ExxonMobil Medicare Supplement Plan

Transcription

Summary Plan Description
201
About Medicare
Supplement
- Information Sources
- Introduction
- Plan at a Glance
Eligibility and Enrollment
The Prescription Drug
Program
Other Plan Provisions
Accepting Assignment
Covered Expenses
Exclusions
SPD
As of January 2015
About The Medicare Supplement Plan
This summary plan description (SPD) is a summary of the ExxonMobil Medicare
Supplement Plan (the Plan). It does not contain all Plan details. In determining your
specific benefits, the full provisions of the formal Plan documents, as they exist now or
as they may exist in the future, always govern. Copies of these documents are
available for your review.
The Medicare numbers used in this SPD are current for 2015 but are subject to
change. The dollar amounts in the examples are for explanation purposes only and
may not reflect what a specific service might cost or how much Medicare and the Plan
would pay toward that service.
Coordination of Benefits
Claims
Information Sources
Partners in Health
When you need information, you may contact:
Continuation Coverage
Prescription Drug Program - Express Scripts is the claims processor for outpatient
prescription drugs provided through mail order for long-term prescriptions or a local
retail pharmacy for short-term prescriptions.
Administrative and ERISA
Information
Key Terms

Benefit Summary

Phone Numbers:
Express Scripts Pharmacy
Mail-order Pharmacy:
800-695-4116
800-497-4641
(international, use
appropriate country access code
depending on country from which you are
calling)*
For questions regarding Retail
Prescriptions –
Express Scripts:
800-695-4116
800-497-4641
(international, use
appropriate country access code
depending on the country from which you
are calling)*


Address:
Mail-order Pharmacy:
P.O. Box 650322
Dallas, TX 75265-0322
Non-network and
Retail Prescriptions Claims
Processing: Express
Scripts
ATTN: Commercial Claims
P.O. Box 2872
Clinton, IA 52733-2872
page 2
*To be able to reach this international access line for Express Scripts, please use the
appropriate access number (e.g., AT&T Direct Service) for the country you are calling
from.
Another way to locate retail network pharmacies and order refills is via the Express
Scripts web site at www.express-scripts.com.
All Other Medical — Aetna, the claims administrator, provides claim forms, claims
payment information and advance approval for in-home skilled-nursing care. Aetna is
also the claims processor for all medical expenses except outpatient prescriptions.
Phone Numbers:
Address:
Aetna Member Services
800-222-3992
210-366-2416
(international,
call collect)
Monday - Friday 8:00 a.m. to 6:00
p.m. (U.S. Central Time),
except certain holidays
Automated Voice Response
Hours: 24 hours a day, 7 days a
week
Aetna
P.O. Box 981106
El Paso, TX
79998-1106
Benefits Administration — Retirees and survivors can enroll/change coverage on
the ExxonMobil Benefits Service Center website at www.exxonmobil.com/benefits. If
you are unable to access the Internet or need additional information, you may contact:
Phone Numbers:

Retirees and Survivors call:
ExxonMobil Benefits Service Center
Monday – Friday 8:00 a.m. to 6:00 p.m.
(U.S. Eastern Time), except certain
holidays
Toll-Free: 1-800-682-2847
or 800-TDD-TDD4
(833-8334) for
hearing impaired
Address:
ExxonMobil Benefits Service
Center
PO Box 199540
Dallas, TX 75219-9722
ExxonMobil Sponsored Sites — Access to Plan-related information including claim
forms for employees, retirees, survivors, and their family members.



ExxonMobil Family, the Human Resources Internet Site — Can be
accessed by everyone at www.exxonmobilfamily.com.
Retiree Online Community Internet Site — Can be accessed by retirees and
survivors only at www.emretiree.com.
ExxonMobil Benefits Service Center at Xerox Internet Site — Can be
accessed by everyone at www.exxonmobil.com/benefits.
page 3
Introduction
The ExxonMobil Medicare Supplement Plan, referred to as the Plan in this SPD, is a
medical plan for retirees, survivors and their eligible family members who are also
eligible for Medicare. It is designed to work with Medicare Parts A and B to give you
medical coverage similar to that available to employees and retirees not eligible for
Medicare.
The ExxonMobil Medicare Supplement Plan also covers care and supplies such as
outpatient prescription drugs, in-home skilled-nursing care and medical care received
outside the United States, which are not covered by Medicare Parts A and B; however,
if you enroll in a Medicare Advantage (Part C) plan which provides a Medicare
prescription drug benefit or Medicare Part D (coverage for prescription drugs), the
Plan will not cover any outpatient prescription drugs even if they are not covered
under Medicare Part C or D.
While the Plan is designed to work with Medicare Parts A and B, it is not intended to
pay all amounts that Medicare does not cover. Benefits payable under the Plan are
considered together with the benefits received from Medicare.
The Plan does not involve an insurance policy. All claims are funded by contributions
from ExxonMobil, other participating employers and participants. Aetna Life Insurance
Company (Aetna) and Express Scripts are paid fees to provide services such as
processing claims, answering questions, and managing the pharmacy network and
mail-order pharmacy service. Neither Aetna nor Express Scripts has any responsibility
for funding benefits under the Plan.
Aetna does not render medical services or treatments. Neither the Plan nor
Aetna is responsible for the health care that is delivered by providers
participating in the ExxonMobil Medicare Supplement Plan and those providers
are solely responsible for the health care they deliver. Providers are not the
agents or employees of the Plan or Aetna.
The Plan is described in detail in this SPD. These tools help you find specific
information quickly and easily:




Plan at a Glance, a quick user's guide highlighting Plan basics.
Charts and tables to provide information, examples, highlights of Plan
provisions, including a Benefit Summary chart.
References to places where you can find more information.
A list of Key Terms containing definitions of some words and terms used in
this SPD.
A careful reading of this SPD will help you understand how the Plan works so you can
make the best use of the Plan provisions. You may obtain additional information from
the sources shown on page 1.
page 4
Plan at a Glance
Eligibility
Retirees and their eligible family members who are also eligible for Medicare may
participate. Survivors of retirees or deceased employees may also be eligible once
they become Medicare eligible. See page 6.
The Prescription Drug Program
The Plan offers cost-saving ways to buy outpatient prescription drugs if you are not
participating in a Medicare Advantage (Part C) plan which provides a Medicare
prescription drug benefit or Medicare Part D — at local participating network
pharmacies and through mail order. See page 10.
You must satisfy an annual deductible of $300 before the Plan starts paying. If you
meet your annual out-of-pocket limit of $3,000, the Plan's reimbursement level —
when combined with Medicare Parts A and B — is 100% of most covered charges for
the rest of that calendar year. The Plan covers some items Medicare may not, such as
transition benefits from pre-65 medical plans sponsored by ExxonMobil, in-home
skilled-nursing care and medical care received outside the United States. See page
18.
If your doctor or other health care providers accept assignment, they accept the
amount Medicare approves as payment in full for each service or supply. You must
still pay any co-insurance amount. See page 25.
Covered and Excluded Expenses
The Plan provides benefits for many, but not all, types of treatment, care and services.
See page 28 for Covered Expenses and page 31 for Exclusions.
The Plan treats Medicare coverage as another group plan for purposes of coordinating
benefits. See page 33.
Claims
All claims should be submitted to Medicare first. If you participate in Medicare Direct,
your Medicare Part B claim is automatically forwarded from Medicare to Aetna. If you
do not participate in Medicare Direct, you submit the claim along with the Explanation
of Medicare Benefits forms to Aetna. See page 35.
Partners in Health
Tools and resources are available to you and your family members to help you better
manage your health care. See page 38.
COBRA
Your family members who lose eligibility may continue medical coverage for a limited
time in certain circumstances. See page 40.
page 5
Administrative and ERISA Information
The Plan is subject to rules of the federal government, including the Employee
Retirement Income Security Act (ERISA), not state insurance laws. See page 44.
Key Terms
This is an alphabetized list of words and phrases, with their definitions, used in this
SPD. See page 50.
Benefit Summary
Key features of the Plan and Medicare are highlighted. See page 56.
About Medicare Supplement
Q. Who can participate in the Plan?
- Eligible Retiree
- Eligible Family Members
- Eligibility for Medicare
- Enrolling in Medicare
- When Plan Eligibility Ends
A. There are three conditions for eligibility for the Plan. You must:



Program
Covered Expenses
Exclusions
Be eligible for Medicare;
Be an eligible retiree or eligible family member; and
Have been covered by an employer-sponsored group medical
plan immediately before Plan eligibility. You will have to show
loss of coverage under an employer sponsored group medical
plan (any group medical plan sponsored by either the
Corporation or another employer) to enroll any time after your
Medicare eligibility. You have 60 days from the date of loss of
coverage under an employer sponsored group medical plan to
provide documentation of loss of this coverage and enroll in the
ExxonMobil Medicare Supplement Plan. If you do not enroll
within 60 days from your loss of coverage you will not have
another opportunity to enroll.
Eligible Retiree
Claims
For purposes of the Plan, you are an eligible retiree if you attained retiree status from:
Partners in Health



Information

Key Terms
ExxonMobil;
Exxon;
Mobil; or
Superior Oil Company.
Retirees of Station Operators, Inc. doing business as ExxonMobil Company Operated
Retail Stores (CORS) are not eligible for coverage under this plan.
Benefit Summary
Eligible Family Members
For purposes of the Plan, eligible family members include:




The spouse of an eligible retiree.
The surviving spouse, who has not remarried, of a deceased eligible retiree.
The surviving spouse, who has not remarried, of a deceased employee.
The child of an eligible retiree.
page 7


The child, whose surviving parent has not remarried, of a deceased employee
or eligible retiree.
A person who becomes an eligible family member of an ExxonMobil eligible
retiree by marriage after becoming eligible for Medicare. To participate in the
Plan under this provision, prior group health coverage is not required.
However, the person must be added as a covered family member within 30
days of becoming eligible.
Eligibility for Medicare
In general, you are eligible for Medicare if you are at least 65 years of age or have
received Social Security disability benefits for 24 consecutive months. Anyone,
including children, can be eligible for Medicare by virtue of a disability as described on
page 51.
No one becomes eligible for Medicare as the dependent of someone who is eligible for
Medicare. For example:


If you are 65 years of age and your spouse is 61 and not disabled, you are
eligible for Medicare but your spouse is not; or
If you are under age 65 and not disabled and have a spouse either over 65 or
eligible due to disability, your spouse is eligible for Medicare but you are not.
Enrolling in Medicare
If you are receiving Social Security benefits, your Social Security office should contact
you with information about Medicare before your 65th birthday. If you are not receiving
Social Security benefits or if you have not been contacted by Social Security and are
nearing your 65th birthday, contact your local Social Security office. To receive
maximum benefits from the Plan and Medicare, you must enroll in both:


Part A covers hospital care and care in a skilled-nursing facility. There is no
premium for most Part A participants.
Part B covers physician bills and some out-of-hospital expenses. A premium
for Part B is deducted from your Social Security check. Contact Medicare for
current premium information.
If your spouse worked in a job not covered by Social Security or did not work long
enough to qualify for free Part A coverage, the Plan pays full benefits with or without
Part A coverage. The spouse must, however, sign up for Part B to receive
maximum benefits.
page 8
Enrolling in Medicare Advantage (Part C) or Medicare Part D
Participants who choose to enroll in a Medicare Advantage (Part C) plan which
provides a Medicare prescription drug benefit or Medicare Part D Prescription
Drug Plan will no longer be eligible for outpatient prescription drug coverage
under the Plan. If you enroll in a Medicare Part C plan which provides a Medicare
prescription drug benefit or Part D program and continue your Plan participation, your
required contributions remain the same, but you will not be eligible for outpatient
prescription drug benefits under the Plan.
Questions About Medicare?
Contact Social Security Administration:


Call toll free 800-772-1213 .
Access the Web site at www.socialsecurity.gov.
Enrolling in the Plan
The ExxonMobil Benefits Service Center (EMBSC) contacts retirees and their spouses
and surviving spouses shortly before their 65th birthdays. If you have not been
contacted by the time you become eligible for Medicare, contact the EMBSC. This is
particularly important if you become eligible for Medicare by virtue of disability rather
than age. You should also contact the EMBSC when your child or spouse becomes
eligible for Medicare.
Important Notice About Becoming Medicare-Eligible
Retirees or survivors or covered family members of a retiree or survivor who become
Medicare eligible either due to age or Social Security disability status are no longer
eligible to participate in the ExxonMobil Medical Plan (POS II Options and HMO
Options). Medicare eligible participants must change their Company-provided
coverage from the ExxonMobil Medical Plan to the ExxonMobil Medicare
Supplement Plan and enroll in Medicare Parts A and B. (Note: There are no HMO
options under the ExxonMobil Medicare Supplement Plan).
Even if you enroll in the ExxonMobil Medicare Supplement Plan, but choose not to
enroll in Medicare Parts A and B, you will receive no reimbursement from the
ExxonMobil Medicare Supplement Plan for claim expenses that would have been
paid by Medicare had you been enrolled. The ExxonMobil Medical Plan is not
available to retirees and survivors who are Medicare-eligible.
Don't Be Without Coverage!
Notify the ExxonMobil Benefits Service Center as soon as you or your family
members receive notice of eligibility for Medicare Parts A and B due to either age or
disability.
page 9
When Plan Eligibility Ends
Eligibility for the Plan ends:







When a participant fails to make the required contributions.
When you cancel your coverage in writing.
For a spouse following a divorce.
For a surviving spouse and stepchildren upon remarriage.
For children upon the marriage of the surviving parent.
For the surviving spouse and children of an employee who died with less than
15 years of ExxonMobil benefit service after a period from the date of death
equal to twice the deceased employee's length of ExxonMobil benefit service.
If, at some future date, the Plan is terminated or replaced.
If you cancel your coverage, you will not be allowed to re-enroll in the future.
Also, if you are not covered under this or another medical plan to which ExxonMobil
contributes, your otherwise eligible family members cannot continue coverage under
any ExxonMobil medical plans.
The Prescription Drug Program
Q. Does the Plan cover outpatient prescription drugs?
Program
- Short-Term Prescriptions
- Long-Term Prescriptions
- Comparing Retail Pharmacy
A. Yes, but only if you are not enrolled in Medicare Part D or a
Medicare Part C plan that provides a Medicare prescription drug
benefit. The Plan's prescription drug benefits offer cost-saving ways to
buy outpatient prescription drugs:
with Express Scripts Pharmacy
- Covered Prescriptions
- Limitations



A network of local participating retail pharmacies for short-term
prescriptions.
Express Scripts Pharmacy, the mail-order service for long-term
or maintenance prescriptions.
Express Scripts Specialty Pharmacy.
No deductible is required.
Covered Expenses
Exclusions
Claims
Partners in Health
Information
Key Terms
Benefit Summary
Note: Prescription medications, including injections, billed by and provided in a
hospital or a doctor's office are not covered under the prescription drug program but
may be covered medical expenses under the Medicare Supplement Plan. Medications
billed to you by a pharmacy vendor are not covered under the Medicare Supplement
Plan.
For Certain Prescription Drugs:
You must call Express Scripts for pre-certification of certain prescription drugs.
This applies whether you are inside or outside the United States.
In the therapeutic chapters listed below, there will be targeted drugs determined by
Express Scripts which will not be covered unless pre-certified by Express Scripts.
Non-targeted drugs will be covered without such authorization, and will continue to be
dispensed with no further action by either a participant or the prescribing physician.
These classes are proton pump inhibitors, sleep agents, depression, osteoporosis,
respiratory, cardiovascular, triptans, growth hormone, stimulants for Attention Deficit
Hyperactivity Disorder (ADHD), prostate therapy drugs, topical steroids and stroke
prevention. Additional prior authorization rules apply to certain therapeutic chapters of
drugs; miscellaneous immunological agents, central nervous system/miscellaneous
neurological therapy, biotechnology/adjunctive cancer therapy, central nervous
system/headache therapy, central nervous system/analgesics,
neurology/miscellaneous psychotherapeutic agents, and miscellaneous pulmonary
agents. Certain drugs within each chapter as determined by Express Scripts will only
be covered to the extent they are authorized by Express Scripts. If you have a
question regarding a drug in any of these therapeutic chapters, contact Express
Scripts to determine whether your drug is covered without precertification.
You must identify yourself as a member of the Express Scripts retail pharmacy
program to receive Plan savings.
Call Express Scripts at 800-695-4116
or check the Express Scripts web site at
www.express-scripts.com to locate a participating retail pharmacy near you.
page 11
Short-Term Prescriptions
A short-term prescription is written for a drug taken for a limited period of time, such as
an antibiotic for a specific illness or if your doctor wants you to try the prescription
before having a long-term prescription filled. The Plan provides benefits for up to a 34day supply. See page 16 for limitations.
You have the choice of filling your prescriptions at:


A local participating retail pharmacy (part of Express Script's extensive network
of retail pharmacies), where you will pay your share — co-payment — of the
discounted cost. There are no claims to file.
A non-participating pharmacy of your choice, where you will pay the full retail
price and file a claim for partial reimbursement of the cost.
To receive the discounted price:



Present your prescription and either your prescription drug identification card
or the primary participant's identification number at a participating network
pharmacy.
The pharmacist enters the prescription and the primary participant's
identification number into the pharmacy's computer system to confirm:
 That you are a participant or family member covered by this option.
 That it is a covered prescription.
 Your share of the prescription's cost.
You do not file a claim.
The term primary participant refers to the participant whose identification number is
used for identification purposes. The primary participant is the retiree, survivor or
individual who elected COBRA coverage. Covered family members use the primary
participant's identification number to access all medical benefits. Be sure to give
identification cards or the primary participant's identification number to your spouse
and any covered family members who may live away from home.
Note: Family members who elect COBRA coverage must use their own identification
number after the date they enroll as a COBRA participant.
Refills Too Soon?
Refills can be obtained if prescribed and needed. You must have used at least 75%
of the previous prescription, based on the dosage prescribed, before you can obtain
a refill and receive Plan benefits.
Co-Payments
For prescription drugs purchased at a participating retail pharmacy, you pay a
percentage of the discounted cost of the drugs.
Type of Drug:
Retail Pharmacy Percentage CoPayment:
Generic drugs
30%
Formulary preferred brand name drugs
30%
Formulary non-preferred brand name drugs
50%
page 12
Examples:
Generic drug purchased at a retail network pharmacy — discounted cost of
medication is $24.
You pay 30% co-payment ($24 x .30)
=
$7.20
Preferred brand name drug purchased at a retail network pharmacy (if no
generic is available) — cost of medication is $42.
=
$12.60
Non-preferred brand name drug purchased at a retail network pharmacy (if no
generic is available) — cost of medication is $64.
=
$32
Retail Refill Limitation
For the third and subsequent refills of a long-term or maintenance drug, which is a
drug you take for an extended period of time, such as for ongoing treatment of
diabetes, arthritis, a heart condition or high blood pressure, you will pay an additional
25% percentage co-payment. The additional 25% co-payment does not apply to your
annual prescription drug out-of-pocket maximum.
For example, the percentage co-payment for a generic maintenance drug purchased
at a retail network pharmacy is 55%.
Cost of a Generic
Maintenance Medication
Obtained at a Retail
Pharmacy
$50.00
Cost of generic maintenance
drug (30-day supply)
Percentage of Co-payment
If you purchase the generic maintenance drug at
retail
$50.00 Cost of generic drug (30-day supply)
x 30% Percentage co-payment
$15.00 Your percentage co-payment if you
purchase the generic on the first fill and next 2 refills
If you purchase the drug on the third refill: Your copayment will be $50.00 x 55% = $27.50
The additional $12.50 paid to purchase the third
and subsequent refills will not count toward
meeting your annual out-of-pocket maximum
Retail Pharmacy Percentage Co-Payment for the third and subsequent refill of a
long-term maintenance drug:

Generic drugs 55%

Formulary preferred brand name drugs 55%

Formulary non-preferred brand name drugs 75%
page 13
Using a Non-Participating Pharmacy or Not Identifying Yourself as a Express
Scripts Participant
You are not eligible for a discounted price if you:


Have your prescription filled at a non-participating pharmacy; or
Do not identify yourself as an Express Scripts participant at a network
pharmacy.
In either case:



You pay the full non-discounted price of the prescription at the time of
purchase.
You must submit a completed Direct Reimbursement Claim Form to Express
Scripts. You may obtain a claim form by calling Express Scripts at the number
shown in the front of this SPD.
You will be responsible for:
 100% of the difference between the non-discounted and discounted
cost of the prescription (the ineligible cost);
PLUS
 Your percentage co-payment portion of the discounted cost.
This example shows how you would save money when you use a network pharmacy
and show your prescription ID card. In this case, you would save $10.
Without Express
Scripts Discount
Full retail cost of preferred brand name
prescription (non-discounted)
Discounted cost
Ineligible cost
With Express
Scripts Discount
$ 50.00
N/A
-$ 40.00
$ 10.00
$ 40.00
0.00
Ineligible cost
30% co-payment ($40 x .30)
$ 10.00
$ 12.00
$ 0.00
$ 12.00
Your cost
$ 22.00
$ 12.00
Long-Term Prescriptions
A long-term or maintenance drug is one you take for an extended period of time, such
as for ongoing treatment of diabetes, arthritis, heart condition or high blood pressure.
The Plan generally provides benefits for up to a 90-day supply through the mail-order
prescription service. See page 16 for limitations.
If you need maintenance medication immediately, ask your doctor for two
prescriptions — one for an immediate supply to be filled at a local pharmacy and a
second for an extended supply to be ordered by mail.
Express Scripts Pharmacy — Mail-Order Pharmacy
With Express Scripts Pharmacy, the mail-order pharmacy, you save money and have
the convenience of home delivery. Ask the doctor to write a prescription for up to a 90day supply with appropriate refills. Enclose your original prescription(s) and payment
of your percentage co-payment in an envelope. If you are paying via check or money
order, you may obtain a calculation of your percentage co-payment from the Express
Scripts web site or by calling Express Scripts directly. If you are paying via credit card,
Express Scripts will deduct the appropriate percentage co-payment and you will
receive notification of the deduction with your medication.
page 14
For each prescription filled, you pay:
Type of Drug:
Percentage Co-Payment:
Generic drugs
25%
Preferred brand name drugs
25%
Non-preferred brand name drugs
45%
Your prescription will be delivered to the address on your order form within 14 working
days. By law, prescriptions may not be sent outside the U.S.
Refills
You may order refills by calling Express Scripts or sending in the refill label provided
with your previous order. You may also order refills through Express Scripts web
site. You should order a refill about three weeks before your current supply will be
exhausted, but remember that you must have used at least 75% of the previous
prescription based on the prescribed dosage.
Comparing Retail Pharmacy with Express
Scripts Pharmacy
This example shows how you can save money by purchasing long-term medication
through the mail-order pharmacy.
Assume you purchase a 90-day supply of a preferred brand name drug:
At a Participating Retail Pharmacy:
Through Express Scripts Pharmacy:
$108.00 Cost of preferred brand name
$324.00 Cost of preferred brand name
x 30%
Percentage co-payment
x 25%
$32.40
Your co-payment for a 30-day
supply or $97.20 for a 90-day
supply
$81.00
Your co-payment
You pay $97.20 for a 90-day supply
You pay $81.00 for a 90-day supply.
By purchasing a 90-day supply of this prescription through mail order, you would save
$16.20. That is $64.80 a year for one prescription. Note this example does not include
in the calculation the additional 25% co-payment for the third and any subsequent
refills from a participating retail pharmacy. Actual savings may be greater.
Whether you fill prescriptions through Express Scripts Pharmacy, at a local
pharmacy or through Express Scripts Specialty Pharmacy:
 Your payments and co-payments under the outpatient prescription drug
benefits do not apply toward your deductible for other benefits under the Plan.
 Your prescription drug payments and co-payments do not apply toward your
annual medical out-of-pocket limit.
 Your prescription drug annual out-of-pocket maximum is $2,500 for each
individual in your family, or $5,000 for your entire family. Additionally, there is
a per prescription out-of-pocket maximum for drugs purchased at retail and
through mail order, as shown in the table.
 The additional cost for purchasing brand-name prescription drugs when a
generic is available, in addition to the additional coinsurance charged for
purchasing third and subsequent refills of maintenance medications obtained
at retail pharmacies, will not count toward your annual out-of-pocket
maximum.
page 15
Retail
Per Prescription
Out-of-Pocket
Maximum
(30-day or less supply)
Mail
Per Prescription
Out-of-Pocket
Maximum
(Generally 90-day
supply
$50
$100
Preferred Brand Name Drugs
$115
$200
Non-Preferred Brand Name Drugs
$170
$300
Generic
Covered Prescriptions
The Plan covers drugs, medicines and supplies that are:




Obtainable only with a physician's prescription or are specifically covered
expenses (see Covered Expenses on page 28);
Approved by the U.S. Food and Drug Administration for the specific diagnosis;
Medically necessary (see page 53);
Not experimental or investigational.
Generic Drugs
The program encourages consideration of generic alternatives, which are less
expensive to you and the Plan. About half of all brand name medications have a
generic equivalent available. By law, the brand name and generic medications must
meet the same standards for safety, purity, strength and effectiveness. The
pharmacist will only dispense generics which receive FDA approval and only if
authorized by your doctor.
Note: If both generic and brand name drugs are available to treat your condition, your
percentage co-payment amount will depend on which medication you select. If you
purchase the brand name drug, you are responsible for paying the generic drug
percentage co-payment PLUS the difference in cost between the generic drug and the
brand name drug up to the brand per prescription maximum. This difference in cost
will not count toward your annual prescription drug out-of-pocket maximum.
Here is an example of how you can save by choosing a generic drug at a retail
pharmacy when a brand-name drug is available on the Plan's formulary list of
medications.
Cost Difference Between
Percentage Co-Payment
Brand and Generic
$100.00 Cost of
preferred
brand-name
drug
(30-day
supply)
$50.00
Cost of generic
drug
(30-day
supply)
$ 50.00 Cost difference
If you purchase the generic drug:
$50.00
Cost of generic drug
(30-day supply)
x 30%
$15.00
Your co-payment if you purchase the
generic
If you purchase the brand name drug: Your copayment will be $15.00 + $50.00 (cost difference) =
$65.00
The additional $50 does not count toward your
annual prescription drug out-of-pocket maximum.
page 16
Available Alternatives
Sometimes, a generic drug or a less expensive brand name drug which provides the
same therapeutic effect, but at a lower cost to you, may be available. If so, the network
system will inform the pharmacist that a less expensive alternative medication is
available to fill your prescription. A pharmacist from the network or Express Scripts
Pharmacy may contact your doctor to discuss the generic or less expensive brand
name alternative. If the doctor authorizes a substitution, the pharmacist will dispense it
based solely on your doctor's agreement. If Express Scripts Pharmacy fills a
prescription with a generic or an alternative brand name drug, your order will include
an explanation of the doctor's change and a credit for any excess co-payment.
The Network Formulary Program
A formulary is a list of commonly prescribed medications within particular therapeutic
categories. The drugs on the list have been selected based on their effectiveness and
cost. To be included in the formulary list, a drug must meet rigorous standards of
approval by the Express Scripts Pharmacy and Therapeutic Committee - a group of
nationally recognized medical professionals.
It is always up to your doctor to decide which medications to prescribe. If you have
questions about the Express Scripts formulary, you should contact Express Scripts
directly.
Drug Monitoring Service
All prescriptions, both mail order and retail, are screened by the network's
computerized drug monitoring service.
This service analyzes all of your prescriptions in the system for potential problems
such as adverse drug interactions, drug duplications and unusually high or low
dosages. This service will also detect if a refill is requested too soon. If a potential
problem is detected, the drug monitoring service transmits a message to the
pharmacist. The pharmacist will contact your doctor about the potential problem or
otherwise resolve the issue before dispensing the prescription. Of course, your doctor
makes the final decision about any change in your prescription or course of treatment.
Limitations
In most cases, the pharmacist will fill the prescription according to the doctor's written
orders. However, there are some limitations:



