated Fees for most covered services after you have
met an Annual Deductible. If you choose to use a provider who does not participate in CIGNA’s OAP
network, you will be reimbursed for 60% of Reasonable and Customary charges for most covered
services after you meet the Annual Deductible. Special provisions apply to the reimbursement of certain
services and procedures (see Mental Health Benefits and Managed Care Provisions).
• Retirees and / or eligible Dependents age 65 and older – CIGNA Indemnity Coverage
Your coverage and reimbursement under the Retiree Medical Plan is secondary to Medicare. You and
your family may use the services of any eligible provider at any time, without referral by a Primary Care
Physician. The Plan pays 80% of the Medicare-approved Amount for covered services after you have
met an Annual Deductible minus the amount paid by Medicare. If Medicare reimburses 80% of the cost
of covered services, you may not receive any additional reimbursement from the Retiree Medical Plan.
Special provisions apply to the reimbursement of certain services and procedures (see Mental Health
Benefits).
You and Schlumberger share the cost of providing medical coverage for you and your eligible Dependents.
Some commonly used terms have specific meaning in the context of the Retiree Medical Plan. These terms
are capitalized throughout this document. Please refer to the Terms to Know section at the back of this
booklet for definitions.
Eligibility and Enrollment
Eligibility
Over the years, Schlumberger has amended its eligibility requirements for coverage under the Retiree
Medical Plans. In 2005, Schlumberger revised the eligibility requirements for Active Employees who retire on
or after January 1, 2005. In addition to modifying the age and service requirements for coverage,
Schlumberger included requirements for retaining access to retiree medical coverage while actively
employed.
Retiree Medical Access and RMA Service
Under the current requirements, an Active Employee must make an election on retaining access to
coverage. At age 40 (or, if later, the employee’s date of hire in the US or date of transfer to the US), an
Active Employee has a one-time opportunity to decide whether to retain access to Schlumberger Retiree
Medical coverage (if it is available) upon retirement. Employees who elect to retain access will pay a
monthly access fee and begin to accumulate RMA Service, which is used to determine eligibility at
retirement.
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RMA Service begins on the date the employee attains age 40, or the date the employee is first hired,
whichever is later. An employee stops accumulating RMA Service upon termination of employment,
retirement or when he or she stops paying the required plan access fee while still an active US employee.
RMA Service is granted back to age 40 (or to the most recent date of hire adjusted for breaks in service, if
later) for Schlumberger employees who were in active service on September 30, 2004 and who elect to
retain access to Retiree Medical coverage at the time they are first eligible to do so.
Employees who leave Schlumberger and are later rehired will receive credit for their prior RMA Service if
they were paying the required plan access fee at the time they left the Company and the prior service
qualifies as RMA Service at the time of rehire. In addition, prior service will only be reinstated if the
employee repays the entire amount of the RMA access fees that were previously refunded at termination.
Special Rules for determining RMA Service apply to employees transferring into the US (see Special Rules
for Retiree Medical Coverage in Appendix 2).
Eligibility Requirements for Employees Who Retire on or after January 1, 2005
If you left the Company on or after January 1, 2005, you may enroll in the Schlumberger US Retiree Medical
Plan immediately following your termination from the Company provided you meet the criteria listed below.
1. Age and RMA Service Requirements
Your age and RMA Service requirements for coverage depend on your most recent date of hire,
including any rehire date:
• If your most recent date of hire (or rehire) was on or after April 1, 1997, you must be age 55 or
older and have completed at least 15 years of RMA Service as an active employee.
• If your most recent date of hire (or rehire) is before April 1, 1997, you must be age 50 or older and
have completed at least 10 years of RMA Service as an active employee.
2. Other Eligibility Requirements
In addition to the age and RMA Service requirements listed above, you must meet the following
conditions to be eligible to enroll in coverage:
If you are retiring from within the US, you must:
• be employed by a Schlumberger company that offers the US Retiree Medical Plan immediately
prior to your termination;
• retain access to the Plan by paying the required plan access fee up to the time you leave
Schlumberger; and
• enroll in the Plan directly from active service (proof of existing medical coverage will be required
when you enroll).
If you are retiring from outside the US, you must:
• have elected RMA access when you were first eligible (if applicable);
• have earned at least 10 years of service in the US during your Schlumberger career;
• reside in the US upon retirement; and
• enroll in the Plan directly from active service (proof of existing medical coverage will be required
when you enroll).
Eligibility Requirements for Employees Who Retired before January 1, 2005
If you left the Company prior to January 1, 2005, you are subject to the eligibility requirements in place at the
time of your retirement. For additional information the requirements that apply based on your termination
date, please contact the NAM Employee Regional Support Center.
Special Eligibility and Service Requirements for Employees of Acquired Companies
Special eligibility and RMA Service requirements under the Retiree Medical Plan may apply to employees
and former employees of companies that were acquired by Schlumberger (see Special Rules for Retiree
Medical Coverage in Appendix 2).
Forfeiture of Benefits
Employees who elect to enroll in the Medicare Prescription Drug Program (also known as Medicare Part D
or Medicare Rx) will forfeit their right to coverage under the Plan.
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Additionally, employees who terminate employment on or after March 1, 2006 and subsequently accept
employment with a company deemed to be a competitor or client of Schlumberger within two years of
termination or retirement will forfeit their right to Schlumberger Retiree Medical coverage. All coverage,
including that of a Spouse or other eligible Dependent, will be forfeited (see Other Retiree Medical
Considerations – Forfeiture of Benefits, Effective March 1, 2006).
An employee may petition the Administrative Committee for a waiver of the forfeiture provisions prior to
accepting employment with another company. Waiver requests will be considered by the Committee based
on the facts and circumstances of each individual situation and shall be granted on a reasonable and
consistent basis.
The forfeiture provisions described above may be waived solely at the discretion of the Company in cases of
involuntary termination, such as a reduction in force or similar business situations. Once benefits are
forfeited, they may not be reinstated.
Enrollment
If you are eligible and choose to enroll in coverage, you must submit your application to Personnel or your
Benefits Administrator within 31 days following your last day of work. If you elect coverage, you will continue
to be enrolled in your existing medical coverage through the end of the calendar year. On the January 1
coincident with or next following your last day of work, you and your eligible Dependents will participate in
the Retiree Medical Plan.
Enrollment Elections
The coverage available to you and your eligible Dependents is based on age:
• Retirees and / or eligible Dependents under age 65 – Open Access Plus (OAP) Coverage
• Retirees and / or eligible Dependents age 65 or older – CIGNA Indemnity Coverage.
You may elect one of the following coverage levels:
• Retiree Only;
• Retiree + 1 Dependent; or
• Retiree + 2 or more Dependents.
Coverage is available to you and your eligible Dependents at the time of your retirement. Once you have
enrolled your Dependents in the Plan, you may not add any new Dependents at a later date.
If you die while covered under the Retiree Medical Plan, any of your Dependents who are covered under the
Plan at the time of your death may continue their coverage so long as they remain an eligible Dependent
and continue to make the required contributions for coverage.
If Your Spouse Is a Schlumberger Retiree
If both you and your Spouse are eligible retirees under the Retiree Medical Plan, each of you may enroll as
a retiree or one of you may choose to waive coverage and be covered as a Dependent under your Spouse’s
coverage.
You cannot be covered under the Plan as both an employee and a Dependent, and no one can be
considered a Dependent of more than one retiree.
Enrollment Elections – Surviving Spouse
If an employee is eligible for Retiree Medical coverage and dies prior to enrolling in the Plan, his or her
surviving Spouse may elect coverage under the Plan in the same manner and at the same coverage levels
as available to retirees (see Enrollment Elections above).
Qualified Medical Child Support Orders (QMCSOs)
In general, a QMCSO is a court order that gives a Dependent Child the right to participate in the Plan if the
child does not otherwise qualify because he or she does not reside with the Schlumberger retiree. To be
considered “qualified”, the court order must satisfy certain conditions as prescribed by federal law. Upon
receipt of a court order concerning your Dependent Child, the NAM Employee Regional Support Center will
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notify you and, at your request, provide you with a copy of the Plan procedures for determining whether the
order qualifies as a QMCSO. You and your eligible Dependents may also obtain a copy of the QMCSO
procedures without charge by contacting the NAM Employee Regional Support Center.
To be eligible for coverage under this provision of the Plan, the QMCSO must be issued prior to your
enrollment in the Retiree Medical Plan, and the Dependent Child must be covered under the Schlumberger
Medical Plan for Active Employees at the time of your retirement.
Contributions
You and the Company share the cost of providing medical coverage for you and your eligible Dependents.
Your actual contribution amount in a given year depends on:
• your age and completed years of RMA Service; and
• the number of eligible Dependents you choose to enroll in the Plan (if any); and
• your annual Eligible Compensation in the year of retirement (if you retired on or after January 1, 2006);
or
• your annual Base Pay in the year of your retirement (if you retired before January 1, 2006).
Contributions are subject to change at any time and typically change during the first quarter of each calendar
year. You will be notified of any change in your contribution rate. All contributions to the Plan are made on
an After-tax Basis.
Discontinuing Contributions
You may discontinue your medical coverage at any time by stopping your monthly contributions. Once you
have discontinued coverage, you may not re-enroll in the Plan.
CIGNA Open Access Plus (OAP) Coverage
(Participants under age 65)
CIGNA Open Access Plus (OAP) provides coverage after you meet an Annual Deductible of $500 per
person ($1,000 per family) per calendar year. You are not required to select a Primary Care Physician under
the OAP, but if you visit a CIGNA network provider, you will pay less out-of-pocket for the services provided.
Once you meet your Annual Deductible, the OAP pays:
• 80% of Negotiated Fees if you use any CIGNA network provider; or
• 60% of Reasonable and Customary charges if you use any non-network provider.
Benefit Summary
You and your covered Dependents may receive medical services from any eligible provider at any time,
without referral by a Primary Care Physician. The Plan provides benefits regardless of whether the provider
you choose participates in the CIGNA network. However, when a participating provider (network provider)
renders the service, you will:
• take advantage of Negotiated Fees, so you pay less for covered services;
• increase the amount of covered expenses paid for by the Plan; and
• avoid filing a benefit claim form in most cases.
Under the OAP, you pay an Annual Deductible before the Plan begins paying benefits. The Annual
Deductible is the "first dollar" amount you must pay out-of-pocket each year before the Plan starts to
reimburse you for any expenses. Once you meet the Annual Deductible ($500 per person; $1,000 per
family), the Plan pays 80% of most Negotiated Fees for covered medical services rendered by a CIGNA
network provider. You pay the remaining 20% of charges. If you choose a provider who does not participate
in the CIGNA network (an out-of-network or non-network provider), the Plan pays 60% of most Reasonable
and Customary (R&C) charges for covered services. You pay the remaining 40% of charges plus any
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amounts in excess of R&C charges. To receive benefits for services rendered by non-network providers, you
must file a claim form (see Claims Procedure).
There is a maximum limit on the out-of-pocket amount you will pay for covered medical services during a
calendar year (the Annual Out-of-Pocket Maximum). The Annual Out-of-Pocket Maximum varies depending
on whether you use in-network or out-of-network providers, as shown in the chart that follows:
Annual Deductible and Out-of-Pocket Maximum under the OAP
Annual Out-of-Pocket Maximum 1
Annual Deductible
In-network
Individual
$500
1
2
Family 2
$1,000
Out-of-network
Individual
Family 2
Individual
Family 2
$ 4,000
$ 8,000
$8,000
$16,000
All covered expenses apply toward your Annual Deductible, whether or not you use network providers. Amounts you pay
for prescription drugs, vision care, amounts you pay in excess of Reasonable and Customary charges and additional
amounts you pay for failure to pre-certify mental health services or hospital admission or for refusal of case management
services do not apply toward the Annual Deductible or the Annual Out-of-Pocket Maximum.
The family deductible may be met by any combination of individual family members’ medical expenses, however no
family member may contribute more than his or her individual deductible.
Once you reach the Out-of-Pocket limit, the Plan pays medical benefits for the individual (or family) for the
rest of the year as follows:
• 100% of Negotiated Fees for covered services rendered by CIGNA network providers; or
• 100% of Reasonable and Customary charges for covered services rendered by non-network providers.
You are responsible for any amounts over Reasonable and Customary fees charged by non-network
providers. *
The chart that follows gives a summary of how the OAP works, based on whether your covered services are
rendered by a CIGNA network provider or by a non-network provider.
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Using Your Benefits under the OAP
The table below summarizes how your Open Access Plus (OAP) coverage works.
1. You pay an Annual Deductible.
The Annual Deductible is the amount you must pay each year in covered medical expenses
before the Plan begins to pay benefits. The Annual Deductible is $500 per person ($1,000
per family) per calendar year.
2. After you meet the Annual Deductible, the Plan begins paying benefits. 1
For services rendered by a CIGNA network provider:
• The provider files your claim form for you in most cases.
• The Plan pays 80% of the Negotiated Rate for most covered services.
• You pay 20% of the Negotiated Rate after the Plan has paid.
For services rendered by a non-network provider:
• You pay 100% of charges for services rendered.
• You file a claim form to receive reimbursement for covered expenses.
• The Plan reimburses you for 60% of most Reasonable and Customary (R&C) charges
for covered services.
3. Once your portion of covered expenses reaches an Annual Out-of-Pocket Maximum,
the Plan pays all covered expenses for the rest of the calendar year.
There is a limit or maximum amount you will pay for covered medical expenses each year. The
Annual Out-of-Pocket Maximum for in-network services is $4,000 per person ($8,000 per
family) per calendar year. For out-of-network services, it is $8,000 per person ($16,000 per
family) per calendar year. Once you reach this maximum limit, the Plan pays 100% of all other
covered expenses for the individual (or family) for the rest of the calendar year.
1
All treatment for alcohol and/or drug abuse and mental health disorders, whether in or out of network, must
be pre-certified through CIGNA Behavioral Health to be covered under the Plan (see Mental Health
Benefits).
All treatment for alcohol and/or drug abuse and mental health disorders, whether in- or out-of-network, must
be pre-certified through CIGNA Behavioral Health (1-800-554-6931). Failure to pre-certify treatment will
result in a $500 reduction of your mental health reimbursement (see Mental Health Benefits).
The following charges and out-of-pocket payments are not counted toward your Annual Deductible or
Annual Out-of-Pocket Maximum:
•
•
•
•
Any amounts you pay for prescription drugs;
The flat dollar amount (Co-pay) you pay for vision care services;
Any amounts charged by non-network providers in excess of Reasonable and Customary charges; and
Any additional amounts you pay for failure to pre-certify mental health services or hospital admission or
for refusal of case management services (see Managed Care Provisions).
The chart that follows gives a summary of benefits for selected covered services under the Open Access
Plus (OAP). The second chart shows examples of the amounts you would pay for medical services delivered
by CIGNA network and non-network providers.
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Summary of Selected Benefits under the OAP
The following table summarizes benefits payable for selected services through in-network or outof-network providers:
Covered Service
In-network Benefit 1
Out-of-network Benefit 1
Physician services
(in- or out-patient)
Diagnostic tests & x-rays
2
Hospital room & board
Surgical fees
Ambulance
Urgent Care
Physical Therapy
Durable Medical
Equipment
External Prosthetic
Appliances
80% of charges
60% of Reasonable and
Customary charges
Second surgical opinion
100% of charges with no
Deductible
Customary charges
Skilled Nursing Care 3
80% of charges for up to 60
days per calendar year
Home Health Care 3
80% of charges for up to
120 visits per calendar year
Hospice Care
80% of charges
Customary charges for up to 60
days per calendar year
Customary charges for up to 120
visits per calendar year
Customary charges
Periodic Physical Exam
100% of charges with no
Deductible after $15 Copay. Maximum benefit
payable varies according
to the age of the
participant:
• Birth to age 18 − $150
per year
• Age 19 and older − $500
per year
80% of charges 4
Organ Transplants
1
2
3
4
Customary charges
60% of Reasonable and Customary
charges up to a maximum that
varies by procedure. 4 Call CIGNA
for details.
Annual Deductible applies to all services, whether rendered by a CIGNA network provider or a nonnetwork provider, unless otherwise noted. In-network charges refer to Negotiated Fees for Covered
Services.
Hospital admissions require pre-certification / continued-stay review through CIGNA Healthcare. If
you fail to pre-certify, benefits will be reduced by $500. In addition, case management services are
automatically offered for certain conditions. If you decline these services, benefits are reduced by
50% (see Managed Care Provisions)
Treatment maximums apply to the combination of in- and out-of-network benefits for skilled nursing
care and home health care.
The Plan pays 100% of charges if a CIGNA Lifesource Center is used.
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Examples of the Amounts You Pay under the OAP
The following example shows the amount you would pay if you receive services from network
providers vs. non-network providers and if you incurred $3,300 in Reasonable and Customary
(R&C) charges for covered medical services. The example assumes that $3,300 in R&C charges
is equivalent to $2,500 in Negotiated Fees.