If the prescription is written for an amount that is greater than the Plan covers,
the pharmacist will fill the prescription up to the Plan limit. You have the option
to buy the additional amount at that time if purchasing at a retail pharmacy, but
there is no Plan benefit.
If the medicine is a controlled substance or if there is a manufacturer's or
prescription benefit manager's directive, a smaller amount may be provided.
You must use at least 75% of the prescription, based on the dosage
prescribed, before you can obtain a refill and receive Plan benefits.
When a Prescription Drug Becomes Available Over the Counter
When a prescription medication becomes available over the counter, so that it can be
purchased without a prescription, at the same strength and for the same use, it will no
longer be covered under the Prescription Drug Program. In addition, other drugs in the
same therapeutic class may be excluded from the program, but this determination will
be made on a case by case basis, based on available clinical data.
Special Rules for Coordinating Benefits for Prescriptions
If you or your family members are covered under any other group medical plan, the
Plan coordinates benefits with that plan, as described on pages 33-34. In addition,
information about the other coverage is provided to the outpatient prescription drug
network.
page 17
When a pharmacist reviews your family member's eligibility information in the network
system, a code will indicate if your family member has other coverage that should pay
benefits first. In these cases, you must first pay according to the primary plan
provisions (i.e., you cannot purchase prescriptions using the Express Scripts card or
through the mail-order prescription service). After the primary plan has paid, you may
file a claim with the Plan for reimbursement of any remaining amount; the procedure is
the same as when a non-participating pharmacy is used. The Plan will pay the lesser
of what would have been paid if the claim was not filed with the primary plan or the
amount not paid by the primary plan.
Medicare Advantage (Part C) Plans, Medicare Part D, and The Prescription Drug
Program
Participants who choose to enroll in a Medicare Advantage (Part C) plan which
provides a Medicare prescription drug benefit or Medicare Part D Prescription
Drug Plan will no longer be eligible for outpatient prescription drug coverage
under the Plan. If you enroll in a Medicare Part C plan which provides a Medicare
prescription drug benefit or Part D program and continue your Plan participation, your
required contributions remain the same, but you will not be eligible for outpatient
prescription drug benefits under the Plan.
Pre-Certification: Preferred DrugStep Therapy Rules
You must call Express Scripts for pre-certification of certain prescription drugs
described below:
Preferred drug step therapy rules are used for certain therapeutic chapters of drugs, to
encourage the use of effective, lower-cost drugs by excluding some targeted
medications from coverage. In the therapeutic chapters proton pump inhibitors, sleep
agents, depression, osteoporosis, respiratory, cardiovascular, triptans, growth
hormone, stimulants for Attention Deficit Hyperactivity Disorder, prostate therapy
drugs, topical steroids, and stroke prevention, there will be targeted drugs determined
by Express Scripts which will not be covered unless pre-certified by Express Scripts.
Non-targeted drugs will be covered without such authorization and will continue to be
dispensed with no further action by either you or the prescribing physician. If you
have a question regarding a drug in any of these therapeutic chapters, contact
Express Scripts to determine whether your drug is covered. You will be notified
directly by Express Scripts if you are affected by these rules.
Prior Authorization Rules
New prior authorization rules apply to certain therapeutic chapters of drugs; some
therapies in this section will be monitored for appropriate pharmacogenomics
parameters. These classes are miscellaneous immunological agents, central nervous
system/miscellaneous neurological therapy, biotechnology/adjunctive cancer therapy,
central nervous system/headache therapy, central nervous system/analgesics,
neurology/miscellaneous psychotherapeutic agents, and miscellaneous pulmonary
agents. In addition, anabolic steroids, high cost antibiotics, anti-emetics, antivirals,
narcotics, acne dermatologicals and topical pain medications may trigger a prior
authorization. Oral oncology medications will also be limited to ensure appropriate
use. Certain drugs within each chapter as determined by Express Scripts will only be
covered to the extent they are authorized by Express Scripts. If you have a question
regarding coverage for a drug in any of these therapeutic chapters, contact
Express Scripts. You will be notified directly by Express Scripts if you are
affected by these rules.
Split-Fill Program
Express Scripts’ split fill program applies to certain select specialty conditions where
participants often stop or change therapy early in treatment due to side effects or their
ability to tolerate treatment. This program will provide smaller initial fills (15-day
supply) and clinical support to participants as they begin their therapy. Coinsurance
and the per prescription maximum will be applied on a prorated basis so that the
participant will not be disadvantaged financially. This program is designed to help
manage side-effects, eliminate wasted medications and manage specialty drug costs.
Q. How does the Plan work?
Program
- Deductibles
- Annual Out-of-Pocket Limit
- No Lifetime Limit
- Mental Health Treatment
- Transition Benefits
- Examples
- In-Home Skilled-Nursing Care
A. In addition to outpatient prescription drugs, the Plan covers certain other expenses.
You and the Plan share costs for covered treatment and services. You must satisfy an
annual deductible before the Plan considers expenses for payment. Once the annual
deductible is met, the Plan's reimbursement level - when combined with Medicare - is
80% for the following expenses: covered charges that are paid by Medicare at less
than 80%, claims from outside the U.S., and in-home skilled nursing care. The Plan
also includes an annual out-of-pocket limit that includes your deductible. If you should
meet your annual out-of-pocket limit, the Plan's reimbursement level — when
combined with Medicare — is 100% of most covered charges for the rest of that
calendar year. For examples, please see chart on page 57.
Deductibles
Covered Expenses
Exclusions
Each year you must meet the deductible before any expenses, other than outpatient
prescription drugs, are eligible for reimbursement by the Plan.
You may become eligible for the Plan during a year in which you have met part or all
of the deductibles under another medical plan to which ExxonMobil contributes. Those
amounts apply to your deductible for the Plan, but do not apply to Medicare
deductibles.
Claims
Partners in Health
Information
Key Terms
Benefit Summary
Annual Out-of-Pocket Limit
The Plan protects you against most extremely high medical expenses. It does so by
limiting your annual out-of-pocket payments for most covered expenses to $3,000 per
person. Once you have spent $3,000 for covered expenses (including your
deductibles), the Plan's reimbursement level when combined with Medicare is 100%
for most covered charges during the remainder of that year.
For the year in which you become eligible for the Plan, this limit includes your out-ofpocket amounts for covered expenses while participating in any medical plan to which
ExxonMobil contributes.
page 19
Certain expenses do not count toward this out-of-pocket limit, including:




Your share of the costs of outpatient prescription drugs.
Your share of the cost of in-home skilled nursing care.
Charges above the Plan's reasonable and customary limits or the Medicare
limiting charge.
Charges not covered by the Plan, such as the difference in cost between a
private and semiprivate hospital room.
To receive credit for medical deductibles and out-of-pocket expenses paid under
another ExxonMobil plan, attach an explanation of benefits from that plan showing
up-to-date information about your expenses when filing your first claim.
No Lifetime Limit
There is no lifetime maximum for the Plan.
Mental Health Treatment
Like other types of covered medical expenses where the Plan may provide a benefit
even though Medicare does not, the Plan will reimburse 80% of reasonable and
customary charges for covered mental health treatment.
Medicare only pays for outpatient mental health care and professional services when
they are provided by a health care professional who can be paid by Medicare. You
should ask your provider if they accept Medicare payment before you schedule
treatment. If Medicare does not cover mental health treatment, the Plan will reimburse
80% of reasonable and customary charges. For example, mental health treatment
rendered outside the U.S. is not covered by Medicare; however, it is covered under
the Plan.
Transition Benefits
A transition benefit will be provided under the Plan when medically appropriate as
determined by Aetna. A transition benefit will be provided:




If such medical expenses were covered under a medical plan that was
sponsored by ExxonMobil, and
the covered person was participating in a medical plan sponsored by
ExxonMobil that covered such care immediately prior to the covered person
becoming Medicare eligible and moving into the Plan, and
expenses for such care are excluded from coverage by Medicare; and
a transition benefit request form is submitted to Aetna by the covered person's
treating physician.
page 20
Examples
Example 1 — Care in a Skilled-Nursing Facility and the Annual Out-of-Pocket
Limit:
This example assumes you have met all Medicare and Plan deductibles when,
following a period of hospitalization, you enter a Medicare-approved skilled-nursing
facility. You remain there 100 days. The facility charges and Medicare approves $300
a day. The total bill is $30,000. It also assumes you have covered out-of-pocket
expenses of $900 before you entered the skilled-nursing facility.
How the Benefit is Calculated
Medicare pays:


All of the first 20 days x $300 per day
All but $157.50 per day for days 21-100
($300 - $157.50) x 80 days
Total
$6,000
+ $11,400
$17,400
The ExxonMobil Plan pays 80% of covered charges minus the amount paid by
Medicare:
$300 per day x 100 days =
$30,000
$30,000 x .80 =
$24,000
$24,000 - $17,400 =
$ 6,600
The Preliminary Results
Medicare pays
$17,400
The ExxonMobil Plan pays
$ 6,600
You would pay
+ $ 6,000
Total
$30,000
The Actual Results - Applying Your Annual Out-of-Pocket Limit
Because the Plan limits your annual out-of-pocket expenses to $3,000, and you had
already incurred $900 in out-of-pocket expenses, the $30,000 bill is paid as follows:
Medicare pays
$17,400
The ExxonMobil Plan pays
$ 10,500
You would pay
$ 2,100
Total
$ 30,000
For skilled-nursing facility services to be considered for payment by the Plan, certain
requirements must be met, see page 29.
page 21
Example 2 — Major Surgery:
This example assumes a seven-day hospital stay for major surgery. In addition to
hospital charges, there are fees for a surgeon and an anesthesiologist. It also
assumes you have not met the Part A deductible but that you have met the Part B and
the Plan deductibles and that all providers accept Medicare assignment. Here is what
such a procedure might cost:
Medicare-approved hospital charges
$22,000
Medicare-approved amount for surgeon and
anesthesiologist
+$1,875
Total Medicare-approved amount
$23,875
How the Benefit Is Calculated
Medicare pays:


All of the Medicare-approved hospital charges except the Part A deductible
$22,000 - $1,260 (Part A deductible) = $20,740
80% of surgeon's and anesthesiologist's Medicare-approved amount $1,875
x .80 = $1,500
The Plan starts with the total Medicare-approved amount.



80% of Medicare-approved hospital charges
minus Medicare payment $22,000 x .80 = $17,600
$17,600 - $20,740 = $0
80% of surgeon's and anesthesiologist's bills minus Medicare payment $1,875
x .80 = $1,500
$1,500 - $1,500 = $0
You Pay



Medicare Part A deductible $1,260
20% of surgeon's and anesthesiologist's bills $1,875 x .20 = $375
Total = $1,635
The Results
In this example, the $23,875 in expenses is paid as follows:
Medicare pays
The Plan pays
You pay
Total
$ 22,240
$0
$1,635
$23,875
Of the total charges, Medicare paid 93%, and you paid the remaining 7%. Because
Medicare paid more than 80%, the Plan pays $0.
page 22
Example 3 — Traveling or Living Outside the United States:
Medicare does not generally cover medical care received while traveling or living
outside the United States. The Plan pays for certain covered expenses at 80% after
your annual medical deductible has been met. (See page 37, Expenses Incurred
Outside the United States, for more information).
In this example, you incur $22,000 in covered medical expenses while vacationing in
Europe.
Medicare does not cover these expenses.
The Plan pays 80% of covered charges after you pay the annual $300 deductible.
Total medical expenses
$22,000
$22,000 - $300 =
$21,700
$21,700 x .80 =
You Pay
 Plan deductible $300
 20% of $21,700 = $4,340
 Total = $4,640
The Preliminary Results
$17,360
Medicare pays
$0
The Plan pays
$17,360
You would pay
+ $4,640
Total
$22,000
The Actual Results - Applying Your Annual Out-of-Pocket Limit
Because the Plan limits your annual out-of-pocket expenses to $3,000, the bill is paid
as follows:
Medicare pays
$0
The Plan pays
$19,000
You would pay
+ $3,000
Total
$22,000
See the claims section for information about filing a claim and the Coordination of
Benefits section to learn how the Plan coordinates benefits.
page 23
In-Home Skilled-Nursing Care
With few exceptions, Medicare does not cover skilled-nursing care at home. If you
need nursing care at home, there are two types of care — one is covered by the Plan
and the other is not:


Skilled-nursing care is care that only licensed medical professionals can
provide. Feeding someone intravenously is an example of skilled-nursing care.
This type of care is covered by the Plan but generally not by Medicare.
However, Medicare does cover some intermittent short-term service if a
homebound patient needs occasional skilled-nursing care but only in limited
situations.
Custodial care is care which primarily helps people meet personal needs and
daily living activities — care which does not require the services of a licensed
medical professional. Helping someone eat, walk, bathe and dress — even if
ordered by a physician, and even if performed by a licensed professional —
are examples of custodial care. Custodial care is not covered by either
Medicare or the Plan.
A hospital, nursing home or other facility that mainly provides nursing or
rehabilitation services cannot be considered your home.
If you think you need in-home skilled-nursing care, contact Aetna immediately. Aetna
must pre-approve this care.
When considering whether nursing care is a covered expense, the critical question is:
Does the care require the presence of licensed medical personnel to perform,
observe, evaluate or teach?
If the answer is no, the Plan does not cover such care. The severity of a patient's
condition is not a factor. A patient with an ongoing and steadily deteriorating condition
may require constant attention, but may rarely require the services of a licensed
medical professional. Only services requiring such a professional are covered.
If the answer is yes, the Plan covers in-home skilled-nursing care if you meet these
conditions:



Care has been approved in advance by Aetna. (See Information Sources at
the front of this SPD.)
A physician must certify the care is medically necessary. The care given must
actually be skilled-nursing care as described on this page.
A registered nurse, a licensed practical nurse or a licensed vocational nurse
must provide the care.
After you meet the Plan's annual deductible, the Plan pays 80% of the reasonable and
customary cost of in-home skilled-nursing care with these limits:


The Plan covers as much as 24-hour-a-day care for up to 30 days in any
calendar year.
The Plan covers up to 16 hours a day for as long as the care is needed.
None of the money you spend on in-home skilled-nursing care counts toward
your annual out-of-pocket limit.
page 24
Example 1 — In-Home Skilled-Nursing Care:
In this example, you have satisfied plan requirements for in-home skilled-nursing care,
and you have met the annual deductible. You have not had any other charges for inhome skilled-nursing care during this calendar year. You need such care for four hours
a day for 42 days. Assuming this care costs $40 an hour, the daily cost is $160 a day.
The cost for 42 days is $6,720.
Medicare does not pay for this type of service.
The Plan pays 80% of covered charges:
$160 a day x 42 days =
$6,720
$6,720 x .80 =
$5,376
You pay 20% of covered charges for four hours of care a day:
$6,720 x .20 =
$1,344
The Results
The $6,720 bill is paid as follows:
Medicare pays
$0
The Plan pays
$5,376
Your share
$1,344
None of your share of the cost of in-home skilled-nursing care applies to your annual
out-of-pocket limit. The Plan will never pay 100% of in-home skilled-nursing care
expenses.
Q. What does it mean if a doctor accepts assignment?
Program
- Limiting Charge
- Examples
Covered Expenses
Exclusions
Claims
Partners in Health
Information
Key Terms
Benefit Summary
A. There are basically three Medicare contractual options for
physicians. Physicians may sign a participating agreement and accept
Medicare's allowed charge as payment in full for all of their Medicare
patients. They may elect to be a non-participating physician, which
permits them to make assignment decisions on a case-by-case basis
and to bill patients for more than the Medicare allowance for
unassigned claims. Or they may become a private contracting
physician, agreeing to bill patients directly and forego any payments
from Medicare to their patients or themselves. If your doctor or other
health care providers accept assignment, they accept the amount
Medicare approves as payment in full for that service or supply. You
must still pay the difference between the Medicare-approved amount
and the amount Medicare and the Plan pay (percentage co-payment).
If a doctor does not accept assignment, you may be required to pay the full amount of
the bill when you receive the service. Medicare will then reimburse you for its share of
the bill.
All doctors and medical suppliers must accept assignment in some situations, for
example, for clinical laboratory services covered by Medicare.
Limiting Charge
Medicare sets a limiting charge which is 15% of 95% of Medicare's approved
payment amount. As a general rule, doctors and other health care providers who do
not accept assignment for a particular service may not require you to pay more than
9.25% over the 100% Medicare-approved amount for that service. Under provisions of
the Social Security Act Amendments of 1994, you are not liable for and do not owe
amounts billed in these cases which are in excess of Medicare's limiting charge
(109.25% of the Medicare-approved amount). In cases where a physician is a nonparticipating Medicare provider, the plan benefit amount will be calculated using the
Medicare limiting charge (see example 2 below).
Exceptions to the above limits are services you get from doctors with whom you have
a private contract, or for certain items and services, such as vaccinations, ambulance
services and durable medical equipment. A private contract is an agreement between
you and your doctor who has decided not to give services through the Medicare
program. These physicians are referred to as "opt out" physicians because they have
"opted out of" the Medicare system. Private contracts must meet the following specific
requirements:
page 26

THE PHYSICIAN MUST SIGN AND FILE AN AFFIDAVIT AGREEING TO
FOREGO RECEIVING ANY PAYMENT FROM MEDICARE FOR ITEMS OR
SERVICES PROVIDED TO ANY MEDICARE BENEFICIARY FOR THE
FOLLOWING 2-YEAR PERIOD (either directly, on a capitated basis, or from
an organization that received Medicare reimbursement directly or on a
capitated basis);

Medicare does not pay for the services provided or contracted for;

the contract must be in writing and must be signed by you before any item or
service is provided;

the contract cannot be entered into at a time when you are facing an
emergency or an urgent health situation.
In addition, the contract must state unambiguously that by signing the private contract,
you:

give up all Medicare payment for services furnished by the "opt out" physician;

agree not to bill Medicare or ask the physician to bill Medicare;

are liable for all of the physician's charges, without any Medicare balance
billing limits;

acknowledge that Medigap or any other supplemental insurance will not pay
toward the services; and

acknowledge that you have the right to receive services from physicians for
whom Medicare coverage and payment would be available.
If you enter into such a private contract, Medicare will pay nothing toward the cost of
care and the Plan may pay up to 80% of reasonable and customary charges for
covered expenses.
Examples
Example 1 — A Medicare Participating (MED-PAR) Physician:
MED-PAR physicians are required to take assignment on all Medicare claims. In this
example, the MED-PAR physician must accept the Medicare-approved amount. The
physician's regular fee for this service is $120. The Medicare-approved amount for this
service is $100. You have met all the deductibles for the year.
Medicare pays 80% of its approved amount directly to the physician.
$100 x .80 =
$80
Aetna takes the Medicare-approved amount, calculates the Plan's 80% benefit, and
subtracts the amount Medicare pays. The Plan's benefit is calculated as follows:
$100 x .80 =
$80
$80 - $80 =
$0
page 27
The Results
Payment of the physician's fee is as follows:
Medicare pays
The Plan pays
You pay ($100 x .2)
Total
$80
$0
+$ 20
$100
The payments total $100. Because the physician is a MED-PAR physician who must
accept assignment, he or she, in effect, reduces the original fee by $20.
Example 2 — A Medicare Non-Participating (Non-Med-Par) Physician
We changed the preceding example in two important ways: The physician is a nonMED-PAR physician who determines whether to accept Medicare assignment on a
case by case basis. In this situation, the non-MED-Par physician does not accept
assignment and submits a fee of $120. The Medicare-approved amount for this
service for a non-MED-PAR physician (whether or not assignment is accepted) is 95%
of $100 or $95. Medicare's limiting charge for non-MED-PAR physicians is 115% of
the Medicare-approved amount ($95) or $109.25.
Medicare pays 80% of its approved amount. Medicare pays:
$95 x .80 =
$76.00
The Plan calculated benefit is 80% of Medicare's limiting charge ($109.25). The Plan's
benefit is calculated as follows:
$109.25 x .80 =
$87.40
This amount is reduced by Medicare's payment. The Plan then pays:
$87.40 - $76.00 =
$ 11.40
The Results
You will pay the physician's fee of $109.25 (the full limiting charge) at the point of
service and either you or the physician's office will need to file the claim with Medicare.
Medicare reimburses you
The Plan pays
You pay your physician ($109.25 less $87.40)
Total
$76.00
$ 11.40
+$ 21.85
$109.25
Example 3 — A Physician With Whom you have a Private Contract ("Opt-out
physician")
We changed the preceding example in one important way: You have signed a private
contract with the physician who submits a fee of $120. Since the Medicare-approved
amount is not available, the Plan bases payment on reasonable and customary
charges. The reasonable and customary amount for this service is $110. The Plan
pays 80% of reasonable and customary charges or in this case $88.
The Results
Medicare pays
The Plan pays $110 x .80 =
You pay your physician
Total
$0
$ 88
+$ 32
$120
Covered Expenses
Q. What types of medical services are covered by the Plan?
Program
A. The Plan covers a wide range of medically necessary health care
services, tests, treatments and supplies. Expenses must be approved
by Medicare, must be a covered expense under the Plan (listed below),
and are subject to certain Plan limitations.
In addition, the Plan may pay benefits for the following covered
expenses that are not eligible for reimbursement under Medicare Parts
A and B: outpatient prescription drugs (so long as the person is not
enrolled in Medicare Part D or a Medicare Part C plan that provides a
Medicare prescription drug benefit) and care received while traveling
outside the U.S.
Covered Expenses
Exclusions
The Plan may also pay limited additional benefits for covered expenses
beyond reimbursements by Medicare: in-home skilled-nursing care,
approved transition benefits and skilled-nursing facilities.
Claims
Partners in Health
Information
Key Terms
Benefit Summary
Note: Although Medicare pays for an expense, the Plan may not provide benefits.
All covered expenses must be medically necessary as defined by the Plan. See Key
Terms.
Expenses covered by the Plan are:








Acupuncture treatment performed by a recognized physician.
Anesthesia
Chiropractic services, performed by a licensed doctor of chiropractic who is
acting within the scope of his or her license.
Colonoscopies that are not for the purpose of routine screening, but are related
to the diagnosis and treatment of an injury or illness.
Emergency transportation provided by professional ambulance or air
ambulance for the first trip to or from the nearest hospital that can provide the
necessary care for each illness or injury or non-emergency transportation if
approved by Medicare.
Home-health care, if approved by Medicare.
Hospice care, if approved by Medicare.
Hospital charges for a semiprivate room, meals and general-duty nursing care
(as opposed to the services of a private-duty nurse).
page 29














Laboratory tests, analyses or X-rays made for diagnostic or treatment
purposes.
Outpatient prescription drugs unless you are enrolled in Medicare Part D.
Physical therapy prescribed in writing by a physician and performed by a
licensed physical therapist.
Radiation therapy including X-ray, radon, radium and radioactive isotope
treatments.
Routine pap smears and mammograms, if approved by Medicare.
Prescription smoking deterrent medications.
Prostate cancer screening, if approved by Medicare.
Second surgical opinion, and third surgical opinion, if first and second opinions
contradict.
Skilled-nursing care — in-home — prescribed in writing by a physician,
essential to medical care and approved in advance by Aetna. Remember, you
must need skilled-nursing care on a daily basis. Neither Medicare nor the Plan
will cover your expenses if you need skilled-nursing care only occasionally,
such as once or twice a week.
Skilled-nursing services and skilled-rehabilitation services provided in a skillednursing facility, if approved by Medicare. When your stay in a skilled-nursing
facility is covered by Medicare, the Plan helps pay for your care during
Medicare's 100 days of coverage. If you need skilled-nursing care for more
than 100 days, the Plan will continue to help pay for your care for as long as all
of the following conditions are met:
 You are confined to the Medicare-approved skilled-nursing facility
primarily because you need skilled care.
 Your condition requires daily skilled-nursing or skilled-rehabilitation
services which, as a practical matter, can only be provided in a skillednursing facility.
 Your need for skilled care continues for a consecutive number of days
without interruption beyond Medicare's 100 days.
 A physician certifies that you need, and you receive, skilled-nursing or
skilled-rehabilitation services on a daily basis.
 The care rendered in the Medicare-approved skilled-nursing facility is
primarily non-custodial care as determined by Aetna reasonably
applying Medicare standards.
Surgery or other medical care and treatment by physicians.
Treatment of fractures and dislocations of the jaw and for certain cutting
procedures in the mouth (other than care of the teeth and gums for extractions
and repairs).
Treatment of temporomandibular joint (TMJ) dysfunction, if approved by
Medicare.
Vaccinations for flu and pneumonia, if approved by Medicare and billed by your
physician. Shingles vaccinations, when medically necessary, may be covered
either as a medical benefit if billed by and provided in a hospital or a doctor's
office, or as a prescription drug program benefit if obtained from a pharmacy
and administered by a physician.
page 30
Equipment and Supplies







Appliances to replace lost physical organs or body parts or to help them
function if impaired.
Bandages and surgical dressings.
Blood (if not replaced) or other fluids injected into the circulatory system.
Drugs and medications available only with a physician's written prescription
and not otherwise excluded, and which are approved by the U.S. Food and
Drug Administration for the specific diagnosis.
Durable medical equipment rental for temporary therapeutic use such as:
 Hospital-type beds;
 Rental of a mechanical ventilator or other mechanical equipment for
treating respiratory paralysis;
 Oxygen and the equipment to administer it; and
 Wheelchairs.
The Plan may approve the purchase of these items, if the net cost would be
lower than renting.
Lenses — either first pair of contact lenses, or eyeglass lenses, or intraocular
lenses — if required in conjunction with cataract surgery.
A wig or hairpiece (synthetic, human hair or blends) ordered by a physician for
hair loss due to injury, disease, or treatment of a disease, or ordered in
connection with chemotherapy treatment.
Exclusions
Q. Are there expenses not covered by the Plan?
Program
A. Although the Plan covers many types of treatments and services, it
does not cover all. In addition, if you are enrolled in Medicare Part D
there are no benefits for outpatient prescription drugs under the Plan.
Covered Expenses
No benefits are payable under the Plan for any charge incurred for:
Services
Exclusions


Claims

Partners in Health



Information

Key Terms
Benefit Summary











Care not related to and for diagnosis or treatment of injury or sickness.
Care received in a government hospital, if the patient would not have to pay if
not covered by the Plan.
Cosmetic surgery, except necessary expenses in connection with treatment of
an accidental injury.
Custodial care which primarily helps people meet personal needs and daily
living activities, whether given in or out of a hospital, skilled-nursing facility,
nursing home or similar facility.
Dental treatments, except as noted on page 29.
Experimental or investigational procedures or other procedures not proven by
long-term clinical studies (see Key Terms on page 52).
Home-health care not approved by Medicare.
Hospice care not approved by Medicare.
In-home skilled-nursing care not approved in advance by Aetna.
Mental health condition that does not constitute the definition of a mental
health condition (see Key Terms on page 53).
Nurse's aides.
Private-duty nursing care in a hospital or extended-care facility.
Routine screening colonoscopies.
Routine eye examinations.
Routine hearing examinations.
Routine physical examinations and related diagnostic lab and radiology.
Self-Treatment
Skilled-nursing services and skilled rehabilitation services provided in a skillednursing facility not approved by Medicare.
page 32






Treatment for temporomandibular joint dysfunction (TMJ) not approved by
Medicare.
Treatment for which a covered person is not legally required to pay.
Treatment of conditions for which benefits are provided by worker's
compensation or similar laws.
Treatment of corns, calluses or toenails unless the procedure involves
removing a nail root or treating a metabolic or peripheral-vascular disease.
Treatment of weak, strained or flat feet or any metatarsalgia or bunion unless
the charges involve a cutting procedure.
Vaccinations, inoculations or preventive shots or any charges for examination
for checkup purposes, other than those specifically noted on page 29 or
covered by Medicare Part B.
Supplies







Dental prosthetic appliances or the fitting of such appliances, except as
required on account of accidental bodily injury to physical organs.
Eyeglasses.
Hearing aids. Even though this Plan does not provide coverage for hearing
aids, if you are considering the purchase of hearing aids, you may be able to
lower your out-of-pocket expenses through the HearPO® Discount Program or
the Hearing Care Solutions Discount Program. These programs are available
to Aetna participants and offer discounts on hearing exams, services and
hearing aids. If you go to a participating hearing discount center, your out-ofpocket expenses could be lower. To find a participating hearing discount
center location, you can visit www.aetna.com and search DocFind®, or you
can log in to Aetna Navigator® and click on "Find a Doctor, Facility or
Pharmacy" and then select "Hearing Discount Locations". To compare costs,
please call HearPO® at 1-888-HEARING
(1-888-432-7464 ) or Hearing
Care Solutions at 1-866-344-7756
and identify yourself as an Aetna
member.
Nutritional supplements, even if prescribed by a physician, except for the
treatment of phenylketonuria (PKU).
Non-prescription drugs, vitamins, or medicines that can be purchased over the
counter even if prescribed by a physician (referred to as legend vitamins,
except prenatal vitamins, Rocaltrol).
Orthopedic shoes, foot orthotics and other supportive devices for the feet not
approved by Medicare.
Outpatient prescription drugs purchased in excess of the allowed supply (34day supply for retail pharmacies and 90-day supply for mail order) per
prescription or refill.
Q. How does the Plan coordinate benefits with Medicare?
Program
Covered Expenses
Exclusions
Claims
Partners in Health
Information
Key Terms
Benefit Summary
A. The Plan treats Medicare coverage as another group plan for
purposes of coordinating benefits. Medicare is the primary plan under
which benefits are first payable. Plan benefits are secondary to
Medicare.
The Plan will pay benefits up to the Plan's reimbursement level when combined with
the benefits payable under Medicare. This means that benefits payable under
Medicare are subtracted from the Plan's calculated benefit amount and any remaining
amount is paid by the Plan. Plan benefits are determined assuming that you (and any
Medicare-eligible family members) are enrolled in both Parts A and B of Medicare
even if you (or your family members) have not actually enrolled.
The Plan coordinates benefits with other group plans. As used here, "group" does
not include such organizations as the American Association of Retired Persons
(AARP) or professional societies that offer their members insurance coverage. Nor
does it apply to personal insurance you may purchase as an individual (sometimes
called Medigap plans).
Medicare Advantage Plans
If you are enrolled in a Medicare Advantage Plan, including a group prepayment
plan (HMO) or a Medicare PPO that replaces your Medicare coverage, you are
eligible to receive benefits from the Plan for outpatient prescription drugs only if your
Medicare Advantage Plan does not provide a Medicare Prescription Drug benefit.
You will continue to be eligible for approved transition benefits from pre-65 medical
plans sponsored by ExxonMobil, in-home skilled-nursing care, and certain services
received outside of the U.S.
Some people are eligible for reimbursement from more than one group medical plan in
addition to Medicare. Other group plans that are coordinated with the Plan include any
group plan that is sponsored by or contributed to by another employer or labor union.
If you are covered by another group plan as defined above, you may be reimbursed by
Medicare, the Plan and other group plans. The Plan's benefits can bring you up to —
but not more than — 100% of your cost for covered expenses.
If a group medical plan covers either you or your spouse as an active employee,
Medicare requires that plan (that is, the active employee plan) to process claims
incurred by the employee and family members covered by that plan first. Only after
that can Medicare and the Plan process the claims.
For those providers that are unaffiliated with or have been deactivated by Medicare,
the ExxonMobil Medicare Supplement Plan will assume Medicare benefits.
page 34
If neither you nor your spouse is covered by a group medical plan as an active
employee, but both are covered by a plan for retirees, Medicare is primary and pays
benefits first. After Medicare pays, one of the retiree plans is considered the
secondary plan and the other is third. The secondary plan pays benefits next, without
considering benefits payable by the third plan. The third plan will apply its benefit
formula, up to the total allowable expenses covered by that plan. If the Plan is third, it
will pay remaining amounts under its rules but reimbursement from the Plan will not
make total benefits more than 100% of the covered expense.
If the retiree has a claim, Medicare is primary, the Plan is secondary and your
spouse's plan is third. If another plan covers the spouse and he or she has a claim, the
other plan is secondary and the Plan is third. However, no one may be covered twice
by the Plan, or by the Plan and any other plan to which ExxonMobil contributes. For
example, if you and your spouse both worked for the ExxonMobil, neither you nor your
children may be covered by both you and your spouse under any medical plan or
combination of plans to which ExxonMobil contributes.
Special rules apply to coordinating benefits for prescription drugs. See page 16 for
details.
Claims
Q. When must claims be filed?
Program
A. You must file claims no later than two years after the date you incur
the expense.
Covered Expenses
Exclusions
In most cases, you do not have to file claims if you follow procedures set out for
purchasing outpatient prescription drugs (pages 10-17) and enroll in the Medicare
Direct program (page 36). In the event you do need to file a claim, be sure to follow
the instructions described in this section.
Outpatient Prescription Drug Claims
You do not have to file a claim for outpatient prescription drugs if you:
Claims
- Outpatient Prescription Drug
Claims
- Other Medical Claims
- Medicare Direct
- Bills for Dental Services
- Expenses Incurred Outside the
United States
- Claim Denial and
Reconsideration
- Right of Reimbursement and
Subrogation
Partners in Health