Amount You Pay
CIGNA OAP Providers
Total covered medical expenses
Your Annual Deductible
Remaining expenses after Deductible
Your share of remaining charges
Total amount you pay
Total amount the Plan pays
$2,500
$500
$2,000
$2,000 x 20% = $400
$900
$1,600
Non-OAP Providers
$3,300
$500
$2,800
$2,800 x 40% = $1,120
$1,620
$1,680
Availability of the Open Access Plus (OAP) Network
If you live in a rural area, a CIGNA network may not be available in your location at the time you enroll. You
can call CIGNA Member Services to find out if you live in a network area.
If you do not live in a CIGNA network area, fees for covered services will be reimbursed at 80% of
Reasonable and Customary charges after you meet the Annual Deductible. In addition, you must file a claim
form each time services are rendered to receive benefits. When CIGNA network coverage is extended to
your area, you will need to use in-network providers to continue receiving benefits at the higher rate.
CIGNA updates its network areas regularly, so you should verify the network status of the providers you and
your covered Dependents regularly use on an annual basis. You can check the provider directory on
CIGNA’s website for up-to-date information.
Claims Incurred Outside the CIGNA OAP Network
Except in an emergency, if you live in a CIGNA network area, but incur a claim while traveling outside of the
network area, your claim will be paid according to the out-of-network provisions of the OAP.
Managed Care Provisions
The following managed care provisions determine your level of reimbursement under the OAP. Decisions on
supplies, services and care are the responsibility of you and your physician.
Hospital Pre-Certification
When your doctor recommends that you or your covered Dependent be hospitalized, you must contact the
Plan’s pre-certification company, CIGNA Healthcare, before entering the hospital or undergoing nonemergency surgery or treatment to be eligible for all benefits provided by the Plan.* If you are admitted to
the hospital in an emergency, you or a family member must contact CIGNA Healthcare within 48 hours
following admission to obtain a continued-stay review. The CIGNA Healthcare telephone number (1-800244-6224) is listed on your CIGNA identification card (see Identification Cards).
If admission is certified, the CIGNA Healthcare counselor will periodically review your medical progress with
your physician periodically following hospitalization to certify that you continue to need hospital confinement.
If CIGNA Healthcare does not certify the need for hospital admission or for continued confinement, your
physician can request a review of this decision.
If you or a covered dependent enter the hospital without obtaining a pre-certification review as described
above, your benefits for covered expenses will be reduced by $500.
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* Pre-certification is not required for hospital admissions related to childbirth provided the stay is less than
48 hours (or 96 hours for delivery by Caesarian section). However, pre-certification is required for longer
stays.
Case Management
In addition to hospital pre-admission certification, CIGNA Healthcare performs other review procedures
under the OAP. These review procedures help manage health care costs which, in turn, help control the
contributions you and Schlumberger make to the Plan.
CIGNA Healthcare evaluation services are mandatory. However, it is up to you and your family to decide
whether or not to use the options and alternatives recommended by CIGNA Healthcare. If you refuse case
management services, your benefits will be reduced by 50%.
CIGNA Healthcare will provide case management services if you and/or your covered Dependents require
extensive care for catastrophic or chronic illnesses or injuries. Examples of conditions that may be subject to
case management include, but are not limited to, the following:
•
•
•
•
•
•
High-risk pregnancy;
Organ transplant;
Terminal cancer;
Renal conditions;
Neurological conditions; and
Cardiovascular conditions.
The purpose of the case management review is to help coordinate and manage the costs of recovery or
care. Here's how the review process works:
• The CIGNA Healthcare Case Worker will speak with you or your Dependent to help you and your family
make decisions regarding medical care in connection with your physician's treatment plan by informing
you of options and alternatives.
• Through medical case coordination, all benefits related to that injury or illness will be paid according to
the OAP provisions of the Plan. Your benefits will be coordinated with any other benefits that may be
payable under other plans (such as Worker’s Compensation, auto insurance coverage, etc.) as
appropriate (see Maintenance of Benefits).
Second Surgical Opinion
The Plan pays 100% of Negotiated Fees or Reasonable and Customary charges for second (or even third)
surgical opinions, with no applicable deductible.
Claims Review Award
To help control healthcare costs, you are encouraged to check all hospital bills of less than $20,000 for
possible errors (CIGNA audits bills that exceed $20,000). If you find any over-payments of hospital bills,
Schlumberger will pay you 50% of the over-payment amount, up to a maximum payment of $500.
Should you find an error, please report it promptly to your medical provider. Once a revised, itemized bill is
agreed upon, submit it to CIGNA. After CIGNA reviews the claim, submit proof of both bills to the NAM
Employee Regional Support Center or your Benefits Administrator. The Plan Administrator will review both
bills and certify your eligibility for the award.
Since medically acceptable alternatives to long-term hospitalization help reduce costs and often enhance
the convenience and comfort of the patient, the OAP covers medical expenses for in-home treatment
provided by home health care agencies, or care in an approved convalescent facility or hospice. The
following services are available:
Home Health Care Services
While recuperating at home, you or your covered dependents may receive necessary services and supplies
from an agency specializing in home health care. To be covered, home care services must be provided by a
licensed Home Health Care Agency.
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To qualify for benefits, the attending physician must approve a home health care plan in writing and certify
that proper care would otherwise require continued confinement as an inpatient in a hospital. Covered
services and supplies include:
• professional nursing services by a registered nurse (RN) or licensed practical nurse if an RN is not
available;
• visits for medical care by home health aides;
• medical supplies;
• necessary laboratory services; and
• physical and speech therapy.
Care in a Skilled Nursing Facility
The Plan covers necessary care at a skilled nursing facility is covered under the Plan. To qualify for benefits,
care delivered in a skilled nursing facility must involve rehabilitative services to help you or your covered
Dependent resume self-care in daily living activities. The care must take place in a licensed skilled nursing
facility that is supervised by a physician or registered nurse and that provides 24-hour professional nursing
services under the direction of a full-time registered nurse. Covered services and supplies include:
• semi-private room and board, or a private room up to the cost of the facility’s average charge for a semiprivate room;
• general medical and nursing services;
• X-ray and laboratory examinations;
• use of special treatment rooms;
• physical or speech therapy;
• oxygen and other gas therapy;
• drugs, biologicals, solutions, dressings, casts; and
• other required medical services customarily provided by convalescent facilities.
Hospice Care
Hospice care involves medical, psychological, and nursing care provided to terminally ill patients, as well as
supportive services to their families.
Covered Expenses, Services and Supplies
The OAP covers Reasonable and Customary expenses and Negotiated Fees (these are referred to as
covered expenses) for the following services and supplies:
Physician’s Services
• physician’s fees, including fees for obstetrical procedures, in-hospital visits, office visits, consultations,
diagnosis, and other medically necessary treatments and services related to injury or illness when they
are performed by a legally qualified physician, podiatrist, chiropractor, or osteopath;
• physician's charges for inpatient and outpatient surgery, including assistant surgeon, anesthetist,
pathologist, or radiologist;
• periodic physical exams for you and your covered Dependents as provided under the Preventive Care
Benefits provision of the OAP (see Preventive Care Benefits).
In-Hospital Services and Supplies
• hospital charges for semi-private room and board or for a private room, up to the cost of the hospital’s
negotiated or Reasonable and Customary rate for a semi-private room;
• hospital charges for general nursing services, intensive care units, use of operating, delivery and
treatment rooms, equipment, drugs, medicines, X-rays, lab tests, blood, plasma, oxygen,
electrocardiograms and fluoroscopy.
Family Planning, Maternity, Pre- and Post-natal Care
• family planning, including tests and counseling occurring during office visits, surgical sterilization
procedures for vasectomy and tubal ligations (excludes reversals), services of physician, inpatient
facility and outpatient facility;
• infertility treatment and associated office visits, including tests and counseling, services of inpatient
facility, outpatient facility and physician, limited to procedures for correction of infertility (excludes invitro fertilization, artificial insemination, GIFT, ZIFT, etc.);
• maternity coverage, including initial visits to determine pregnancy, all subsequent prenatal visits,
postnatal visits, delivery, hospital and birthing center services. Midwives are covered if they are licensed
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by the state and if the midwife is associated with a physician. The minimum hospital stay for a vaginal
delivery is 48 hours (96 hours for a Cesarean section) after giving birth. Pre-certification is not required
for the minimum hospital stay; however, longer stays do require it. You have the right to leave the
hospital prior to completion of the minimum stay.
• abortion (elective and non-elective) for any eligible family member, performed at an inpatient facility or
outpatient surgical facility; includes physician’s services.
Emergency Services
• ambulance service to the first hospital where treatment is given in cases of emergency;
• emergency care by a doctor’s office, hospital emergency room, outpatient facility, urgent care facility, or
ambulance.
Treatments, Therapy, Tests and Procedures
• diagnostic X-rays and laboratory tests;
• oxygen and anesthesia;
• X-ray, radium, and radioactive therapy;
• dental or cosmetic treatment or surgery resulting from a congenital abnormality or arising out of a nonoccupational accident or injury;
• dental care, limited to accidental injury of sound, natural teeth, including doctor’s office, inpatient facility,
outpatient surgical facility and physician’s services;
• outpatient short term rehabilitation, including physical therapy, speech therapy, occupational therapy or
chiropractic therapy (includes chiropractors);
• speech therapy is covered if claimant had normal speech which is lost because of illness or injury;
• treatment for TMJ is provided on a limited, case-by-case basis; appliances and orthodontic treatment
are not included;
• organ transplants, including all medically appropriate, non-experimental transplants, inpatient facility
and physician’s services (certain limits may apply; call CIGNA for details);
• when medically necessary, bariatric surgery is covered; however, certain restrictions apply. Contact
CIGNA for details.
Durable Medical Equipment and Prosthesis
• rental or purchase (whichever is less costly) of durable medical or surgical equipment (repairs of such
equipment are not covered);
• breast prosthesis or breast implants needed as a result of disease (removal and / or replacements may
not be covered);
• external prosthetic appliances.
Clinical Trials
• charges made for routine patient services associated with cancer clinical trials approved and sponsored
by the federal government.* In addition, the following criteria must be met:
– the cancer clinical trial is listed on the NIH web site www.clinicaltrials.gov as being sponsored by
the federal government;
– the trial investigates a treatment for terminal cancer and: (1) the person has failed standard
therapies for the disease; (2) cannot tolerate standard therapies for the disease; or (3) no effective
non-experimental treatment for the disease exists;
– the person meets all inclusion criteria for the clinical trial and is not treated “off-protocol”;
– the trial is approved by the Institutional Review Board of the institution administering the treatment.
* Routine patient services do not include, and reimbursement will not be provided for:
• the investigational service or supply itself;
• services or supplies listed herein as Exclusions;
• services or supplies related to data collection for the clinical trial (i.e., protocol-induced costs);
• services or supplies which, in the absence of private health care coverage, are provided by a
clinical trial sponsor or other party (e.g., device, drug, item or service supplied by manufacturer and
not yet FDA approved) without charge to the trial participant.
Other Services
• approved home health care services, up to 120 days per calendar year;
• treatment in an approved skilled nursing facility for up to 60 days per calendar year;
• hospice care; and
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• reconstructive surgery following a mastectomy for:
– all stages of the reconstruction of the breast on which mastectomy has been performed;
– surgery and reconstruction of the other breast to achieve a symmetrical appearance;
– prostheses;
– treatment of physical complications, including lymphedemas, at all stages of mastectomy; and
– any further procedure or requirements as may be established in accordance with the Women’s Health
and Cancer Rights Act of 1998.
Preventive Care Benefits under the Open Access Plus
A selection of preventive care benefits is available under the OAP (see Preventive Care Benefits for details).
Mental Health Benefits under the Open Access Plus
Your mental health benefits, including treatment of alcohol and / or drug abuse and mental health disorders
are administered by CIGNA Behavioral Health (see Mental Health Benefits for details).
Vision Care under the Open Access Plus
Your vision care benefits are administered by Vision Service Plan (VSP) (see Vision Care Benefits for
details).
Prescription Drug Benefits under the Open Access Plus
Your prescription drug benefits are administered by CVS / Caremark (see Prescription Drug Benefits for
details).
Wellness Benefits under the Open Access Plus
You and your family have access to a selection of Wellness benefits and services (see Wellness Benefits
and Services for details).
Exclusions
Some of the services, procedures and supplies not covered under the OAP are listed below. Other
exclusions may also apply. Contact CIGNA for more information.
• Routine health checkups, except as covered under the Preventive Care Benefits provision of the Plan
(see Preventive Care Benefits)
• Medical expenses due to an occupational accident or sickness
• Cosmetic surgery, unless a) it is required as a result of a congenital abnormality; b) it qualifies as reconstructive surgery following medically necessary surgery; or c) it arises out of a non-occupational
injury
• Dental treatment, except as necessary because of a non-occupational injury
• Care in a nursing home for the aged, or custodial care
• Charges for maintenance care
• Anything that is not ordered by a physician or that is not necessary for medical care other than that
which is specifically covered herein
• Unusual, unnecessary, or excessive charges, as determined by the Claims Administrator
• Surgical treatment for correction of refractive errors, including radial keratotomy (see Wellness Benefits
and Services, Healthy Rewards for discounts on laser eye surgery)
• Expenses incurred as a result of an altercation in which you were the aggressor
• Experimental or investigational procedures and treatments not approved by the American Medical
Association, Federal Drug Agency, or other regulatory certifying agency and not eligible under the
Clinical Trial requirements
• When two or more surgical procedures are performed at one time, the maximum amount payable will be
the amount payable for the most expensive procedure, and 1/2 of the amount payable for all other
surgical procedures
• Charges made by an assistant surgeon in excess of 20% of the surgeon's allowable charge; or charges
made by a co-surgeon in excess of the surgeon's allowable charge (an allowable charge is the amount
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•
•
•
•
•
•
•
•
•
•
•
•
•
payable to the surgeon prior to any reductions due to your share of costs (e.g., your Annual Deductible
or 20% co-insurance)
Hearing aids or examinations for fitting (see Wellness Benefits and Services, Healthy Rewards for
discounts on hearing aids)
Eyeglasses or examinations except as provided under the Vision Care benefits of the Plan or for the
first pair of lenses or glasses following cataract surgery (see Wellness Benefits and Services, Healthy
Rewards for discounts on selected eyewear)
Charges made for, or in connection with, tired, weak, or strained feet for which treatment consists of
routine foot care including, but not limited to, the removal of calluses and corns or the trimming of nails,
unless medically necessary
Speech therapy is excluded if a) it is used to improve speech skills that have not been fully developed;
b) can be considered custodial or educational; or c) it is intended to maintain speech communication.
Speech therapy which is not restorative in nature will not be covered
The services of a person who is a member of your family or your Dependent's family, or who normally
lives in your home or your Dependent's home
Charges which you are not legally required to pay
Charges made by a hospital owned or operated by the U.S. government, if the charges are directly
related to a sickness or injury connected to military service
Any injury resulting from, or in the course of, any employment for wage or profit
Charges in excess of the Reasonable and Customary allowance
Reversal of any sterilization procedures
Charges for in-vitro fertilization, artificial insemination, or any other similar procedure
Transsexual surgery and related services
Amniocentesis, ultrasound, or any other procedures requested solely for sex determination of a fetus,
unless medically necessary to determine the existence of a sex-linked genetic disorder.
CIGNA Indemnity Coverage
(Medicare-eligible participants, generally after age 64)
CIGNA Indemnity coverage is secondary to your Medicare Part A and / or Part B coverage. This means the
Schlumberger Retiree Medical Plan only pays benefits after Medicare has paid the amount due on the claim.
If you are eligible for Medicare Parts A and / or B, you should enroll in coverage. If you do not enroll, the
benefits you receive under the Schlumberger Plan will be reduced by the amount Medicare would have paid
if you had enrolled.* The actual amount you receive (if any) is the maximum benefit payable under the
Schlumberger Plan minus the amount Medicare has paid (or would have paid). If the benefit payable under
your CIGNA Indemnity coverage is equal to the amount Medicare pays, the CIGNA Indemnity coverage
pays nothing and you are responsible for any additional charges.
Your CIGNA Indemnity coverage begins paying benefits after you meet an Annual Deductible of $200 per
person ($400 per family). Once your covered expenses exceed the Annual Deductible, CIGNA Indemnity
pays 80% of the Medicare-approved Amount (minus the amount Medicare paid or would have paid). After
you meet the CIGNA Indemnity coverage Out-of-Pocket Maximum, the Plan and Medicare coordinate to pay
100% of covered charges for the rest of the calendar year.
Please refer to www.medicare.gov for details on your Medicare coverage.
* This does not apply to the prescription drug portion of Medicare (“Medicare Part D” or “Medicare Rx”). If
you elect coverage under Medicare Rx, your coverage under the Schlumberger Retiree Medical Plan will
automatically end and will not be reinstated.
If you choose not to enroll in Medicare Rx coverage when you first become eligible, you will not lose any
subsequent rights to participate in Medicare Rx since your coverage under the Schlumberger Plan counts
as “creditable coverage”. Please refer to your Medicare Rx Creditable Coverage Notice for details.
Benefit Summary
You and your covered Dependents may receive medical services from any eligible provider at any time,
without referral by a Primary Care Physician. The Plan pays benefits regardless of whether the provider you
choose participates in a CIGNA network.
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You pay an Annual Deductible before the Plan begins paying benefits. The Annual Deductible is the amount
you must pay out-of-pocket each year before the Plan starts to reimburse you for any expenses. Once you
meet the Annual Deductible ($200 per person; $400 per family), the Plan pays 80% of the Medicareapproved Amount for covered services for the rest of the calendar year. You are responsible for any
amounts over 80% of the Medicare-approved Amount until you reach the out-of-pocket maximum.
The chart below gives a summary of how your CIGNA Indemnity coverage works.
Using Your CIGNA Indemnity Benefits
The table below summarizes how your CIGNA Indemnity coverage works with your Medicare Parts A
and B coverage.
1. You pay an Annual Deductible.
The Annual Deductible is the amount you must pay each year before the Plan begins to pay
benefits. The Annual Deductible is $200 per person ($400 per family) per calendar year.
2. After you meet the deductible, the Plan begins paying benefits. The Amount you receive (if
any) is 80% of the Medicare-approved Amount, less the amount Medicare pays on the claim. 1
3. Once you meet the Out-of-Pocket Maximum ($2,000 / person or $4,000 / family per calendar
year, the Plan and Medicare coordinate to pay 100% of covered charges for the rest of the
calendar year.
1
In most cases, Medicare pays 80% of the Medicare-approved Amount. For services where the Schlumberger Plan
also pays 80% of the Medicare-approved Amount, the Schlumberger Plan pays no benefit.
The following charges and out-of-pocket payments are not counted toward your Annual Deductible:
• Any amounts you pay for prescription drugs;
• The flat dollar amount (Co-pay) you pay for vision care services; and
• Any amounts charged by providers in excess of the Medicare-approved Amount.
The chart that follows gives a summary of benefits for selected covered services under your CIGNA
Indemnity coverage.
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Summary of Selected CIGNA Indemnity Benefits
The following table summarizes benefits payable under your CIGNA Indemnity coverage for selected
services rendered by providers that accept Medicare assignment. If the Benefit Payable is equal to the
amount Medicare pays, you may pay all additional charges in excess of the amount Medicare pays.
To find out the amounts you pay for services through providers that do not accept Medicare assignment,
please consult your Medicare Handbook.
Service
Benefit Payable 1
Physician services
Diagnostic tests & x-rays (in- or out-patient)
Hospital room & board
Surgical fees
Second surgical opinion
Ambulance
Urgent care
Physical therapy
Durable medical equipment
External prosthetic appliances
Mental health / substance abuse benefits
80% of the Medicare-approved Amount
Skilled nursing care 2
80% of the Medicare-approved Amount for up
to 60 days per calendar year
80% of the Medicare-approved Amount for up
to 120 visits per calendar year
80% of the Medicare-approved Amount
Home health care 2
Hospice care
Periodic physical exam
1
2
80% of the Medicare-approved Amount with
$15 Co-pay
Annual Deductible applies to all services unless otherwise noted.
Treatment maximums apply to the combination of in- and out-of-network benefits for skilled nursing care and
home health care.
Examples of the Amounts You Pay under CIGNA Indemnity Coverage
The following example shows the amount you would pay if you incurred $2,500 of Medicareapproved charges for covered medical services that are reimbursed through Medicare at 80%.
The example assumes the provider accepts Medicare assignment and you have already met your
Annual Deductible.
Amount You Pay
Standard fee charged by provider
Medicare-approved Amount
Maximum amount the Plan may pay
Minus amount paid by Medicare
Amount actually paid by the Plan
Amount you pay
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$3,200
$2,500
$2,500 x 80% = $2,000
$2,500 x 80% = $2,000
$0
$500
19
If you are not enrolled in Medicare Parts A and B and you incur a claim, the amount of reimbursement you
are eligible to receive will be determined as if Medicare had paid the Medicare-approved Amount, as shown
in the following example.
Amounts You Pay If You Are Not Enrolled in Medicare Parts A and B
The following example shows the amount you would pay if you are eligible for Medicare Parts A
and B but have chosen not to enroll in coverage and you incurred $2,500 of Medicare-approved
charges for medical services that are covered under the Schlumberger Plan. The example
assumes the provider accepts Medicare assignment and you have already met your Annual
Deductible.
Amount You Pay
Amount charged by provider
Maximum amount the Plan may pay
Minus amount Medicare would have paid
Amount actually paid by the Plan
Amount you pay
$3,200
$2,500
$2,500 x 80% = $2,000
$2,500 x 80% = $2,000
$0
$2,500
Claims incurred outside the US
Claims incurred outside the US are eligible for reimbursement under the Plan. If you incur a claim outside
the US, the amount the Plan will pay is equal to 80% of the cost of covered services. (In these cases, the
Medicare-approved Amount is not considered when determining the reimbursement you receive.)
Since medically acceptable alternatives to long-term hospitalization help reduce costs and often enhance
the convenience and comfort of the patient, the Plan covers medical expenses for in-home treatment
provided by approved home health care agencies, or care in an approved convalescent facility or hospice.
The following services are available:
Home Health Care Services
While recuperating at home, you or your covered dependents may receive necessary services and supplies
from an agency specializing in home health care. To be covered, home care services must be provided by a
licensed Home Health Care Agency.
To qualify for benefits, the attending physician must approve a home health care plan in writing and certify
that proper care would otherwise require continued confinement as an inpatient in a hospital. Covered
services and supplies include:
• professional nursing services by a registered nurse (RN) or licensed practical nurse if an RN is not
available;
• visits for medical care by home health aides;
• medical supplies;
• necessary laboratory services; and
• physical and speech therapy.
Care in a Skilled Nursing Facility
The Plan covers necessary care at a skilled nursing facility is covered under the Plan. To qualify for benefits,
care delivered in a skilled nursing facility must involve rehabilitative services to help you or your covered
Dependent resume self-care in daily living activities. The care must take place in a licensed skilled nursing
facility that is supervised by a physician or registered nurse and that provides 24-hour professional nursing
services under the direction of a full-time registered nurse. Covered services and supplies include:
• semi-private room and board, or a private room up to the cost of the facility’s average charge for a semiprivate room;
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•
•
•
•
•
•
•
general medical and nursing services;
X-ray and laboratory examinations;
use of special treatment rooms;
physical or speech therapy;
oxygen and other gas therapy;
drugs, biologicals, solutions, dressings, casts; and
other required medical services customarily provided by convalescent facilities.
Hospice Care
Hospice care involves medical, psychological, and nursing care provided to terminally ill patients, as well as
supportive services to their families.
Covered Expenses, Services and Supplies
CIGNA Indemnity coverage covers expenses up to the Medicare-approved Amount (these are referred to as
covered expenses) for the following services and supplies:
Physician’s Services
• physician’s fees, including fees for obstetrical procedures, in-hospital visits, office visits, consultations,
diagnosis, and other medically necessary treatments and services related to injury or illness when they
are performed by a legally qualified physician, podiatrist, chiropractor, or osteopath;
• physician's charges for inpatient and outpatient surgery, including assistant surgeon, anesthetist,
pathologist, or radiologist;
• periodic physical exams for you and your covered Dependents as provided under the Preventive Care
Benefits provision of the Plan (see Preventive Care Benefits).
In-Hospital Services and Supplies
• hospital charges for semi-private room and board or for a private room, up to the cost of the hospital’s
Medicare-approved Amount rate for a semi-private room;
• hospital charges for general nursing services, intensive care units, use of operating, delivery and
treatment rooms, equipment, drugs, medicines, X-rays, lab tests, blood, plasma, oxygen,
electrocardiograms and fluoroscopy.
Family Planning, Maternity, Pre- and Post-natal Care
• family planning, including tests and counseling occurring during office visits, surgical sterilization
procedures for vasectomy and tubal ligations (excludes reversals), services of physician, inpatient
facility and outpatient facility;
• infertility treatment and associated office visits, including tests and counseling, services of inpatient
facility, outpatient facility and physician, limited to procedures for correction of infertility (excludes invitro fertilization, artificial insemination, GIFT, ZIFT, etc.);
• maternity coverage, including initial visits to determine pregnancy, all subsequent prenatal visits,
postnatal visits, delivery, hospital and birthing center services. Midwives are covered if they are licensed
by the state and if the midwife is associated with a physician. The minimum hospital stay for a vaginal
delivery is 48 hours (96 hours for a Cesarean section) after giving birth. Pre-certification is not required
for the minimum hospital stay; however, longer stays do require it. You have the right to leave the
hospital prior to completion of the minimum stay.
• abortion (elective and non-elective) for any eligible family member, performed at an inpatient facility or
outpatient surgical facility; includes physician’s services.
Emergency Services
• ambulance service to the first hospital where treatment is given in cases of emergency;
• emergency care by a doctor’s office, hospital emergency room, outpatient facility, urgent care facility, or
ambulance.
Treatments, Therapy, Tests and Procedures
• diagnostic X-rays and laboratory tests;
• oxygen and anesthesia;
• X-ray, radium, and radioactive therapy;
• dental or cosmetic treatment or surgery resulting from a congenital abnormality or arising out of a nonoccupational accident or injury;
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• dental care, limited to accidental injury of sound, natural teeth, including doctor’s office, inpatient facility,
outpatient surgical facility and physician’s services;
• outpatient short term rehabilitation, including physical therapy, speech therapy, occupational therapy or
chiropractic therapy (includes chiropractors);
• speech therapy is covered if claimant had normal speech which is lost because of illness or injury;
• treatment for TMJ is provided on a limited, case-by-case basis; appliances and orthodontic treatment
are not included;
• organ transplants, including all medically appropriate, non-experimental transplants, inpatient facility
and physician’s services;
• when medically necessary, bariatric surgery is covered; however, certain restrictions apply. Contact
CIGNA for details.
Durable Medical Equipment and Prosthesis
• rental or purchase (whichever is less costly) of durable medical or surgical equipment (repairs of such
equipment are not covered);
• breast prosthesis or breast implants needed as a result of disease (removal and / or replacements may
not be covered);
• external prosthetic appliances.
Clinical Trials
• charges made for routine patient services associated with cancer clinical trials approved and sponsored
by the federal government.* In addition, the following criteria must be met:
– the cancer clinical trial is listed on the NIH web site www.clinicaltrials.gov as being sponsored by
the federal government;
– the trial investigates a treatment for terminal cancer and: (1) the person has failed standard
therapies for the disease; (2) cannot tolerate standard therapies for the disease; or (3) no effective
non-experimental treatment for the disease exists;
– the person meets all inclusion criteria for the clinical trial and is not treated “off-protocol”;
– the trial is approved by the Institutional Review Board of the institution administering the treatment.
* Routine patient services do not include, and reimbursement will not be provided for:
• the investigational service or supply itself;
• services or supplies listed herein as Exclusions;
• services or supplies related to data collection for the clinical trial (i.e., protocol-induced costs);
• services or supplies which, in the absence of private health care coverage, are provided by a
clinical trial sponsor or other party (e.g., device, drug, item or service supplied by manufacturer and
not yet FDA approved) without charge to the trial participant.
Other Services
• approved home health care services, up to 120 days per calendar year;
• treatment in an approved skilled nursing facility for up to 60 days per calendar year;
• hospice care; and
• reconstructive surgery after mastectomy for:
– all stages of the reconstruction of the breast on which mastectomy has been performed;
– surgery and reconstruction of the other breast to achieve a symmetrical appearance;
– prostheses;
– treatment of physical complications, including lymphedemas, at all stages of mastectomy; and
– any further procedure or requirements as may be established in accordance with the Women’s Health
and Cancer Rights Act of 1998.
Preventive Care Benefits under CIGNA Indemnity Coverage
Preventive care benefits are available under your CIGNA Indemnity coverage (see Preventive Care Benefits
for details).
Vision Care under CIGNA Indemnity Coverage
Your vision care benefits are administered by Vision Service Plan (VSP) (see Vision Care Benefits for
details).
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Prescription Drug Benefits under CIGNA Indemnity Coverage
Your prescription drug benefits are administered by CVS / Caremark (see Prescription Drug Benefits for
details).
Wellness Benefits under CIGNA Indemnity Coverage
You and your family have access to a selection of Wellness benefits and services (see Wellness Benefits
and Services for details).
Exclusions
Some of the services, procedures and supplies not covered under your CIGNA Indemnity coverage, as
listed below. Other exclusions may also apply. Contact CIGNA for more information.
• Routine health checkups, except as covered under the Preventive Care Benefits provision of the Plan
(see Preventive Care Benefits)
• Medical expenses due to an occupational accident or sickness
• Cosmetic surgery, unless a) it is required as a result of a congenital abnormality; b) it qualifies as reconstructive surgery following medically necessary surgery; or c) it arises out of a non-occupational
injury
• Dental treatment, except as necessary because of a non-occupational injury
• Care in a nursing home for the aged, or custodial care
• Charges for maintenance care
• Anything that is not ordered by a physician or that is not necessary for medical care other than that
which is specifically covered herein
• Unusual, unnecessary, or excessive charges, as determined by the Claims Administrator
• Surgical treatment for correction of refractive errors, including radial keratotomy (see Wellness Benefits
and Services, Healthy Rewards for discounts on laser eye surgery
• Expenses incurred as a result of an altercation in which you were the aggressor
• Experimental or investigational procedures and treatments not approved by the American Medical
Association, Federal Drug Agency, or other regulatory certifying agency and not eligible under the
Clinical Trial requirements
• When two or more surgical procedures are performed at one time, the maximum amount payable will be
the amount payable for the most expensive procedure, and 1/2 of the amount payable for all other
surgical procedures
• Charges made by an assistant surgeon in excess of 20% of the surgeon's allowable charge; or charges
made by a co-surgeon in excess of the surgeon's allowable charge (an allowable charge is the amount
payable to the surgeon prior to any reductions due to your share of costs (e.g., your Annual Deductible
or 20% co-insurance)
• Hearing aids or examinations for fitting (see Wellness Benefits and Services, Healthy Rewards for
discounts on hearing aids)
• Eyeglasses or examinations except as provided under the Vision Care benefits of the Plan or for the
first pair of lenses or glasses following cataract surgery (see Wellness Benefits and Services, Healthy
Rewards for discounts on selected eyewear)
• Charges made for, or in connection with, tired, weak, or strained feet for which treatment consists of
routine foot care including, but not limited to, the removal of calluses and corns or the trimming of nails,
unless medically necessary
• Speech therapy is excluded if a) it is used to improve speech skills that have not been fully developed;
b) can be considered custodial or educational; or c) it is intended to maintain speech communication.
Speech therapy which is not restorative in nature will not be covered
• The services of a person who is a member of your family or your Dependent's family, or who normally
lives in your home or your Dependent's home
• Charges which you are not legally required to pay
• Charges made by a hospital owned or operated by the U.S. government, if the charges are directly
related to a sickness or injury connected to military service
• Any injury resulting from, or in the course of, any employment for wage or profit
• Charges in excess of the Reasonable and Customary allowance
• Reversal of voluntary sterilization procedures
• Charges for in-vitro fertilization, artificial insemination, or any other similar procedure
• Transsexual surgery and related services
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• Amniocentesis, ultrasound, or any other procedures requested solely for sex determination of a fetus,
unless medically necessary to determine the existence of a sex-linked genetic disorder.
Preventive Care Benefits
To encourage prevention and early detection of health risks and diseases, the Retiree Medical Plan offers
preventive care benefits to all covered participants. You may receive a periodic physical exam through the
doctor of your choice. Or, if you are enrolled in the CIGNA OAP, you may elect the Comprehensive Physical
exam offered through Executive Health Exams International (EHE).
Periodic Physical Exams
Open Access Plus (OAP)
If you are enrolled in the OAP, your benefit varies according to whether you choose an in-network or out-ofnetwork provider to conduct your exam:
• In-network – You pay a $15 Co-payment with no Deductible. The Plan pays all other charges up to a
maximum of $150 (for participants from birth to age 18) or $500 (for participants age 19 and older). If
there is a balance remaining after the Plan has paid the maximum benefit payable, it is treated as any
other in-network medical expense (i.e. after you meet the Annual Deductible, the Plan will reimburse
80% of the additional cost).
If your physician includes any diagnosis on the itemized bill other than "routine physical exam", the
covered expenses for services applicable to the diagnosis or conditions indicated will be considered as
a regular medical claim and the $150 or $500 benefit described above will not be payable. In this case,
your Annual Deductible will apply to the claim and you will be responsible for paying any amounts not
reimbursed under the OAP.
• Out-of-network – The entire cost of your exam is covered as any other out-of-network medical expense
(i.e. after you meet the Annual Deductible, the Plan will reimburse 60% of the cost, subject to
Reasonable and Customary limits).
CIGNA Indemnity
If you are enrolled in CIGNA Indemnity coverage, you pay a $15 Co-pay with no deductible. The Plan pays
all other expenses up to the following amounts:
Participant Age
Birth – 18
19 and older
Benefit
$150 per year
$500 per year
Maintenance of benefits will apply to any tests and procedures that are covered by Medicare.
Covered Services – The following services and procedures are covered as part of the periodic physical
exam provided by the Plan:
•
•
•
•
•
•
examination of body systems;
X-ray and lab tests to support the exam;
review by one physician of the results of the exam and consultation with the participant;
routine Pap test;
mammogram; and
immunizations.