Use a participating network retail pharmacy and identify yourself as an Express
Scripts participant; or
Purchase drugs through Express Scripts Pharmacy, the mail-order pharmacy.
Otherwise, you must submit a completed Direct Reimbursement Claim Form to
Express Scripts. You may obtain a claim form by calling Express Scripts at the number
shown in the front of this SPD.
Note: If you enroll in a Medicare Advantage (Part C) plan which provides a Medicare
prescription drug benefit or a Part D Prescription Drug Plan, you are not eligible to
submit claims for outpatient prescription drug benefits under the Plan.
Other Medical Claims
The Plan has contracted with Aetna to process claims for expenses other than
outpatient prescription drugs. If you need to file a claim:
Information

Key Terms

Benefit Summary



Submit a completed claim form which can be found at
www.exxonmobilfamily.com.
Include copies of what Medicare has paid (explanation of benefits, EOB).
If expenses submitted are not covered by Medicare, submit itemized bills and
Medicare's denial EOB.
Keep a copy of a submitted claim.
Keep your explanation of benefits.
page 36
You may obtain claim forms by contacting Aetna. See Information Sources at the
front of this SPD.
Medicare Part A Claims
On admission, a hospital generally asks if you have any coverage other than
Medicare. Show your Plan identification card.
The hospital usually bills Medicare first, the Plan second, and then bills you for the
balance.
Medicare Part B Claims
You or your provider or physician should submit your bills first to Medicare. If your
provider or physician submits the itemized bill to Medicare, be sure to get a copy.
Medicare processes the claim and sends you an explanation of benefits. Send the
explanation of benefits to Aetna along with a copy of the itemized bill. Be sure to
include the primary participant's Aetna Member Identification number. Aetna
processes the claim and sends you an EOB.
Medicare Direct
Medicare Direct, also known as Medicare Crossover, is a program providing you an
easier way to handle Medicare Part A and Medicare Part B bills for services received
such as office visits, outpatient hospital treatment and medical supplies.
With this program, Medicare forwards information about claims directly to Aetna. This
allows faster claims processing as well as less cost and paperwork for you. Plan
benefits are paid directly to the provider if you have assigned Medicare benefits to the
provider.
To enroll in Medicare Direct, contact Aetna Member Services. You may begin or stop
using this program at any time. Changes in your enrollment may take from 45 to 60
days to implement. There is no additional cost for using Medicare Direct.
Bills for Dental Services
This Plan does not cover dental services.
If you participate in the ExxonMobil Dental Plan, your claim will then be processed with
no further action required on your part.
page 37
Expenses Incurred Outside the United
States
If you receive medical care or mental health treatment when traveling or living outside
the United States, generally you must pay the medical or mental health treatment bills
first. For reimbursement, submit an itemized bill along with a claim form. If the original
bills are in a foreign language, you should obtain an English translation, if possible, of
the services rendered.
Bills should be submitted in the appropriate foreign currency. The claims administrator
will convert the bill to U.S. dollars.
Claim Denial and Reconsideration
If all or part of a claim is denied, the claims administrator will provide you with a written
explanation, including the Plan provisions supporting the denial and describing
additional information, if any, that may improve the claim's likelihood of being
approved. See Administrative and ERISA Information on page 44.
Right of Reimbursement and Subrogation
If your claim results from an accident or other injury that may be the fault of another
party, you must reimburse any amount paid by the Plan that you recover from the
responsible party. The Plan does not require reimbursement from any personal
medical insurance you may carry, such as medical coverage under your automobile
insurance. The Plan's right to subrogation and reimbursement also constitute an
"equitable lien" against any payments by such third party made or payable to you, your
covered family members, or anyone acting on your behalf, now or in the future,
regardless of how the payments are characterized. For example, injury, illness or
disability related payments that you receive for expenses such as past medical
expenses, future medical expenses, attorneys' fees and expenses, or other costs or
compensation, up to the full amount of all benefits paid by the Plan, must first be used
to repay the Plan before any money goes to you. By accepting benefits from the Plan
you are agreeing to this arrangement. The Plan's right to do this is called its right to
impose an equitable lien or constructive trust.
Partners in Health
Q. What is Partners in Health?
Program
Covered Expenses
Exclusions
Claims
Partners in Health
- 24 Hour Nurse Line
Information
Key Terms
Benefit Summary
A. Partners in Health is a program designed to help you improve your
health and to assist you in obtaining good health care, when care is
needed. It reflects a commitment by you and the company to good
health and quality care.
The resources offered through Partners in Health are available to you
at no additional charge. However, health care claims (e.g., doctor's
fees or facilities charges) are processed according to the Plan
provisions discussed earlier. (See the sections How to File Claims,
Covered Expenses, and Exclusions.)
page 39
24 Hour Nurse Line
Highly trained, licensed nurses are available by telephone at 1-800-556-1555 , 24hours a day, seven days a week to answer routine questions about your health, or
questions about a specific medical situation, condition or concern. However, these
nurses cannot diagnose medical conditions/ailments, prescribe medication or give
specific medical instruction. Topics discussed during your call may include services
and expenses covered or not covered under the Plan.
Q. Can coverage be continued after eligibility in the Plan ends?
Program
A. Yes. The Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA) entitles you and your covered family members to extend
medical benefits beyond the date your coverage would normally end.
Covered Expenses
Exclusions
Claims
Partners in Health
- Introduction
- What Is COBRA Coverage?
Information
Key Terms
Benefit Summary
Introduction
You are required to be given the information in this section because you are covered
under a group health plan (the Plan). This section contains important information
about your right to COBRA continuation coverage, which is a temporary extension of
coverage under the Plan. This section generally explains COBRA continuation
coverage, when it may become available to you and your family, and what you
need to do to protect the right to receive it.
The right to COBRA continuation coverage was created by a federal law, the
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA
continuation coverage can become available to you when you would otherwise lose
your group health coverage. It can also become available to other members of your
family who are covered under the Plan when they would otherwise lose their group
health coverage. For additional information about your rights and obligations under the
Plan and under federal law, you should review this SPD or contact Benefits
Administration at the telephone numbers or address listed under Benefits
Administration on page 43.
IMPORTANT: "Benefits Administration" references throughout this section change
depending on your status. Unless specifically stated otherwise, you should refer to the
correct Benefits Administration entity using the list below. The contact information for
each of these entities is shown on page 43.