The Comprehensive Physical exam is offered to retirees and Spouses under age 65 in lieu of the periodic
physical exam routinely provided through your OAP coverage The exam will include the tests and
procedures outlined in the chart that follows, according to your age.
Your exam will be performed by a physician you select from among an established group of physicians
contracted by Executive Health Exams International (EHE) to perform these physicals. You may take your
Comprehensive Physical exam at any of the five EHE-owned facilities in the US.
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After your exam, you will receive a written narrative report from the doctor, including any findings that should
be followed-up with your personal physician.
Enrollment and Cost
You may enroll in the Comprehensive Physical exam at any time by calling Executive Health Exams to
schedule an appointment. You will pay a Co-pay of $800 toward the cost of the exam, and Schlumberger will
pay all other fees for the services listed in the chart that follows.
If you are enrolled in OAP coverage, you and / or your covered Spouse may elect an optional
Comprehensive Physical exam offered through Executive Health Exams in lieu of the periodic
physical exam provided under the Plan when you enroll in this benefit, your physical exam will
include the following tests and procedures in the frequency listed below.
Age of covered individual on December 31
of the year in which the exam will take place
18 – 39
Annual Co-pay
Medical family history
Physical examination
Near, distant and color vision
Audiometric evaluation
Tonometry
Spirometry
Electrocardiogram
Cardiovascular lipid profile
CBC with differential
SMAC-25 chemistries
Urinalysis
Pap Smear
Prostrate specific antigen (PSA)
Thyroid function test
Cardiac Stress test
Mammogram
Health Risk Analysis
Cardiac risk assessment 2
$875
21
2
1
2
2
2
2
1 baseline for women
age 35 – 39, inclusive
1
-
Stool test for occult blood
Colonoscopy 3
as medically indicated
Chest X-ray (PA and lateral)
1
2
3
40 – 49
50 and older
$875
1
1
1
1
1
1
1
1
1
1
1
1
3
1
$875
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
as medically
indicated
1 baseline & as medically indicated
1
-
“1” indicates the test or procedure is given annually. “2” indicates the test or procedure is given every other
year, and “3” indicates the test or procedure is given once every 3 years.
Includes vascular screening for participants age 50 and older as medically indicated when services are
provided through an EHE facility or network location.
Colonoscopy is included when services are provided through an EHE facility or network location.
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Mental Health Benefits
(Participants enrolled in OAP coverage)
Mental health benefits, including treatment for alcohol / drug abuse and mental health disorders, are
included as part of your medical coverage under the Retiree Medical Plan. If you are enrolled in the OAP,
these benefits are administered through CIGNA Behavioral Health. The benefits payable vary according to
whether you choose a provider who participates in the CIGNA Behavioral Health network (a CBH provider).
A summary of your mental health benefits is shown in the following chart.
Mental Health Benefits under the Plan
Mental health benefits (including treatment for alcohol and drug abuse and mental health disorders) are
included as part of your medical coverage.
OAP Coverage
If you are enrolled in the OAP, the Plan pays benefits after you have met the Annual Deductible. The
benefit you receive depends on whether you choose a CIGNA Behavioral Health (CBH) provider to
render the service, as shown below. You must pre-certify all treatment through CBH to be eligible for full
benefits under the Plan (see Pre-certification Requirements for Mental Health Benefits under the OAP).
Amount Paid by the Plan
Covered Treatment 1
Services through
a CBH Provider
Services through a
Non-CBH Provider
Inpatient treatment
• Alcohol & drug abuse
• 80%
• Mental health disorders
• 80%
• 60% of Reasonable and Customary charges
Outpatient treatment
• Alcohol & drug abuse
• Mental health disorders
1
• Not covered
• 80%
• Not covered
Covered treatment is a medically necessary program of therapy prescribed and supervised by a legally qualified
therapist.
Pre-certification Requirements for Mental Health Benefits under the OAP
To be eligible for benefits under the OAP, you must pre-certify treatment through CIGNA Behavioral Health
(CBH):
• In-network – All treatment for alcohol, drug abuse and / or mental health disorders, whether provided on
an inpatient or outpatient basis. Failure to pre-certify treatment will result in a $500 reduction of your
mental health benefit reimbursements. If you stop treatment for more than six months, you must recertify through CIGNA Behavioral Health if you intend to resume treatment for the same condition.
In case of an emergency, CBH must receive notification by the next scheduled work day for you to be
eligible for reimbursement at the in-network level.
• Out-of-network – All inpatient care must be pre-certified within 24 hours of admission, and you must
comply with care management recommendations. Failure to pre-certify and / or to comply with care
management recommendations will result in a $500 reduction of your out-of-network mental health
benefit reimbursements.
In case of an emergency, CBH must receive notification by the next scheduled work day.
To pre-certify mental health treatment, call CIGNA Behavioral Health 24 hours a day at 1-800-554-6931.
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Continuing Certification of Treatment under the OAP
All mental health and substance abuse treatment (whether in- or out-of-network) are subject to a clinical
review by CIGNA Behavioral Health to determine medical necessity. In the event the review cannot be
obtained from a provider, or the review does not clearly demonstrate the medical necessity for continuing
treatment, there will be no reimbursement under the Plan for the services provided.
Mental Health Benefit Claims under the OAP
To avoid delays in receiving your reimbursement for treatment of alcohol and/or drug abuse, and mental
health disorders, you should submit all related claims directly to CIGNA (see Claims Procedure).
Mental Health Exclusions under the OAP
The following are specifically excluded from Mental Health and Substance Abuse services:
• any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole,
probation or custody or visitation evaluations unless Medically Necessary and otherwise covered under
this policy or agreement;
• treatment of disorders which have been diagnosed as organic mental disorders associated with
permanent dysfunction of the brain;
• developmental disorders, including but not limited to, developmental reading disorders, developmental
arithmetic disorders, developmental language disorders or developmental articulation disorders;
• counseling for activities of an educational nature;
• counseling for borderline intellectual functioning;
• counseling for occupational problems;
• counseling related to consciousness raising;
• vocational or religious counseling;
• I.Q. testing;
• custodial care, including but not limited to geriatric day care;
• psychological testing on children requested by or for a school system; and
• occupational / recreational therapy programs even if combined with supportive therapy for age-related
cognitive decline.
Mental Health Benefits
(Participants enrolled in CIGNA Indemnity coverage)
Mental health benefits, including treatment for alcohol / drug abuse and mental health disorders, are limited
to Medicare-approved services. You may choose any provider for your care and the Plan pays 80% of the
Medicare-approved Amount (minus the amount Medicare pays or would have paid, if applicable) for all
covered services after you have met the Annual Deductible.
Mental Health Exclusions under CIGNA Indemnity Coverage
Treatments, therapies and services not covered by Medicare are not covered by the Schlumberger Plan. In
addition, the following are specifically excluded from the Mental Health and Substance Abuse services under
the Plan:
• any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole,
probation or custody or visitation evaluations unless Medically Necessary and otherwise covered under
this policy or agreement;
• treatment of disorders which have been diagnosed as organic mental disorders associated with
permanent dysfunction of the brain;
• developmental disorders, including but not limited to, developmental reading disorders, developmental
arithmetic disorders, developmental language disorders or developmental articulation disorders;
• counseling for activities of an educational nature;
• counseling for borderline intellectual functioning;
• counseling for occupational problems;.
• counseling related to consciousness raising;
• vocational or religious counseling;.
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•
•
•
•
I.Q. testing;
custodial care, including but not limited to geriatric day care;
psychological testing on children requested by or for a school system; and
occupational / recreational therapy programs even if combined with supportive therapy for age-related
cognitive decline.
Vision Care Benefits
Vision care benefits are included as part of your retiree medical coverage. These benefits are administered
through Vision Service Plan (VSP), and are the same for both OAP and CIGNA Indemnity participants.
The vision care benefits provided by the Plan include an eye examination once every 12 months, and
corrective spectacle lenses and frames or contact lenses once every 24 months. If your lens prescription
changes before you are eligible for new lenses and your prescription changes meet the following criteria,
lenses will be replaced at a 12-month frequency instead of a 24-month frequency:
• an axis change of 20 degrees or a .50 diopter cylinder change; and
• a new prescription would improve your visual acuity by at least one line on the standard eye chart.
The benefits paid by the Plan are different depending on whether you choose an eye doctor who participates
in the Vision Service Plan network (a VSP provider) or an out-of-network provider (non-VSP provider) to
deliver the service. When a VSP provider performs your eye examination and provides any required
glasses, contact lenses and/or frames, the Plan reimburses the doctor directly for all covered expenses. You
pay only the flat dollar amounts (referred to as Co-payments or Co-pays) and the cost of any cosmetic items
you choose.
If you choose an eye doctor who does not participate in the VSP network (a non-VSP provider), you will pay
the full charge for your eye exam and any required lenses and/or frames. You will then send your itemized
receipt (or an HCFA-1500 form used by most eye doctors) to VSP for reimbursement (see Claims
Procedure). VDT benefits are not covered if you use a non-VSP provider.
The chart that follows lists the VSP covered expenses up to the maximum benefit allowances and their Copay amount.
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Vision Care Reimbursements
Vision care benefits are included as part of your medical coverage. The Plan pays different benefits
depending on whether you choose a VSP provider or a non-VSP provider to render the service, as
shown below.
Amount Paid by the Plan
Covered Services &
Supplies
Services through
a VSP Provider
Annual eye examination 100% of covered expenses, after a
$10 Co-pay
Lenses
• Single vision
• Bifocal
• Tri-focal
• Lenticular
Services through
a Non-VSP Provider
$40, after a $10 Co-pay
100% of covered expenses, after a
$20 Co-pay
•
•
•
•
Frames
Selected frames are covered at
100% after a $20 Co-pay
$45
Contact lenses, when
1
medically necessary
2
$20 Co-pay
$210 2
Elective contact lenses
Up to $105 for covered expenses 2
$105 2
$40 per pair, after a $20 Co-pay
VDT benefits (Active Employees only)
Eye examination
Lenses
Frames
1
2
Included as part of your annual eye
exam
$20 Co-pay
An allowance is provided based on
wholesale frame costs
Not covered
Not covered
Not covered
Contact lenses are paid at 100% only when your doctor determines that they are medically necessary. Necessary
conditions include post-cataract surgery, correction of extreme visual acuity problems that cannot be corrected with
spectacle lenses, certain conditions of anisometropia, and keratoconus.
Contact lens benefits are paid in lieu of the benefits listed for covered eyeglasses and frames. Covered expenses
include professional fitting, testing and contact lenses.
The chart that follows summarizes how to use your Vision Care benefits based on whether you choose a
VSP provider or an out-of-network provider to render these services.
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Using Your Vision Care Benefits
Here’s how to use your Vision Care benefits under the Plan:
If you choose a VSP provider to render the services:
• Locate a VSP provider in your area by calling VSP at 1-800-877-7195 or by checking the
VSP Home Page at www.vsp.com.
• Contact the doctor of your choice for an appointment. 1
• The doctor will verify your eligibility for benefits with VSP. If you are not eligible for benefits
at the time, the doctor will notify you.
• The doctor will perform the exam and, if necessary, order and fit glasses and/or contact
lenses for you.
• Pay the doctor the required Co-pay(s) for services rendered and for any cosmetic options or
out-of-pocket costs on frames you selected.
• VSP will pay the doctor directly for all other charges related to covered services.
If you chose a non-VSP provider to render the services:
• Contact the doctor of your choice for an appointment.
• The doctor will perform the exam and, if necessary, order and fit glasses or contact lenses
for you.
• You pay the bill in full for services rendered, then submit an itemized claim form to receive
your benefits (see Claims Procedure).
• VSP will reimburse you up to the maximum benefit allowances shown in the preceding
chart.
1
You will need to provide the Social Security number of the covered retiree and your Schlumberger group
name, and state that you are covered by VSP at the time you make your appointment.
Prescription Drug Benefits
Prescription drug benefits are included as part of your medical coverage. These benefits are administered
by CVS / Caremark, and are the same for both OAP and CIGNA Indemnity participants. Please note that
eligible individuals who elect to enroll in the Medicare Prescription Drug program will lose their coverage
under the Retiree Medical Plan (see Forfeiture of Benefits for more information).
How you use the prescription drug benefits of the Plan depends on how long you will need to take the drug
your doctor has prescribed, as outlined below.
Prescription Drug Benefits for a 30-day Supply
If your prescription is for less than a one-month supply (or 100-unit dose, whichever is less), you will fill your
prescription directly through any pharmacy.
CVS / Caremark Participating Pharmacy – When you choose a pharmacy that participates in the CVS /
Caremark network (a CVS / Caremark pharmacy), you or your covered Dependent will present your CVS /
Caremark identification card at the time you get your prescription filled. The amount you pay will vary
according to whether a generic or brand name drug is dispensed and whether the medication qualifies as a
maintenance drug (see Prescription Drug Supplies for More than One Month):
• Generic drug – You pay a $7 Co-pay for each prescription or refill (provided the medication does not
qualify as a maintenance drug). *
• Preferred Brand Name Drug – You pay a $40 Co-pay for each prescription or refill (provided the
medication does not qualify as a maintenance drug). You also pay the difference in cost between the
generic and the Preferred brand if the Preferred Drug is dispensed as a matter of personal choice (i.e. if
you choose the brand name drug when your doctor's prescription indicates that use of an available
generic alternative is medically acceptable).*
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• Non-preferred Brand Name Drug – You pay a $60 Co-pay for each prescription or refill (provided the
medication does not qualify as a maintenance drug). You also pay the difference in cost between the
generic and the Non-preferred brand if the Non-preferred Drug is dispensed as a matter of personal
choice (i.e. if you choose the brand name drug when your doctor's prescription indicates that use of an
available generic alternative is medically acceptable). *
* If no generic drug is available or if your doctor’s prescription does not permit use of a generic
substitute, you will pay the brand name Co-pay for the prescription according to whether it is a
Preferred or Non-preferred Drug. Regardless of the type of drug you receive, your total cost will not
exceed the actual price of the drug.
Your CVS / Caremark participating pharmacist can tell you whether your prescription is for a generic,
Preferred or Non-preferred Drug. You can also refer to the CVS / Caremark Preferred Drug list to find
out if your medication is a Preferred Drug.
If your medication qualifies as a maintenance drug and you do not use the maintenance drug program, the
mail order Co-pay will apply after the medication has been dispensed three times through a non-CVS retail
pharmacy (see Prescription Drug Supplies for More than One Month). This requirement is waived for
maintenance drugs dispensed while you are confined in a nursing facility.
Non-participating Pharmacy – If you choose a pharmacy that does not participate in the CVS / Caremark
pharmacy network (a non-participating or non-CVS / Caremark pharmacy), you will pay the entire cost of the
prescription and then mail a claim form to CVS / Caremark to request reimbursement from the Plan (see
Claims Procedure). You will receive reimbursement of the Reasonable and Customary cost of the
prescription, less your share of the cost as described for participating pharmacies above, based on whether
you have received a generic, Preferred or Non-preferred brand name drug and whether or not the
medication qualifies as a maintenance drug. Again, if no generic drug is available or if your doctor’s
prescription does not permit use of a generic substitute, you will pay the brand name Co-pay for the
prescription according to whether it is a Preferred or Non-preferred Drug, and the Plan will pay all other
charges.
If your doctor has written a prescription that includes one or more refills, you may obtain a refill when you
have used 75% of the current prescription.
This example shows the amount you pay for prescription medications dispensed through a retail pharmacy:
Example of the Amount You Pay for Medications
Dispensed through a Retail Pharmacy
The example below shows the amount you would pay for a generic, Preferred and Non-preferred
brand medication depending on whether your doctor permits use of a generic alternative and / or
whether one is available. This example assumes the medication does not qualify under the
Maintenance Drug Provisions of the Plan.
If your doctor permits a generic alternative and one is available
Drug
Drug A (generic)
Drug B (Preferred)
Hypothetical
Price of the Drug
$65
$85
$60 ($40 Co-pay + $20 difference in price between
$105
$100 ($60 Co-pay + $40 difference in price between
Amount You Pay
$7 Co-pay
the generic and the Preferred brand)
Drug C (Non-preferred)
the generic and the Non-preferred brand)
If your doctor does not permit a generic alternative or a generic is not available
Drug
Drug B (Preferred)
Drug C (Non-preferred)
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Hypothetical
Price of the Drug
$85
$105
Amount You Pay
$40 Co-pay
$60 Co-pay
31
Prescription Drug Benefits for More than a 30-day Supply (Maintenance Drug Provisions)
For chronic conditions, such as asthma and high blood pressure, you can order up to a 90-day supply of a
long-term medication (referred to as a maintenance drug) through the CVS / Caremark mail order service.
You can apply for up to 3 refills of the same medication. These supplies are delivered to your home by first
class mail; Federal Express delivery is available at an extra cost to you. If you prefer, you may instead fill
your prescription at any CVS / Caremark pharmacy.
Regardless of the dispensing method you choose, the amount you pay will vary according to whether a
generic or brand name drug is dispensed:
• Generic drug – You pay a $14 Co-pay for each prescription or refill. *
• Preferred Brand Name Drug – You pay a $80 Co-pay for each prescription or refill. *
• Non-preferred Brand Name Drug – You pay a $120 Co-pay for each prescription or refill. *
* If no generic drug is available or if your doctor does not permit use of a generic substitute, you will
pay the brand name Co-pay for the prescription according to whether it is a Preferred or Nonpreferred Drug. Regardless of the type of drug you receive, your total cost will not exceed the actual
price of the drug.
To fill a prescription via mail order, you will need to complete a CVS / Caremark Mail Service Order form
available on the CVS / Caremark website or by calling 1-877-9AskHR9 or 1-800-966-5772. Have your
physician write your prescription then mail it with your completed order form to CVS / Caremark (see Claims
Procedure). Be sure to include your script number on the order form. Refills can be ordered on the CVS /
Caremark website or by calling 1-877-9AskHR9 or 1-800-966-5772. You may also order by mail.
Prescriptions not written on prescription forms cannot be considered.
Although the maintenance drug co-pays are somewhat more than you pay for drug supplies of less than one
month, you save money because you receive a larger quantity of the drug you need each time you fill the
prescription. You also avoid paying the cost difference between the generic and the Preferred (or Nonpreferred) Drug if a brand name medication is dispensed as a matter of personal choice (i.e. when your
doctor's prescription indicates that use of an available generic alternative is medically acceptable).
If you are required to take any medication for more than one year, you must file a new prescription each
year, even if you have not had the maximum number of refills. In addition, other state or governmental
requirements may apply with respect to the frequency of providing new prescriptions for certain medications.
The following chart gives a summary of how to use your prescription drug benefits based on whether you
need more than a one-month supply of the medication.
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Using Your Prescription Drug Benefits
The table below summarizes how to use the prescription drug benefits provided under the Plan,
depending on whether you need less than a 30-day supply of a drug (or up to a 100-unit dose,
whichever is less) or more than a 30-day supply.
Less than a One-month Supply (benefits through CVS / Caremark)
Take your prescription to a pharmacy of your choice.
If you choose a CVS / Caremark participating pharmacy:
• You pay a Co-pay for each prescription or refill that varies according to whether a
generic or brand name drug is dispensed:
− Generic drug − You pay a $7 Co-pay *
− Preferred Brand Name Drug − You pay a $40 Co-pay; you also pay the difference
in cost between the generic and the Preferred brand if the Preferred Drug us
dispensed as a matter of personal choice (i.e. if you chose the brand name drug
when your doctor's prescription indicates that use of an available generic
alternative is medically acceptable. *
− Non-preferred Brand Name Drug − You pay a $60 Co-pay; you also pay the
difference in cost between the generic and the Non-preferred brand if the Nonpreferred Drug is dispensed as a matter of personal choice (i.e. if you choose the
brand name drug when your doctor's prescription indicates that use of an
available generic alternative is medically acceptable). *
* If your medication qualifies under the Maintenance Drug Provisions of the Plan,
the mail order Co-pay will apply after the medication has been dispensed three
times through a retail pharmacy (see More than a One-month Supply below).
• The Plan pays the remaining CVS / Caremark-negotiated cost of the drug.
If you choose a non-CVS / Caremark pharmacy:
• You pay the full cost of the prescription.
• You file a claim with CVS / Caremark for reimbursement (see Claims Procedure).
• You receive reimbursement in an amount equal to the Reasonable and Customary
cost of the drug less the amount you pay for a generic, Preferred or Non-preferred
Brand Name drug, as described for participating pharmacies above.
More than a One-month Supply (benefits through CVS / Caremark)
Fill your prescription through any CVS pharmacy or use the mail order service available
through the Maintenance Drug feature of the Plan:
• Obtain a Mail Service Order form from CVS / Caremark.
• Have your physician write the prescription.
• Mail the prescription and CVS / Caremark Mail Service Order form to CVS / Caremark
along with your Co-pay for each prescription or refill: $14 (for a generic drug), $80 (for
a Preferred Brand Name Drug) or $120 (for a Non-preferred Brand Name Drug).
• Your prescription will be delivered to your home by first class mail (Federal express
delivery is available at an additional charge to you). Allow at least seven to ten days
from the time you file your prescription order for receipt of your prescription.
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The chart below gives an example of how you save money by using the Maintenance Drug provisions of the
Plan.
How the Maintenance Drug Provision
Can Save You Money
Assume you are taking a generic maintenance drug for a chronic condition and will need a oneyear supply of your medication. The chart below shows how you save money using the
Maintenance Drug feature of the Plan. If you were taking a brand name medication, your savings
would be even higher.
Prescription filled using your CVS /
Caremark card at your local pharmacy
Maintenance Drug Feature
You pay $7 per prescription;
You pay $14 per prescription;
Each prescription is for a one-month supply.
Each prescription is for a three-month supply.
$7 per prescription x 3 = $21 plus
$14 per prescription x 4 = $56 / year
$14 per prescription x 9 = $126
Total = $56 / year
Total = $147 / year
Covered Prescription Drugs
The prescription drug provisions of the Retiree Medical Plan cover approved charges for the following drugs:
• drugs that bear the legend "Caution: Federal Law prohibits dispensing without a prescription";
• drugs that are a compound medication of which at least one ingredient is a prescription drug;
• drugs that require a prescription by a physician to dispense and that are approved by the U.S. Food and
Drug Administration for general use in treating the sickness or injury for which they are prescribed;
• drugs that may be dispensed under authorization by a physician under any state law;
• injectable insulin, which, under many state laws does not require a prescription; and
• drugs that are purchased from a physician, dentist or any other person or organization licensed to
dispense drugs.
Prescription Drug Exclusions
The following drugs are not covered under the Prescription Drug provisions of the Plan:
• a prescription drug for which the approved charge is equal to or less than the Co-payment amount;
• a covered drug that is consumed at the time and place the prescription is filled, unless dispensed by a
licensed public pharmacy;
• drugs that are deemed experimental in terms of generally accepted medical standards;
• the administering of drugs or insulin;
• use of Retin-A for any covered person age 26 or older without CVS / Caremark approval and written
documentation from a physician stating that the drug is being used for medical reasons;
• a quantity of drug in excess of the amounts normally prescribed by a physician or dentist (in no event
more than a one-month supply or 100-unit dose, whichever is less) under the CVS / Caremark retail
service, and a three-month supply under the Maintenance Drug Provisions of the Plan;
• a prescription refill in excess of the number specified by the physician or dentist, or any refill dispensed
after one year from the date of the prescription order, except for continuing maintenance drugs required
for active and continuing medical conditions under the CVS / Caremark mail order service (the
Maintenance Drug Provisions of the Plan allow 3 refills; however, you must also submit a new
prescription each year);
• medication that is reimbursable under Worker’s Compensation (for any occupational injury or sickness)
or under any municipal, state or federal program;
• medication to treat infertility; and
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• any drug or medication not listed as a covered prescription drug under "Covered Expenses, Services
and Supplies", even if dispensed as a written or oral prescription from a physician (see Covered
Expenses, Services and Supplies under the OAP).
Wellness Benefits and Services
When you enroll in the Retiree Medical Plan, you and your family automatically have access to certain
wellness benefits and services that are designed to support your efforts to adopt a healthy lifestyle and
become a prudent consumer of medical care.
The Wellness program includes the following benefits and services:
• CIGNA 24-Hour Health Information Line (Nurse Line) – You and your family members can access
this telephone service to speak with an experienced registered nurse 24 hours a day, seven days a
week. Call the 24-Hour Health Information Line at 1-877-9AskHR9 (or 1-800-244-6224 for direct dial) to
get answers to your questions about immediate health concerns, evaluate self-care options and
research treatment options. If medical attention is necessary, the nurse can help you prepare questions
to ask a treating physician.
• CIGNA HealthCare Healthy Rewards – CIGNA HealthCare Healthy Rewards offers discounts on
many wellness products and services not covered by the Schlumberger Retiree Medical Plan, including:
– Selected weight-loss programs;
– Hearing aids, eyeglasses and contact lenses;
– Certain chiropractic care and therapeutic massage;
– Acupuncture;
– Laser vision correction;
– Herbal and vitamin supplements; and
– Non-prescription health and beauty products.
For more information on the program and to locate CIGNA HealthCare Healthy Rewards network
providers in your area, visit mycigna.com.
For OAP participants, the Wellness program also includes these programs:
• Comprehensive Physical – Retirees and Spouses may elect a Comprehensive Physical exam
conducted by Executive Health Exams, International in lieu of the periodic physical exam offered under
the OAP (see Preventive Care Benefits).
• CIGNA Health Advisor (Health Coach) – The CIGNA Health Advisor program offers Schlumberger
Medical Plan participants a personalized, single point of contact for health-related information and
assistance. CIGNA’s team of registered nurses, behavioral health clinicians, health educators and
nutritionists will reach out to Plan participants at risk for significant health issues early in their healthcare
experience to provide appropriate coaching and resources.
• CIGNA Well Aware Disease Management Program – The CIGNA Disease Management program
offers health education and assistance to retirees and Spouses with certain chronic conditions and
health risks related to cardiovascular disease, diabetes, low back pain and / or complications related to
weight. If your CIGNA medical or prescription drug claims indicate you would benefit from these
services, a CIGNA representative will contact you to discuss the program and explain all of the
resources and benefits available to you.
During the initial call from CIGNA, you will be given an opportunity to indicate whether or not you wish to
participate in the Disease Management program. If you choose to take advantage of these services,
you will be assigned a specially trained nurse who can answer your questions, refer you to other Retiree
Medical Plan resources as appropriate, and help you better manage your condition.
Lifetime Maximum
If you are enrolled in the OAP, you and each of your covered Dependents may receive up to $1.5 million in
benefits under the Retiree Medical Plan during the course of your covered lifetime, for as long as the Plan
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remains in existence. This includes treatment for alcohol and/or drug abuse and mental health disorders.
Your total lifetime protection also includes any benefits paid under any prior coverage in a group health plan
sponsored by Schlumberger and / or any of its affiliates or subsidiaries, including the active employee plan.
Once you are enrolled in CIGNA Indemnity coverage, your available lifetime benefits are $150,000. If you
are age 65 or older when you first become covered under the Plan, your CIGNA Indemnity enrollment
begins at that time. Otherwise, you are enrolled in CIGNA Indemnity coverage on the first of the month in
which you turn age 65.
Coverage Begins
If you meet the eligibility and enrollment requirements, coverage for you and your eligible Dependents
begins on the January 1 coincident with or next following your termination or retirement from active service
(see Eligibility and Enrollment).
Identification Cards
You will receive identification cards from CIGNA and from CVS / Caremark. CIGNA supplies a separate card
for you and each covered Dependent; CVS / Caremark supplies two cards, each bearing your name and the
names of your covered Dependents. These cards contain important information about your group coverage
required by many physicians, hospitals and pharmacies.
Death of a Retiree
In the event of your death or divorce, your covered Dependents may continue coverage under the Plan
provided they meet the eligibility requirements and continue to make the required monthly contributions.
Maintenance of Benefits
If you or your covered Dependent(s) are covered under more than one health plan, benefits payable from all
such plans will be coordinated. Coverage under the Schlumberger Retiree Medical Plan in addition to
coverage under another plan or Medicare will not guarantee 100% reimbursement of covered medical
claims.
In cases of coverage under more than one plan, the Retiree Medical Plan will pay up to the coverage limits
based on whether our plan is the primary or secondary payer. For example, if your Spouse has coverage
under both the Schlumberger Retiree Medical Plan and another employer’s plan, and both plans cover a
certain bill at 80%, the Schlumberger Plan would not pay an additional benefit after the other plan paid.
Alternatively, if the other employer’s plan covers a certain bill at 80% and the Schlumberger Plan covers the
same bill at 100%, then the Schlumberger Retiree Medical Plan would pay the additional 20% of the covered
charges (after you meet the Annual Deductible).
The same rule applies to your Medicare coverage. If both the Schlumberger plan and Medicare would pay a
certain bill at 80% of the Medicare-approved Amount, the Schlumberger Plan would not pay an additional
benefit after Medicare has paid. Alternatively, if Medicare would cover a certain bill at 80% and the Retiree
Medical Plan covers the same bill at 100%, then the Schlumberger Plan would pay the additional 20% of
covered charges (after you meet the Annual Deductible).
“Plan” means any of the following:
• group, blanket or franchise insurance coverage;
• service plan contracts, group or individual practice or other pre-payment plans;
• coverage under any labor-management trust plans, union welfare plans, employer organization plans,
or employee benefit organization plans; or
• coverage under federal, state, or local government plans, or programs including Medicare.
“Plan” does not include coverage under individual policies or individual contracts.
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Coordination of Benefits
The Schlumberger Retiree Medical Plan coordinates benefits with other plans, as shown below:
• the plan with primary liability pays the full benefit amount payable under that plan; then
• the other plan(s) is the secondary payer and may pay any difference between amounts paid by the
primary plan and the amount payable for the same covered expenses under its own plan.
When benefits from all plans have been paid, total benefits may be less than or equal to 100% of covered
medical expenses, however benefits paid will not exceed 100% of covered medical expenses. The Retiree
Medical Plan pays benefits as a secondary payer so that benefits from both the primary and the secondary
plan combined will equal no more than that which the claimant would have received if the Schlumberger
Plan was primary.
When benefits from a plan are in the form of services, such as those provided by a Health Maintenance
Organization, the reasonable cash value of each service will be deemed to be a benefit paid. Benefits
payable from all other plans include the benefits that would have been payable had a proper claim been
made.
The Retiree Medical Plan reserves the right to release or obtain from any insurance company, organization
or person any information which, in the opinion of the Plan Administrator, is needed for the purpose of
applying the "Maintenance of Benefits" provisions of the Plan.
When payments are made by another plan that should have been paid by the Schlumberger Retiree Medical
Plan, reimbursements will be made to the other plan. Such reimbursements will be considered as if they
were paid to the retiree. If an overpayment is made under the Plan, the Plan Administrator has the right to
recover that payment from the person or organization paid.
Benefit Determination Rules
Coverage under More than One Group Plan
The following rules pertain if there is coverage under more than one plan:
1. An employee's claim is primary on his or her group plan. Coverage for a Spouse's claim is secondary
under the Schlumberger Retiree Medical Plan;
2. A plan that covers the person as an Active Employee, will be considered before a plan that covers the
person as a retired or laid-off employee;
3. Dependent Children's claims are primary for the plan that covers the parent whose birth month is first
in the calendar year.
The following exception applies to rule 3:
• If there is a court decree that establishes financial responsibility for medical, dental or other health care
of the child, the benefits of the plan that cover the child as a Dependent of the parent so responsible will
be primary; otherwise,
• the benefits of a plan that covers the child as a Dependent of the parent with custody take precedence
over a plan that covers the child as a Dependent of a step-parent or a parent without custody;
otherwise,
• the benefits of a plan that covers the child as a Dependent of a step-parent takes precedence over a
plan that covers the child as a parent without custody.
When the preceding Benefit Determination Rules do not establish the order, the benefits of the plan that has
covered the claimant for the longer period of time will be primary.
Coverage under Medicare
For all individuals covered under this Plan and entitled to Medicare, the Schlumberger Retiree Medical Plan
is a secondary payer to Medicare.
For individuals who are eligible for Medicare benefits but who have not applied, the Plan Administrator will
assume the amount payable under Medicare Part A or B to be the amount the individual would receive if he
or she had applied. In this case, the Plan Administrator will only pay covered expenses above the assumed
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Medicare benefits for former employees and their Dependents. Therefore, it is important that former
employees and their Dependents enroll in Medicare when first eligible. A former employee and/or
Dependent is considered eligible for Medicare on the earliest date any coverage under Medicare could
become effective for him or her.
General Retiree Medical Plan Limitations
Subrogation and Right of Recovery
The Plan has certain special rights, called rights of "subrogation" and "recovery" which are described in
more detail below. Subrogation and recovery applies to all medical and prescription drug benefits offered by
the Plan. Subrogation and recovery generally means that the Plan has the right to reimbursement if it has
paid claims on your behalf that you are able to recover from a third party, such as motorist insurance.
The following special terms are used in this section:
A "condition" includes an injury, illness, sickness, or other condition.
A "third party" can be:
• anyone who may be responsible in any way for a covered person’s condition,
• any liability insurance or other insurance (such as homeowner’s insurance) that covers a covered
person or a third party, or otherwise may be responsible to pay benefits relating to a covered
person’s condition, or
• a covered person's own uninsured motorist insurance or underinsured motorist insurance or no-fault
insurance or school insurance.
When the Plan is "subrogated to" your rights to recover from a third party (or the rights of your covered
Dependent to recover from a third party), it means the Plan has the right to be paid first from any recovery a
covered person obtains from a third party as a result of the condition.
The Plan may pay or owe benefits relating to a condition for which you or your covered Dependent may be
entitled to compensation from a third party. This compensation may include entitlement to payments by that
third party to or on behalf of you or your covered Dependent. If this occurs, the Plan is subrogated to all of
your (or your covered Dependent's) rights against, claims against and partial or full recoveries from that third
party, up to the amount paid (or owed) by the Plan. This is true regardless of whether the Plan actually has
paid the benefits described above, and regardless of whether you (or your covered Dependent) have been
fully compensated or "made whole" for the condition.
In addition, if you (or a covered Dependent) receive a full or partial recovery from a third party relating to a
condition, the Plan is entitled to an independent right of immediate and first reimbursement from that
recovery (before anyone else is paid anything from that recovery, including you or your covered Dependent),
up to the amount paid (or owed) by the Plan for that condition. This is true regardless of whether the Plan
actually has paid the benefits described above, regardless of whether you (or your covered Dependent)
have been fully compensated or "made whole" for that condition, regardless of your (or your covered
Dependent's) fault or negligence, and regardless of how you (or your covered Dependent) obtained that
recovery from the third party (for example, by a settlement agreement, court order or otherwise).
You (or your covered Dependent) will be responsible for payment of the legal fees associated with your
rights of recovery against a third party. The Plan's rights of subrogation and recovery described in this
section apply to all amounts that you or your covered Dependent recover (rather than just the amounts
remaining after payment of any legal fees and costs). This is true even if the law of the state in which you
are pursuing recovery from the third party provides otherwise. The Plan's rights of reimbursement and
subrogation apply to the first monies that you (or your covered Dependent) are paid or receive, without
deductions of any type, including costs or attorney's fees that you (or your covered Dependent) incur in
order to obtain a payment from a third party with respect to a condition.
As a condition of paying any benefits, the Plan requires that you (or your covered Dependent) do anything
that may be necessary or helpful, in the Plan Administrator's or claims processor’s discretion, related to the
Plan's rights described in this section, including signing (or obtaining signatures on) relevant documents. No
benefits are payable from this Plan unless and until such properly executed forms are received by either the
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Plan Administrator or the claims processor. If the covered Dependent with the condition is a minor child, the
child's parent or guardian must sign the required documents on behalf of the child. However, should the Plan
pay benefits before the receipt of these documents, the Plan shall have full rights to subrogation and
recovery described in this section regardless of whether these documents are ever properly executed and
provided to the Plan. Neither you, any member of your family, nor anybody else at your direction may do
anything to harm the Plan's rights to subrogation and recovery. If you or they do not comply with any
reasonable Plan request in this regard, the Plan may withhold benefits that otherwise may be due under the
Plan, and you will be responsible to reimburse the Plan, in the Plan Administrator’s discretion, for any costs
incurred as a result of such action.
You or your covered Dependent must promptly notify the claims processor of the possibility of obtaining a
recovery from a third party for a condition for which the Plan has provided benefits (or may be responsible
for providing benefits). This is true regardless of whether that recovery may be obtained by a settlement
agreement, court order or otherwise. You or your covered Dependent must not agree to a settlement
regarding that condition without first obtaining the written consent of the Plan, which may be provided
through a designee. If you or your covered Dependent settle a claim with a third party in a way that results in
the Plan being reimbursed less than the amount of Plan benefits related to a condition, or in any way that
relieves the third party of future liability for medical costs, the Plan may refuse to pay additional benefits for
that condition unless the Plan Administrator approves the settlement in writing.
The Plan may enforce its subrogation and recovery rights in any of the following ways:
• The Plan may require you or your covered Dependent to make a claim against any insurance
coverage under which you or the covered Dependent may be entitled to a recovery for a condition.
• The Plan may intervene in any legal action you or a covered Dependent bring against a third party
related to a condition.
• The Plan may bring a legal action against (a) you or your covered Dependent, (b) the attorney for
you, your covered Dependent or anyone else, and (c) any party holding any proceeds recovered by
or with respect to you or your covered Dependent.
The Plan shall have a lien on all amounts recovered related to a condition for which it pays (or may owe)
benefits, up to the amount of the Plan payments. This is true regardless of whether the amounts recovered
are obtained by a settlement agreement, court order or otherwise. The Plan may seek relief from anyone
who receives settlement proceeds or amounts collected from judgments related to the condition. This relief
may include, but is not limited to, the imposition of a constructive trust and / or an equitable lien.
If you or your covered Dependent or any other beneficiary accepts payment from the Plan or have Plan
benefits paid on your (or their) behalf, that person does so subject to the provisions of the Plan, including the
provisions described in this Subrogation and Recovery section.
Recovery
The Plan is also entitled to recover any amounts paid that exceed amounts actually owed under the Plan.
These excess Plan payments may be recovered from you, your covered Dependent, any other persons with
respect to whom the payments were made, the person who received the benefit payment, any insurance
companies, and any other organization or any other beneficiary of the Plan. The Plan may also, at its option,
deduct the amount of any excess Plan payments from any subsequent Plan benefits payable to, or on behalf
of, you or your covered Dependent.
Automobile Insurance
No payment will be made for medical expenses incurred by you or any one of your Dependents to the extent
that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy
written to comply with:
• a "no fault" insurance law; or
• an Uninsured Motorist insurance law.
The Plan Administrator will take into account any adjustment option chosen under such part by you or any
one of your Dependents.
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Other Retiree Medical Plan Considerations
Claims Administrator
The Claims Administrators for the Plan are as follows: CIGNA Corporation, Executive Health Exams
International, Vision Service Plan and CVS / Caremark (see Claims Administrators section of Appendix 4).
When Coverage Ends
Generally, your coverage under the Retiree Medical Plan terminates on the first to occur of the following:
• you fail to make the required contributions for coverage;
• you no longer meet the eligibility requirements of the Plan (see Eligibility and Enrollment); or
• other termination events described in the Plan.
Coverage for your Dependents ends on the first to occur of the following:
• the first of the month following the month in which you fail to make the required contributions;
• the date your coverage ends (except in the case of your death);
• the date they no longer qualify as eligible Dependents under the Plan (see Terms to Know, definition of
Spouse and definition of Dependent Children); or
• other termination events described in the Plan.
At the time you or your covered Dependents would otherwise lose coverage under the Plan, you may be
entitled to continue your coverage under COBRA (see COBRA Continuation of Coverage in Appendix 5).
Forfeiture of Benefits, effective March 1, 2006
Employees will forfeit their right to Schlumberger Retiree Medical coverage if they (i) terminate employment
or retire on or after March 1, 2006 and (ii) within two years of termination or retirement, accept employment
with (or become a consultant of or an independent contractor for) a company deemed to be a competitor or
client of Schlumberger. All coverage, including that of a Spouse or other eligible Dependent, will be forfeited.
An employee may petition the Administrative Committee for a waiver of this forfeiture provision before he
accepts an employment, consulting or independent contracting position with another company. The
Administrative Committee will review waiver requests on a case by case basis.
Waivers also may be granted by the Administrative Committee to a group of employees if conditions exist
that would warrant a waiver for all individuals in that group if they applied individually for a waiver.
Once benefits are forfeited, they may not be reinstated.
Supplemental Information
Government regulations require the disclosure of certain information with respect to employer-provided
pension and welfare benefits. Please refer to the Administrative and ERISA Information in Appendix 3 for
additional information.
Information on the following is also provided:
• COBRA Continuation Coverage - Appendix 5;
• Newborns’ and Mothers’ Health Protection Act – Appendix 6.
Plan Document Governs
The foregoing description is intended to provide a summary of the benefits provided under the Schlumberger
Retiree Medical Plan. If a discrepancy exists between this summary and the Plan documents, the Plan
documents will govern.
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Appendix 1
TERMS TO KNOW
Active Employee
An Active Employee is an employee who is on a Schlumberger U.S. payroll and is receiving compensation
from the Company. Employees who are absent from work on an unpaid leave of absence are not Active
Employees.
Admissible Compensation
Admissible Compensation is your Base Pay plus merit bonuses, shift differential, overtime pay, commissions
and living allowances in the last calendar year. Pre-tax 401(k) contributions, Pre-tax dependent care
contributions and pre-tax medical contributions are included in Base Pay and therefore are automatically
included in Admissible Compensation.
After-tax (After-tax Basis)
After-tax basis means that contributions are deducted from your paycheck after all taxes have been
withheld.
Annual Deductible (Deductible)
The Annual Deductible is the amount you must pay out-of-pocket each year for covered medical expenses
before the Retiree Medical Plan starts to reimburse any expenses.
Annual Out-of-Pocket Maximum (Out-of-Pocket Maximum)
The Annual Out-of-Pocket Maximum is the maximum amount you pay for covered medical expenses during
a given calendar year. Once you reach your annual out-of-pocket limit, the Retiree Medical Plan pays 100%
of Reasonable and Customary covered medical expenses for the rest of the calendar year. Co-payments
you make for in-network services do not count toward your Annual Out-of-Pocket Maximum.
Base Pay (Base Salary)
Base Pay is your base rate of pay excluding overtime, shift differential, bonuses, incentive compensation
and other amounts paid in addition to your base rate of pay. Your Base Pay includes 401(k) contributions
and any before-tax medical or dependent care contributions.
Company
Schlumberger Technology Corporation and any of its subsidiaries.
Co-payment (Co-pay)
A Co-payment is the flat dollar amount you pay at the time services or supplies are rendered.
Dependents
Eligible Dependents include your Spouse (i.e. your husband or wife as recognized under the laws of the
state in which you live) and your eligible dependent children, provided they were covered under the
Schlumberger Medical Plan for active employees as of the date you retired. *
Coverage for dependent children ends on the last day of the month in which the first of these events occurs:
•
•
•
•
they reach their nineteenth birthday for unmarried children;
they enter into the military;
they reach their twenty-fifth birthday for unmarried children who are full-time students; or
they become legally married.
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Appendix 1
If your unmarried dependent child is physically or mentally handicapped, continued coverage may be
available under the Schlumberger Retiree Medical Plan. Call CIGNA for details.
* Special provisions apply to full-time students ages 19-25 on medically necessary leave of absence or
reduction of hours:
Regardless of the requirements listed above, if your eligible Dependent Child is enrolled in the Plan, on
the basis of being a full-time student and experiences a medically necessary leave of absence and as a
result, is no longer considered a full-time student under the Plan, he or she will be eligible to continue
coverage under the Plan until the earlier of:
• One year after the first day of the medically necessary leave of absence; or
• The date the coverage would otherwise terminate under the terms of the Plan.
Dependent Children
See Dependents.
Eligible Compensation
For individuals who retired prior to January 1, 2006, “Compensation” is Base Pay in the year of retirement.
For all other retirees, Eligible Compensation is the higher of:
• Base Pay in the year of retirement; or
• Admissible Compensation at December 31 of the calendar year preceding retirement.
The Medicare-approved Amount is the maximum amount a doctor or supplier who accepts Medicare can
receive as payment in full for services and supplies normally payable by Medicare. You pay the Medicare
deductible, coinsurance, or co-pay amounts.
For doctors or suppliers who do not accept Medicare assignment, the maximum charge is 115% of the
Medicare-approved Amount.
Please refer to www.medicare.gov for information on your Medicare coverage and benefits.
Negotiated Fees (Negotiated Rates)
Negotiated Fees (or Negotiated Rates) are the rates a provider agrees to charge for covered services.
Negotiated Rates are typically lower than what the provider might otherwise charge for services.
Non-preferred Drug (Non-preferred Brand Name Drug)
A Non-preferred Drug is any brand name prescription medication that CVS / Caremark does not classify as
a Preferred Drug. In general, brand name medications cost significantly more than generics and therefore
you (and Schlumberger) pay more when these drugs are dispensed.
The list of CVS / Caremark Preferred Drugs may change from year-to-year as new medications are
evaluated for therapeutic effectiveness and cost. Your CVS / Caremark participating pharmacist can tell you
whether your medication is a Preferred brand, Non-preferred brand or generic drug.
Preferred Drug (Preferred Brand Name Drug) *
A Preferred Drug is any brand name prescription medication that CVS / Caremark has evaluated for its
therapeutic and economic value and has classified as “Preferred”. In general, brand name medications cost
significantly more than generics and therefore you (and Schlumberger) pay more when these drugs are
dispensed. However, you will pay less for a Preferred brand than you would for an equivalent Non-preferred
brand.
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Appendix 1
The list of CVS / Caremark Preferred Drugs may change from year-to-year as new medications are
evaluated for therapeutic effectiveness and cost. Your CVS / Caremark participating pharmacist can tell you
whether your medication is a Preferred brand, Non-preferred brand or generic drug. You can also refer to
the CVS / Caremark Preferred Drug list to find out if your medication is a Preferred brand.
* CVS / Caremark Preferred Drugs may sometimes be referred to as Performance Drugs.
RMA Service
Active employees who choose to retain access to Schlumberger medical coverage upon retirement begin
accumulating RMA Service at age 40 or on date of hire, whichever is later.* You stop accumulating RMA
Service when you terminate employment, retire or when you stop paying the required plan access fee while
you are still an active US employee.
Your RMA Service is used to determine your eligibility for benefits under the Schlumberger Retiree Medical
Plan when you retire.
* RMA Service is granted back to age 40 (or to your most recent date of hire adjusted for breaks in service, if
later) for existing employees on September 30, 2004 who choose to retain access to the Plan. Employees
who leave Schlumberger and are later rehired will receive credit for their prior RMA Service if they were
paying the required plan access fee at the time they left the Company and the prior service qualifies as RMA
Service at the time of rehire.
Reasonable and Customary
Reasonable and Customary refers to the upper limit of the range of fees charged for a given medical service
or procedure by health care providers in a particular geographic area. Reasonable and Customary charges
are determined semi-annually based on the combined data of at least 85 major insurance companies
compiled and reported by the Health Insurance Association of America (HIAA). The Schlumberger Retiree
Medical Plan does not pay benefits for expenses that exceed Reasonable and Customary fees. These may
be reimbursable under the Health Care Spending Account.
Spouse
Your Spouse is your husband or wife as recognized under the laws of the state in which you live. Spouses
under common-law are not considered a Spouse for purposes of the Plan unless your state recognizes your
common-law or informal marriage as a legal marriage.
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Appendix 2
SPECIAL RULES FOR
RETIREE MEDICAL COVERAGE
Employees Transferring into the US
Schlumberger employees who transfer into the US from any other country are eligible to make an RMA
election upon date of hire in the US if they meet the following conditions:
• they will be age 40 or older as of December 31 of the current year, and
• they have not previously made an RMA election.
Transferring employees who have previously made an RMA election are not eligible to make a new election
upon return to the US. The RMA status of these employees will be treated as follows:
• Employees who were paying the RMA access fee immediately prior to transfer outside the US will
automatically resume paying the required monthly access fee upon return to the US.
• Employees who a) waived access, b) previously received a distribution of their required monthly access
fee for any reason, or c) initially elected access but subsequently stopped paying the required monthly
fee prior to transfer outside the US will not pay the RMA access fee upon their return to the US. These
employees will remain ineligible for retiree medical coverage.
Employees of legacy Smith companies, including Smith International, Inc., M-I L.L.C., Wilson
Industries, L.P. and At-Balance Americas LLC
Notwithstanding any provision of the Plan to the contrary, if you were employed by a legacy Smith company,
including but not limited to Smith International, Inc., M-I L.L.C., Wilson Industries, L.P. or At-Balance
Americas LLC (collectively referred to as “the legacy Smith companies”) and you became a Schlumberger
employee as a result of the August 27, 2010 acquisition, you are not eligible to participate in the Plan under
any circumstances unless you were a Schlumberger retiree actually enrolled in Schlumberger retiree
medical plan coverage on August 26, 2010.
In addition, if you were hired by Schlumberger at one of the legacy Smith companies on or after August 27,
2010, you are not eligible to participate in the Retiree Medical Plan under any circumstances.
If you were a Schlumberger retiree actually enrolled in coverage under the Plan on August 26, 2010 and
become employed by Schlumberger as a result of the August 27, 2010 acquisition, you may re-enroll in
coverage under the Plan immediately following your subsequent termination from Schlumberger if you meet
the following criteria:
1. Schlumberger continues to offer the Plan,
2. You retain access to the Plan while employed in the US by paying the required Plan access fee (if
any) throughout your re-employment with Schlumberger,
3. You re-enroll in the Plan immediately following your termination from active employment with
Schlumberger, and
4. You provide proof of existing medical coverage at the time you re-enroll in Plan coverage
Employees of Other Companies Acquired by Schlumberger
Unless specifically provided otherwise, employees of companies who have been acquired by Schlumberger
do not receive credit for service earned prior to the date of acquisition for purposes of qualifying for
Schlumberger Retiree Medical benefits. RMA Service for these employees begins on the later of the date
the company was acquired by Schlumberger or at age 40. However, there are some cases where Service
may begin before or after that date. If this is the case, special provision for crediting service toward Retiree
Medical eligibility is noted in this section. In addition, prior service with an acquired company is not counted
when determining the applicable Retiree Medical contribution paid by eligible employees of acquired
companies unless provided otherwise in this section.
In the event the requirements for Retiree Medical change at any time in the future, the new provisions will
also be applied to employees of an acquired company as may be modified in this section. Special age and
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Appendix 2
RMA Service requirements under the Retiree Medical Plan apply to employees of the following companies
that were acquired by Schlumberger:
Special age and RMA Service requirements under the Retiree Medical Plan apply to employees of the
following companies that were acquired by Schlumberger:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
CellNet Data Systems, Inc. (CellNet);
Camco International Incorporated and affiliated companies (Camco);
Convergent Group (Convergent);
Coastal Management Corporation (CMC);
Danyl Corporation;
DBR Fluids;
Intera Information Technologies, Inc.;
Merak Projects Inc.;
S. A. Holditch;
Saracino-Kirby (SKS);
Sema plc (Sema);
Sensa;
Technoguide, LLC;
WesternGeco Joint Venture (WesternGeco);
ElectroMagnetic Instruments (EMI);
Operational Services, Inc. (OSI).
Age and RMA Service Requirements for Employees (and former Employees) of Acquired
Businesses
CellNet Data Systems, Inc. (CellNet), acquired May 17, 2000
Convergent Group (Convergent), acquired December 1, 2000
Saracino-Kirby (SKS), acquired March 1, 2001
Sema plc (Sema), acquired April 6, 2001
If you became a Schlumberger employee as a result of one of the acquisitions listed above or were hired by
one of the companies listed above before January 1, 2002, and you have uninterrupted service with
Schlumberger, you are eligible for Retiree Medical coverage if you are at least age 55 and have completed
15 years of RMA Service when you retire or terminate your employment with Schlumberger.
Any service you earned prior to January 1, 2002 is not included for purposes of determining your years of
RMA Service. This means your RMA Service starts on the latest to occur of:
• the date you reach age 40;
• your date of hire;
• January 1, 2002.
Camco International Incorporated and affiliated companies that were part of the Camco organization
acquired August 31, 1998
If you were an employee of the former Camco organization and became a Schlumberger employee as a
result of the August 1998 acquisition, your age and RMA Service requirements for coverage depend on your
most recent date of hire:
• If your most recent date of hire with Camco is on or after April 1, 1997, you must be age 55 or older and
have completed at least 15 years of RMA Service.
• If your most recent date of hire with Camco is before April 1, 1997, you must be age 50 or older and
have completed at least 10 years of RMA Service.
If you left the company after the August 1998 acquisition, and have subsequently been rehired, then your
most recent hire date with Schlumberger will be used to determine the eligibility rules that apply.
Your years of uninterrupted service with Camco and Schlumberger are included for determining your years
of RMA Service. This means your RMA Service starts on the later to occur of:
• your date of hire with Camco (adjusted for any break-in service);
Coastal Management Corporation, acquired April 1, 1998
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Appendix 2
If you became a Schlumberger employee as a result of the April 1, 1998 acquisition, you must be at least
age 55 and have completed 15 years of RMA Service when you retire or terminate employment with
Schlumberger to be eligible for coverage.
Service earned prior to April 1, 1998 is not included for determining your years of RMA Service. This means
your RMA Service starts on the latest to occur of:
• April 1, 1998.
Danyl Corporation, Moorestown, NJ, acquired March 1, 1995
If you became a Schlumberger employee as a result of the March 1995 acquisition and have uninterrupted
service with Schlumberger since the acquisition, you must be at least age 50 and have completed 10 years
of RMA Service when you retire or terminate employment with Schlumberger to be eligible for coverage.
Service earned prior to January 1, 1995 is not included for determining your years of RMA Service. This
means your RMA Service starts on the latest to occur of:
• January 1, 1995.
DBR Fluids, acquired April, 2002
If you became a Schlumberger employee as a result of the April 2002 acquisition, you must be at least age
55 and have completed 15 years of RMA Service when you retire or terminate employment with
Your years of uninterrupted service with DBR and Schlumberger are included for determining your years of
RMA Service. This means your RMA Service starts on the later to occur of:
• your date of hire with DBR (adjusted for any breaks-in service).
Intera Information Technologies Inc., acquired November 1996
If you became a Schlumberger employee as a result of the November 1996 acquisition and have
uninterrupted service with Schlumberger since the acquisition, you must be at least age 50 and have
completed 10 years of RMA Service when you retire or terminate employment with Schlumberger to be
eligible for coverage.
Service with Intera is included for determining your years of RMA Service. This means your RMA Service
starts on the latest to occur of:
• your date of hire with Intera (adjusted for any break-in service at Intera).
Merak Projects Inc., acquired August 1, 1999
If you became a Schlumberger employee as a result of the August 1, 1999 acquisition, you must be at least
age 55 and have completed 15 years of RMA Service when you retire or terminate employment with
Service earned prior to August 1, 1999 is not included for determining your years of RMA Service. This
• August 1, 1999.
S.A. Holditch, acquired November 1, 1997
If you became a Schlumberger employee as a result of the November 1997 acquisition and have
uninterrupted service with Schlumberger since the acquisition, you must be at least age 50 and have
completed 10 years of RMA Service when you retire or terminate employment with Schlumberger to be
eligible for coverage.
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Service with S.A. Holditch earned on and after November 1, 1996 is included for determining your years of
• your date of hire with S.A. Holditch;
• November 1, 1996.
Sensa, acquired December, 2001
If you became a Schlumberger employee as a result of the December 3, 2001 acquisition, you must be at
least age 55 and have completed 15 years of RMA Service when you retire or terminate employment with
Service earned prior to December 3, 2001 is not included for determining your years of RMA Service. This
• December 3, 2001.
Technoguide, L.L.C. acquired December 19, 2002
If you became a Schlumberger employee as a result of the December 19, 2002 acquisition, you must be at
least age 55 and have completed 15 years of RMA Service when you retire or terminate employment with
Service earned prior to December 19, 2002 is not included for determining your years of RMA Service. This
• December 19, 2002.
WesternGeco Joint Venture (WesternGeco), effective November 30, 2000
If you became a Schlumberger employee as a result of the November 2000 joint venture with Western
Geophysical, your age and RMA Service requirements for coverage depend on your most recent date of
hire:
• If your most recent date of hire at Western Geophysical is on or after April 1, 1997, you must be age 55
or older and have completed at least 15 years of RMA Service.
• If your most recent date of hire at Western Geophysical is before April 1, 1997, you must be age 50 or
older and have completed at least 10 years of RMA Service.
If you left the company after November 2000, and have subsequently been rehired, then your most recent
hire date with WesternGeco will be used to determine the eligibility rules that apply.
Years of uninterrupted service with Western Geophysical and Schlumberger are included for the purpose of
determining your years of RMA Service for Retiree Medical coverage at retirement.
ElectroMagnetic Instruments (EMI), acquired January 18, 2001
Operational Services, Inc. (OSI), acquired April 28, 2000
If you became a Schlumberger employee as a result of one of the acquisitions listed above or were hired by
one of the companies listed above before January 1, 2003, and you have uninterrupted service with
Schlumberger, you are eligible for Retiree Medical coverage if you are at least age 55 and have completed
15 years of RMA Service when you retire or terminate your employment with Schlumberger.
Any service you earned prior to January 1, 2003 is not included for purposes of determining your years of
• January 1, 2003.
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Appendix 3
ADMINISTRATIVE AND ERISA INFORMATION
Administrative Information
Official Name of Plan
Schlumberger Group Welfare Benefits Plan (The Plan), as it provides medical benefits and as described in
this SPD, is also commonly known as: The Schlumberger Medical Plan.
Plan Sponsor and Other Employers Participating in Plan
The Plan Sponsor is:
Schlumberger Technology Corporation
300 Schlumberger Drive
Sugar Land, TX 77478
Upon written request to the Plan Administrator, participants and beneficiaries will be provided information as
to whether any other particular employer participates in the Plan and, if so, that employer’s address.
Employer Identification Number
22-1692661
ERISA Plan Number
502
Type of Plan
The Plan is a welfare benefit plan providing medical benefits.
Plan Administration
The Plan is administered by the Plan Administrator (named below) with the assistance of the Claims
Administrator (named below) who has contracted to perform claim processing services for the Plan. The
Claims Administrator is the named fiduciary under the Plan for purposes of claims and initial appeals under
the Plan.
Plan Administrator
Administrative Committee
Schlumberger Group Welfare Benefits Plan
3600 Briarpark Drive, 3rd floor
Houston, TX 77042
Telephone: 713-789-9600
The Administrative Committee is a group of Company employees appointed by the Company to serve as Plan
Administrator.
Claims Administrators
For Medical:
CIGNA Corporation
P.O. Box 9012
Sherman, TX 75091
Account Number: 2094762
For mental health disorders or alcoholism and substance abuse:
ComPsych
NBC Tower
24th Floor
455 North Cityfront Plaza Drive
Chicago, IL 60611-5506
For vision care:
Vision Service Plan
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ATTN: Claims Processing
P.O. Box 997105
Sacramento, CA 95899-7105
For prescription drugs (local pharmacy):
CVS / Caremark
P.O. Box 52116
Scottsdale, AZ 85072-2116
For prescription drugs (mail order):
CVS / Caremark
P.O. Box 3223
Wilkes-Barre, PA 18773-3223
Agent for Service of Legal Process
Legal process may be served on the Plan Administrator. The person designated to receive service of legal
process on the Plan is:
Administrative Committee
Schlumberger Group Welfare Benefits Plan
Houston, TX 77042
Telephone: 713-789-9600
Plan Contributions
The responsibility of the Company (and participating employers) and the responsibility of employees to pay for
the cost of Plan coverage is described under the “Contributions” heading in the body of this SPD. Employees
will be advised when there is a change in required employee contributions for coverage.
How Plan Contributions are Used; Trust and Trustee for the Plan
Plan contributions are either (i) used immediately for the payment of Plan benefits or (ii) held in a trust fund
known as the Schlumberger Master Health Care Trust, under an agreement with the Northern Trust
Company.
The Trustee for the Plan is:
The Northern Trust Company
50 South LaSalle Street
Chicago, IL 60675
Source of Medical Benefits
Benefits may be paid from the Schlumberger Master Health Care Trust or from the general assets of the
Company.
Right to Change or Terminate the Plan
Schlumberger Technology Corporation (“STC”) intends and expects to continue the Plan. However, STC has
reserved the right to change or terminate the Plan at any time for any reason, in whole or in part, with respect
to any employer or all employers participating in the Plan. STC has given the Plan Administrator the authority
to amend or modify the Plan. An employer’s participation in the Plan shall terminate automatically if it ceases
to be an affiliate of STC. In the event that the Plan is terminated, any remaining Plan assets that are held in
trust will be used for the payment of Plan expenses and benefits that are properly due and payable under the
Plan through the date of termination. Any Plan assets remaining after payment of such Plan expenses and
benefits may able transferred to a successor Plan or, in the event that no successor Plan is established, may
be refunded to Plan Participants. In general, no Plan assets may ever revert to or be paid to the Company.
Plan Year
Plan financial records are kept on a calendar year basis. The end of the year, for the purpose of maintaining
financial records is December 31.
Problem Resolution Procedure
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Appendix 3
If you have questions or problems concerning your benefits, you should first contact the NAM Employee
Regional Support Center for assistance:
Schlumberger NAM Employee Regional Support Center
Houston, TX 77042
Telephone: 713-789-9600
If the NAM Employee Regional Support Center is not able to resolve your problem, write to the Plan
Administrator. See Administrative and ERISA Information – Plan Administrator for further details.
ERISA Rights
As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement
Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to:
Receive Information About Your Plan and Benefits
• Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as
worksites and union halls, all documents governing the plan, including insurance contracts and
collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the
plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee
Benefits Security Administration.
• Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of
the plan, including insurance contracts and collective bargaining agreements, and copies of the latest
annual report (Form 5500 Series) and updated summary plan description. The administrator may make
a reasonable charge for the copies.
• Receive a summary of the plan’s annual financial report. The Plan Administrator is required by law to
furnish each participant with a copy of this summary annual report.
In addition to the above, under the Plan, participants with medical coverage are also entitled to:
• Continue health care coverage for yourself, Spouse or Dependents if there is a loss of coverage under
the Plan as a result of a qualifying Event. You or your Dependents may have to pay for such coverage.
Review this SPD and the documents governing the Plan on the rules governing your COBRA
continuation of coverage rights.
• Reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group
health plan. If you have creditable coverage from another plan. You should be provided a certificate of
creditable coverage, free of charge, from your group health plan or health insurance issuer when you
lose coverage under the Plan, when you become entitled to elect COBRA continuation, coverage, or if
you request it up to 2 months after losing coverage. Without evident of creditable coverage, you may
be subject to preexisting condition exclusion for 12 months (18 months for late enrollees) after your
enrollment date in your coverage. If you request it, the Plan will provide you with reasonable assistance
in obtaining a certificate of creditable coverage from your prior coverage.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are
responsible for operation of the employee benefit plan. The people who operate your plan, called
“fiduciaries” of the plan, have a duty to do so prudently and in the interest of you and other plan participants
and beneficiaries. No one, including your employer, your union or any other person, may fire you or
otherwise discriminate against you in any way to prevent you from obtaining a plan benefit or exercising your
rights under ERISA.
Enforce Your Rights
If your claim for a plan benefit is denied or ignored, in whole or in part, you have a right to know why this
was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial,
all within certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy
of a plan document or the latest annual report from the plan and do not receive them within 30 days, you
may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the
materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent
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because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied
or ignored, in whole or in part, you may file suit in a state or Federal court (after you have followed all the
claims and appeals procedures provided for under the plan). If it should happen that plan fiduciaries misuse
the plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from
the U.S. Department of Labor, or you may file suit in a Federal court. In addition, if you disagree with the
Plan’s decision or lack thereof concerning the qualified status of a domestic relations order or a medical
child support order, you may file suit in Federal court. The court will decide who should pay court costs and
legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees.
If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is
frivolous.
Assistance with Your Questions
If you have any questions about your plan, you should contact the Plan Administrator. If you have any
questions about this statement or about our rights under ERISA, or if you need assistance in obtaining
documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits
Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of
Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor,
200 Constitution Avenue N.W, Washington, D.C. 20210. You may also obtain certain publications about
your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits
Security Administration.
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Appendix 4
CLAIMS PROCEDURE
Healthcare claims (i.e., claims for medical, prescription drug and vision benefits) are administered by
different providers. Medical claims are administered by CIGNA. In this section describing how to file for
healthcare claims, all of those providers will be referred to by the joint term “Claims Administrator”, as
applicable (see Claims Administrator – Appendix 3 for contact information for the appropriate Claims
Administrator).
Filing Claims
If you enroll in one of the coverage options available under the Medical Plan, you must file a medical claim
form to receive benefits when you choose providers who do not participate in the CIGNA provider network.
• For medical claims other than for alcohol and/or drug abuse and mental health disorders, send your
CIGNA claim form with an itemized bill from the provider to the address on the back of your CIGNA
identification card. Claims must be filed within two years from date of service to be eligible for
reimbursement.
• For mental health disorders or alcoholism and substance abuse claims, send your CIGNA claim form
with an itemized bill to ComPsych. Claims must be filed within two years from date of service to be
eligible for reimbursement.
• For vision care claims, send your itemized bill from the provider (or an HCFA-1500 form used by most
eye doctors) to Vision Service Plan. Claims must be filed within six months from date of service to be
eligible for reimbursement.
• For prescription drug claims (medications filled at your local pharmacy), send your CVS / Caremark
claim form with an itemized bill from the provider to CVS / Caremark. Claims must be filed within two
years from date of service to be eligible for reimbursement.
• For mail order medications through the Maintenance Drug provisions of the Plan, send your CVS /
Caremark Mail Order form (with your prescription) to CVS / Caremark. Contact the provider directly for
information on where to find claim forms and instructions on how to complete them using the 1-8779AskHR9 toll-free line. Claims must be filed within two years from date of service to be eligible for
reimbursement. .
To ensure that all claims are handled quickly and accurately, make sure your claim forms are filled out
completely, including your name and Social Security number on each form. Complete separate claim forms
for each family member, and attach appropriate bills or statements from the provider showing the following
information:
•
•
•
•
•
•
patient name;
relationship to you;
date of treatment;
condition being treated;
kind of treatment given; and
physician tax identification number.
If any of this information is missing from the bill, please write it on the bill. Late claims are not eligible for
reimbursement.
Claim Forms
The Claims Administrator for the Plan must receive claims prepared and submitted in the proper manner
and form, in the time required, and with the information requested before it can consider any claim for
payment of benefits. Most providers will submit your claims directly to the Claims Administrator. At the time
services are provided, inquire if they will file claim forms for you. To assist providers in filing your claims, you
should carry your ID Card with you. (When you receive covered drugs dispensed from a pharmacy that
contracts with Caremark, you will generally not be required to file claim forms as that pharmacy will submit
the claims directly to Caremark for you.)
If your provider does not submit your claims, you will need to submit them to the Claims Administrator using
a claim form provided by the Plan. Claim forms can be obtained by calling the number on your ID Card or
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by contacting the NAM Employee Regional Support Center. When filing claims, remember to include
itemized bills from the health care providers, labs, etc., printed on their letterhead and showing the services
performed, dates of service, charges, and name of the participant involved.
Information and Consents Required from You in Connection With Claims
As a condition of receiving benefits under the Plan, Plan Participants consent to the release of any
information the Claims Administrator determines is necessary to send to parties who need the information
for claims purposes, as well as the release of medical information for use in Plan administration; however,
medical information released to either the Plan Sponsor or the Plan Administrator will not be used to affect
your continued employment, pay, promotion or other incidents of employment. In considering a claim or an
appeal, the Plan has the right to require a medical examination when and as often as may be required. The
Plan also has the right to review your or your covered Dependents’ medical records, and any additional
evidence deemed necessary as evidence on which a claim or an appeal under the Plan may be based.
Who Receives Payment
Generally, benefit payments will be made directly to contracting providers when they bill the Claims
Administrator. Written agreements between the Claims Administrator and some providers may require
payment directly to them. Any benefits payable to you, if unpaid at your death, will be paid to your surviving
spouse, as beneficiary. If there is no surviving spouse, then the benefits will be paid to your estate. Except
with regard to your treating physicians, rights and benefits under the Plan are not assignable, either before
or after services and supplies are provided.
Benefit Payments to a Managing Conservator
Benefits for services provided to your minor Dependent child may be paid to a third party only if the third
party is named in a court order as the managing or possessory conservator of the child; and the Claims
Administrator has not already paid any portion of the claim. In order for benefits to be payable to a
managing or possessory conservator of a child, the managing or possessory conservator must submit to the
Claims Administrator, with the claim form, proof of payment of the expenses and a certified copy of the court
order naming that person the managing or possessory conservator.
The Claims Administrator may deduct from its benefit payment any amounts the Plan is owed by the
recipient of the payment. Payment to you or your provider, or deduction by the Plan from benefit payments
of amounts owed to it, will be considered in satisfaction of its obligations to you under the Plan.
An Explanation of Benefits summary is sent to you so you will know what has been paid.
When to Submit Claims
To help ensure timely and accurate claims processing, all claims for benefits should be properly submitted to
the Claims Administrator within 90 days of the date you receive the services or supplies. Claims not
submitted and received by the Claims Administrator within two years (or six months for vision claims) after
that date will not be considered for payment of benefits.
Receipt of Claims by the Claims Administrator
A claim will be considered received by the Claims Administrator for processing upon actual delivery to the
Claims Administrator in the proper manner and form and with all of the information required. If the claim is
not complete, it may be denied or the Claims Administrator may contact either you or the provider for the
additional information. After processing the claim, the Claims Administrator will notify the participant by way
of an explanation of benefits summary.
For all claims and appeals, the time frame during which a decision must be made begins when the claim or
appeal is filed as required by the Plan, even if all of the information necessary to make a benefit decision is
not included in the filing. However, the deadline for a decision on your claim or appeal can be extended (as
discussed in the following paragraphs) if you do not provide all of the necessary information. If this
happens, you will be given a notice of the additional information that is needed. The deadline for making the
benefit decision will be extended by the length of time that passes between the date you are notified that
more information is needed and the date you provide the requested information, subject to the overall claim
or appeal filing deadline, as applicable. All deadlines described in these Claims Procedures are based on
calendar days (not business days).
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Appendix 4
Urgent Care Claims
The following urgent care Claims procedures apply only to claims filed with CIGNA or ComPsych, only
where prior approval is normally necessary to receive treatment and only where, in the opinion of your
treating physician, you will be subject to serious jeopardy to life, health, the ability to regain maximum
function or severe pain that cannot be adequately managed without the care or treatment which is the
subject of the claim.
If you have an urgent care claim, the Claims Administrator must notify you of an initial claim denial or claim
approval decision either:
• 48 hours after receiving the completed claim or 48-hours after your deadline to provide additional
information, whichever is earlier, or
• 72 hours after receiving the initial claim, provided that it was proper and complete.
The Plan must notify you within 24 hours after receiving an improper or incomplete claim. Oral notification is
enough for improper claims unless you request written notification.
You then have 180 days after receiving the claim denial to appeal the decision. The plan must allow you to
provide information by telephone, fax, or a similar method.
The Plan has 72 hours after receiving the appeal to notify you of the final appeal decision.
Pre-service Health Claims
The Pre-Service Health Claims procedures apply only to precertification claims, where prior approval is
normally necessary to receive benefits.
If you file a pre-service claim before receiving a health service (such as a pre-certification review), the
Claims Administrator must notify you of an initial claim denial or claim approval decision within 15 days of
receiving the request. If the Claims Administrator needs more information from y]ou and if the Claims
Administrator provides an extension notice during the initial 15-day period, the Claims Administrator has 30
days to notify you of a denial or approval decision. (Note, you are not required to request pre-certification for
maternity stays for vaginal deliveries if the hospital stay is less than 48 hours, nor for cesarean section
deliveries if the hospital stay is less than 96 hours. Extended stays, however, must be pre-certified.)
If the claim is improper, the Claims Administrator must notify you within 5 days of receiving the pre-service
claim.
After receiving an extension notice, you have 45 days to complete a non-urgent pre-service claim. Upon
receiving a claim denial, you have 180 days to appeal the decision.
Post-service Health Claims
If you file a claim after receiving a health service, the Claims Administrator must notify you of an initial claim
payment or denial within 30 days of receiving the initial claim. If the Claims Administrator needs more
information from you and if the Claims Administrator provides an extension notice during the initial 30-day
period, the Claim Administrator has 45 days to notify you of a claim payment or denial. After receiving an
extension notice, you have 45 days to complete your claim. If you do not supply the requested information
within the 45-day period, your claim will likely be denied.
Upon receiving a claim denial, you have 180 days to appeal the decision.
Claims that are initially filed more than two years (or, for vision claims, six months) from the date of service
are not eligible for appeal.
Denials of Claims
If any part of your claim is denied you will be given a written or an electronic notice that will include:
• The reason for the denial
• A reference to the specific plan provisions on which the denial was based
• A description of any additional material or information needed to perfect the claim and a statement of
why the information is necessary
• If any internal rule, guideline, or protocol was relied on in denying the claim, a copy of the rule, guideline
or protocol will be provided
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• If the claim was denied on appeal and was based on an exclusion or a limit like “medical necessity” or
“experimental treatment” either the scientific or clinical judgment for the exclusion or limit as applied to
your circumstance, or a statement that such an explanation will be provided to you free of charge upon
request
• A statement describing any appeal procedures offered by the Plan including any applicable deadlines,
and your right to obtain further information about the procedures and
• A statement of your right to file a lawsuit under ERISA if your claim is denied on final appeal to the
Claims Administrator.
If your denied claim was for Urgent Care, the information described above may first be provided to you orally,
and a written or an electronic notice will be given to you within the applicable deadline specified above.
Appealing a Denied Claim
If you wish to file a formal appeal with the Claims Administrator, you may do so. The appeal must be in
writing to the applicable Claims Administrator and made within 180 days after the date on which you receive
the original claim denial. (The contact information for the Claims Administrators is listed in Appendix 4.)
This is the step you must take in order to exhaust your administrative remedies, as provided by the federal
ERISA statute.
You may give the Claims Administrator written comments, documents, records and other information relating
to your claim for benefits that you want to have considered on appeal, and all such information will be
considered, even if this information was not submitted or considered in the original claim decision. The
review will not give deference to the claim denial and will not be made by the person who made the original
claim denial, or a subordinate of that person.
You are also entitled, upon request, to see and get a free copy of any Plan policy statement or guideline that
relates to the denied benefit, even if the policy statement or guideline was not relied on in denying the claim.
You may also request to see all documents, records, and other information relevant to your claim for
benefits and to get free copies of that information. This includes any information that:
• Was relied on in making the benefit decision;
• Was submitted, considered or generated in making the benefit decision, even if it was not relied on;
• Shows that administrative procedures or safeguards were followed to make sure that the benefit
decision was appropriately made based on the Plan documents (excluding information in other
claimants' files); and
• Is a statement of policy or guidance under the Plan concerning the denied treatment or benefit for your
diagnosis, even if it was not relied on in making the benefit decision.
If you are making an Urgent Care Appeal, you may file your appeal orally. In addition, all communications
between you and the Claims Administrator regarding your Urgent Care Appeal may be conducted by phone,
fax or any other available method of communication.
In deciding an appeal of any claim denial that is based in any way on a medical judgment (including things
like whether a treatment is experimental or not medically necessary), the Claims Administrator must get
advice from a health care professional who has training and experience in the relevant area of medicine.
Upon your request, you will be provided the names of any medical experts who were consulted in
connection with your claim denial, even if the advice was not relied upon in making the denial. The health
care professional consulted by the Claims Administrator cannot be a person who was consulted by the
Claims Administrator in connection with the claim denial (or a subordinate of the person who was consulted
in the original claim).
The Claims Administrator must make its decision on your appeal within the following time frames:
Urgent Care Appeals:
Pre-Service Appeals:
Post-Service Appeals:
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As soon as possible after the appeal is received, but not longer than 72
hours.
Within a reasonable time after the written appeal is received, but not
longer than 30 days.
Within a reasonable time after the written appeal is received, but not
longer than 60 days.
55
Appendix 4
Denials of Appeals
If any part of your claim is denied on appeal, you will be given a written or an electronic notice that will
include:
• The specific reason(s) for the denial;
• A reference to each of the specific Plan provision(s) on which the denial is based;
• If any internal rule, guideline or protocol was relied on in denying the claim on appeal, either include that
specific rule, guideline or protocol, or a statement that a rule, guideline or protocol was relied on in
denying the claim and that a copy will be provided to you free of charge on request;
• If the claim denial on appeal was based on an exclusion or a limit like "medical necessity" or
"experimental treatment," either the scientific or clinical judgment for the exclusion or limit as applied to
your circumstances, or a statement that such an explanation will be provided to you free of charge upon
request;
• A statement that you are entitled, upon request, to see all documents, records, and other information
relevant to your claim for benefits and to get free copies of that information;
• A statement describing any further appeal procedures offered by the Plan, including any applicable
deadlines, and your right to obtain further information about any such procedures; and,
• A statement of your right to file a lawsuit under ERISA if your claim is denied on final appeal to the Plan
Administrator.
If your denied appeal was an Urgent Care Appeal, the information described above may first be provided to
you orally, and a written or an electronic notice will be given to you within 3 days after the oral notice.
Voluntary Second Appeal
If a Claims Administrator denies your claim on appeal, you have the option of making a voluntary, second
level appeal to the Plan Administrator. This voluntary, second appeal is entirely optional on your part (and
only applies after you have followed the appeal procedure described above). You are not required to make
this second appeal to the Plan Administrator before filing a lawsuit under ERISA for Plan benefits (although
you are required to follow the first appeal procedure described above before filing suit). The Plan “waives”
any right to claim that you have “failed to exhaust your administrative remedies” (meaning the Plan gives up
its right to defend the lawsuit by claiming it is too soon for your to sue) because you have not first filed a
voluntary, second appeal.
Your decision whether or not to file a voluntary, second appeal will have no effect on your rights to any other
Plan benefits. The Plan Administrator will be the decision-maker on the voluntary, second appeal.
If you choose to make a voluntary, second appeal under the Plan, all of the rules described above for appeals
will apply to that voluntary, second appeal, except that:
• Any deadline described above that is measured from the date your claim was denied instead will be
measured from the date your first appeal was denied and
• Any deadline described above that is measured from the date your appeal was filed instead will be
measured from the date that your voluntary, second appeal was filed and
• Your written appeal must include new information that you wish to have considered that was not
provided to the Claims Administrator on the original appeal.
If you choose to file a second, voluntary appeal (1) you will not be charged any fees or costs as part of this
appeal process, and (2) any deadline (or “statute of limitations”) that applies to pursuing your claim in court
will be extended by the length of time the voluntary appeal process takes (“tolled” during the period of the
voluntary appeals process).
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Appendix 5
COBRA CONTINUATION OF COVERAGE
In certain circumstances, healthcare coverage for you and your covered Dependents can continue beyond
the date it would otherwise end. This continuation of coverage option is required by the Consolidated
Omnibus Budget Reconciliation Act of 1985 (COBRA).
The information included in this section is a general overview of COBRA provisions. If you become eligible for
continued coverage (that is, if you have a Qualifying Event), you’ll be given more information that reflects your
situation at the time. *
* Note, this Section contains a summary of COBRA rights generally available to employees and their
dependents. For a full description of all rights under COBRA, refer to the notice you were provided when
first covered by the Schlumberger Medical Plan or contact the NAM Employee Regional Support Center.
Qualifying Events and Length of Coverage
Eligibility for COBRA is triggered if coverage would be lost because of a Qualifying Event. The following table
describes the types of Qualifying Events and the maximum length of coverage available for each event. If you
decide to continue coverage, you must pay the full cost of that coverage, plus a 2% administrative cost. The
monthly premium amount will be provided to you at the time a Qualifying Event occurs.
Maximum Continuation of Coverage under COBRA
Qualifying Event
Maximum Continuation of Coverage
(from the date of the Qualifying Event)
Employee
Spouse
Termination of employment
18 months
18 months
Dependent
Child(ren)
18 months
Employee and Spouse legally separate
or divorce
N/A
36 months
36 months
Your child no longer qualifies as a
Dependent
N/A
N/A
36 months
Employee dies
N/A
36 months
36 months
Employee becomes entitled to Medicare
(Part A and / or Part B)
N/A
36 months
36 months
Schlumberger files for Chapter 11
bankruptcy and terminates coverage as
a result
Until death
Until death
Until death
When COBRA Coverage Ends
COBRA coverage will end prior to the date mentioned above if:
• You do not pay the required premiums on time and in full;
• If you waive coverage;
• If you first enroll in Medicare Parts A or B after your COBRA election period expires;
• If you become covered by another group health plan without an exclusion for pre-existing conditions (or
the exclusion expires); or
• If Schlumberger cancels all group health plan coverages.
You will be notified if coverage terminates prior to the time periods indicated above. (Note, Medicare
entitlement will not terminate retiree or Dependent COBRA coverage if the coverage was on account of
Schlumberger’s bankruptcy.)
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Appendix 5
Extending COBRA Coverage Due to Disability
COBRA coverage may be extended beyond the 18 month period following a termination of employment if
you or a family member on COBRA are disabled (as determined in accordance with the Social Security Act)
within the first 60 days of your termination of employment and you notify the NAM Employee Regional
Support Center of the disability determination before the end of the original 18 month period. In this case,
coverage for you and your eligible Dependents may be extended from 18 months to 29 months.
COBRA Notification Deadlines
You’ll be notified when you become entitled to continue healthcare coverage. However, for events affecting
only your Dependents, such as divorce, losing full-time student status, reaching the maximum eligible age,
or death of employee, you or your Dependents must notify the NAM Employee Regional Support Center no
later than 60 days from the Qualifying Event. If you do not notify the NAM Employee Regional Support
Center within the 60 day period, your eligible Dependent will lose the right to continue coverage.
You and / or your Dependents must make a COBRA election within 60 days of the later of the following dates:
• The date you and / or your covered Dependent(s) would lose coverage because of a Qualifying Event
or
• The date the Plan Administrator notifies you and / or your covered Dependents of your right to choose
COBRA coverage because of a Qualifying Event.
If you or your Dependents fail to elect COBRA within the 60-day period, you forfeit your right to COBRA
coverage.
Enrollment
When you become eligible for COBRA, you and your covered eligible Dependents may each independently
choose to continue medical vision coverage for up to the entire coverage period. During initial COBRA
enrollment, you may not make changes to your coverage (options) except to stop coverage in a particular
plan. You may, however, decrease your coverage level (e.g., employee, employee plus spouse, employee
plus family). In addition, you or your Dependents will have an opportunity to change your benefit elections
during the Annual Enrollment period for an effective date of January 1st.
If you do not elect COBRA coverage when you first become eligible, you will not be able to enroll at a later
date.
When Payments Are Due
If you elect COBRA coverage, you must make the first payment (including all premiums due but not paid)
within 45 days after your election. COBRA coverage premiums then must be paid monthly and in full within 30
days of each due date. If you elect COBRA coverage, but then fail to pay the full premium due within the initial
45-day grace period or if you fail to pay any subsequent premium in full within 30 days after the due date,
your COBRA coverage will end retroactively on the last day of the period for which you timely paid in full.
Address Changes
In order to help ensure the protection of rights and benefits under this Plan, covered persons must keep the
NAM Employee Regional Support Center office and the respective claims administrators informed of any
changes to their addresses. If you do not do so, you will miss important notices which could impair your rights
under the Plan.
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Appendix 6
NEWBORNS’ AND MOTHERS’
HEALTH PROTECTION ACT
The Company is providing this statement to advise you of your rights under the Newborns’ and Mothers’
Health Protection Act. The Schlumberger Medical and Retiree Medical plans do not currently limit or restrict
length of hospital stay based solely on hours since delivery.
Federal law limits the right of group health plans and carriers to restrict the length of hospital stay in
connection with childbirth for mothers and newborns. In general, plans may not restrict benefits to less than
48 hours following a vaginal delivery, or less than 96 hours following delivery by cesarean section. However,
the plan or carrier may pay for a shorter stay if the attending physician (or nurse midwife or physician
assistant) discharges the mother or newborn earlier, after consultation with the mother. Benefits payable for
any later portion of the 48-hour (or 96-hour) stay may not be less favorable to the mother or newborn than
those payable for any earlier portion of the stay.
In addition, a plan or carrier may not require a physician or other health care provider to obtain prior
authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, you may be required
to obtain pre-certification to use certain providers or facilities, or to reduce your out-of-pocket costs. For
more information on pre-certification, contact the NAM Employee Regional Support Center.
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SCHLUMBERGER RETIREE MEDICAL PLAN

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