Exxon, or Mobil, or Superior Oil, or ExxonMobil retirees, or their survivors, or
their family members refer to ExxonMobil Benefits Service Center; and
Former Exxon or ExxonMobil employees, or retirees, or their survivors, or their
family members, who have elected and are participating through COBRA, refer
to ExxonMobil COBRA Administration.
What Is COBRA Coverage?
Introduction
page 41
This section contains important information about your right to COBRA continuation
coverage, which is a temporary extension of coverage under such plan under certain
circumstances when coverage would otherwise end. This section generally explains
COBRA coverage, when it may become available to you and your family, and
what you need to do to protect the right to receive it. COBRA (and the description
of COBRA coverage described in this section) applies only to the group health plan
benefits offered and not to any other benefits offered under the Plans or by Exxon
Mobil Corporation.
The right to COBRA coverage was created by a federal law, the Consolidated
Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA coverage can become
available to you when you would otherwise lose your group health coverage under the
Plans. It can also become available to your spouse and children, if they are covered
under the Plans, when they would otherwise lose their group health coverage under
the Plans. For additional information about your rights and obligations under the Plans
and under federal law, you should review the Plans summary plan description or
contact the ExxonMobil Benefits Service Center.
You may have other options available to you when you lose group health
coverage. For example, you may be eligible to buy an individual plan through the
Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you
may qualify for lower costs on your monthly premiums and lower out-of-pocket costs.
Additionally, you may qualify for a 30-day special enrollment period for another group
health plan for which you are eligible (such as a spouse’s plan), even if that plan
generally doesn’t accept late enrollees.
What is COBRA Coverage?
COBRA coverage is a continuation of Plan coverage when coverage would otherwise
end because of a life event known as a "qualifying event." If a specific qualifying event
occurs and any required notice of that event is properly provided to the ExxonMobil
Benefits Service Center, COBRA coverage must be offered to each person losing
coverage who is a "qualified beneficiary." Your spouse and your children could
become qualified beneficiaries and would be entitled to elect COBRA if coverage
under the Plan is lost because of the qualifying event. Certain newborns, newly
adopted children, and alternate recipients under QMCSOs may also be qualified
beneficiaries. This is discussed in more detail in separate paragraphs below. Under
the Plan, qualified beneficiaries who elect COBRA must pay for COBRA coverage.
Who is entitled to elect COBRA?
If you are the spouse of a retiree, you will be entitled to elect COBRA if you lose
coverage under the Plan because you become divorced from your spouse. Also, if
your spouse (the retiree) reduces or eliminates your group health coverage in
anticipation of a divorce, and a divorce later occurs, then the divorce may be
considered a qualifying event for you even though your coverage was reduced or
eliminated before the divorce.
A person enrolled as the retiree’s child will be entitled to elect COBRA if he or she
loses coverage under the Plan because the child stops being eligible for coverage
under the Plan as a child.
When Is COBRA Coverage Available?
When the qualifying event occurs and the ExxonMobil Benefits Service Center is
notified, the Plan will offer COBRA coverage to qualified beneficiaries. You should
become familiar with the events which require notification to the ExxonMobil Benefits
Service Center.
You Must Give Notice of the Qualifying Events
In the event of divorce of the retiree and spouse or a child's losing eligibility for
coverage as a child, a COBRA election will be available to you only if you notify the
ExxonMobil Benefits Service Center within 60 days after the later of (1) the date of the
qualifying event; and (2) the date on which the qualified beneficiary loses (or would
lose) coverage under the terms of the Plan as a result of the qualifying event. You
must notify the ExxonMobil Benefits Service Center. If you fail to provide the notice
during the 60-day notice period, THEN ALL QUALIFIED BENEFICIARIES WILL LOSE
THEIR RIGHT TO ELECT COBRA.
page 42
Election of COBRA
Each qualified beneficiary will have an independent right to elect COBRA. Covered
retirees and spouses (if the spouse is a qualified beneficiary) may elect COBRA on
behalf of all qualified beneficiaries, and parents may elect COBRA on behalf of their
children. Any qualified beneficiary for whom COBRA is not elected within the 60-day
election period specified in the Plan’s COBRA election notice WILL LOSE HIS OR
HER RIGHT TO ELECT COBRA.
How long does COBRA coverage last?
COBRA coverage is a temporary continuation of coverage. COBRA coverage under
the ExxonMobil Medical, Medicare Supplement, Dental and Vision Plans can last for
up to a total of 36 months.
The COBRA coverage period described above is a maximum coverage periods.
COBRA coverage can end before the end of the maximum coverage period described
in this notice for several reasons, which are described in the Plans’ summary plan
descriptions which are found on the internet at www.exxonmobilfamily.com.
Are there other coverage options besides COBRA Continuation Coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other
coverage options for you and your family through the Health Insurance Marketplace,
Medicaid, or other group health plan coverage options (such as a spouse’s plan)
through what is called a “special enrollment period.” Some of these options may cost
less than COBRA continuation coverage. You can learn more about many of these
options at www.healthcare.gov.
More Information About Individuals Who May Be Qualified Beneficiaries
Children born to or placed for adoption with the covered retiree during COBRA
coverage period
A child born to, adopted by, or placed for adoption during a period of COBRA
coverage is considered to be a qualified beneficiary provided that the qualified
beneficiary has elected COBRA coverage for himself or herself. The child's COBRA
coverage begins when the child is enrolled in the Plan, whether through special
enrollment or open enrollment, and it lasts for as long as COBRA coverage lasts for
other family members of the retiree. To be enrolled in the Plan, the child must satisfy
the otherwise-applicable Plan eligibility requirements (for example, regarding age).
Alternate recipients under QMCSOs
A child of the covered retiree who is receiving benefits under the Plan pursuant to a
qualified medical child support order (QMCSO) received by Exxon Mobil Corporation
during the covered employee's period of employment with Exxon Mobil Corporation is
entitled to the same rights to elect COBRA as an eligible child of the covered retiree.
Cost of COBRA Coverage
A person who elects continuation coverage may be required to contribute up to 102%
of contributions to maintain the coverage. A person who elects continuation coverage
must pay the required contributions within 45 days from the date coverage is elected.
If You Have Questions
Questions concerning your Plan or your COBRA rights should be addressed to the
ExxonMobil Benefits Service Center. For more information about your rights under
ERISA, including COBRA, the Health Insurance Portability and Accountability Act
(HIPAA), and other laws affecting group health plans, contact the nearest Regional or
District Office of the U.S. Department of Labor's Employee Benefits Security
Administration (EBSA) in your area or visit the EBSA Web site at www.dol.gov/ebsa.
(Addresses and phone numbers of Regional and District EBSA Offices are available
through EBSA's website.) For more information about the Marketplace, visit
www.HealthCare.gov.
Keep Your Plan Informed of Address Changes
In order to protect your family's rights, you should keep the correct Benefits
Administration entity informed of any changes in your address as well as the
addresses of family members. You should also keep a copy, for your records, of any
notices you send to the ExxonMobil Benefits Service Center.
page 43
Notice Procedures for Qualifying Events
Notices of qualifying events from retirees and survivors must be made via the
ExxonMobil Benefits Web or by calling the ExxonMobil Benefits Service Center. Notice
is not effective until the ExxonMobil Benefits Web change is made or the properly
completed form is received.
FAILURE TO NOTIFY THE EXXONMOBIL BENEFITS SERVICE CENTER COULD
RESULT IN YOUR LOSS OF COBRA RIGHTS.
Phone Numbers:
Address:
Retirees, their survivors and covered family members call:
ExxonMobil Benefits Service Center
Monday – Friday except certain holidays
8:00 a.m. to 6:00 p.m. (U.S. Eastern Time
800-682-2847
(toll free)
800-TDD-TDD4
(833-8334) for the hearing
impaired
ExxonMobil Benefits Service
Center
P.O. Box 1014
Totowa, NJ 07512-1014
Administrative and ERISA Information
Q. What other information do I need to know about the Plan?
Program
Covered Expenses
Exclusions
A. This section contains technical information about the Plan and
identifies its administrator. It also contains a summary of your rights
with respect to the Plan and instructions about how you can submit an
appeal if your claim for benefits is denied.
The formal name of the Plan is the ExxonMobil Medical Plan. Effective December 21,
2007, the ExxonMobil Medicare Supplement Plan (EMMSP) merged with and into the
ExxonMobil Medical Plan (EMMP). The EMMP is the surviving Plan, provided,
however, that the EMMSP continues as a constituent part of the EMMP, and all
EMMSP benefits shall continue to be provided under the EMMSP document.
Claims
Partners in Health
Information
- Basic Plan Information
- Benefit Claims Procedures
- No Implied Promises
- Future of the ExxonMobil
Medicare Supplement Plan
- Your Rights Under ERISA
- Federal Notices
Key Terms
Benefit Summary
Plan Sponsor and Participating Affiliates
The ExxonMobil Medical Plan is sponsored by:
Exxon Mobil Corporation
5959 Las Colinas Blvd.
Irving, TX 75039-2298
All of Exxon Mobil Corporation's divisions and most of the major U.S. affiliates
participate in the ExxonMobil Medical Plan. A complete list of participating affiliates is
available from the Administrator-Benefits upon written request.
Certain employees covered by collective bargaining agreements do not participate in
the Plan.
Basic Plan Information
Plan Administrator
The Plan Administrator for the ExxonMobil Medical Plan is the Administrator-Benefits.
The Administrator-Benefits is the Manager-Global Benefits Design, Exxon Mobil
Corporation. You may contact the Administrator-Benefits at the following address.
Legal process may be served upon the Administrator-Benefits c/o Exxon Mobil
Corporation by serving the Corporation's Registered Agent for Service of Process,
Corporation Service Company (CSC).
Administrator-Benefits
ExxonMobil Medical Plan
P. O. Box 2283
Houston, TX 77252-2283
For service of legal process:
Corporation Service Co.
211 East 7th Street, Suite 620
Austin, Texas 78701-3218
page 45
Authority of Administrator-Benefits
The Administrator-Benefits (and those to whom the Administrator-Benefits has
delegated authority) has the full and final discretionary authority to determine eligibility
for benefits, to construe and interpret the terms of the Medical Plan in its application to
any participant or beneficiary, and to decide any and all claim appeals.
Claims Administrator
The claims administrator provides information about claims payment, and benefit predeterminations. The claims administrator is Aetna for medical claims and advanced
approval for in-home skilled-nursing care. Express Scripts is the claims administrator
for prescription drugs claims.
Claims Fiduciary and Appeals
The claims fiduciary is the person to whom all appeals are filed. The claims fiduciary is
Aetna for medical mandatory appeals, Express Scripts for prescription drug appeals
and the Administrator-Benefits for all non-prescription drug voluntary appeals. You
may contact the claims fiduciary as follows:
Medical Mandatory
Appeals:
Aetna
P. O. Box 14463
Lexington, KY 40512
Prescription Mandatory
and Voluntary Appeals:
Express Scripts
P. O. Box 650322
Dallas, TX 75265-0322
Voluntary Medical
Appeals:
Administrator-Benefits
ExxonMobil Medical Plan
P.O. Box 2283
Houston, TX 77252-2283
Type of Plan
The ExxonMobil Medical Plan is a welfare plan under ERISA providing medical
benefits.
Plan Numbers
The ExxonMobil Medical Plan is identified with government agencies under two
numbers: the Employer Identification Number, 13-5409005, and the Plan Number
(PN), 538.
Plan Year
The plan year is the calendar year.
Plan Funding
Benefits are funded through employee and employer contributions. Beginning January
1, 2014, benefits for certain retirees and their family members may be funded from an
I.R.C. Section 401(h) account established within the ExxonMobil Pension Plan and
Trust.
Benefit Claims Procedures
Filing a Claim
If you have a problem with a Plan benefit, contact the claims administrator's Member
Services. You must file a claim in writing to the appropriate claims administrator, either
Aetna Member Services for medical claims or Express Scripts for prescription drug
claims. Aetna is responsible for determining and informing you of your entitlement to a
benefit and any amounts payable to you with regard to medical services or supplies.
Express Scripts is responsible for determining and informing you of your entitlement to
a benefit and any amount payable to you under the prescription drug program.
Claims for benefits where the Plan provisions do not require approval before medical
care is obtained are the most common claims filed under the Plan. The claims
administrator will review your claim and respond within a designated response time,
usually 30 days after receiving your claim. If the claims fiduciary needs additional time
(an extension) to decide on your claim because of special circumstances, you will be
notified within the claim response period. An additional 15 days is all that is allowed. If
an extension is necessary due to incomplete information, you must provide the
additional information within 45 days from the date of receipt of the extension notice.
page 46
Denied Claims
If your claim for benefits is denied completely or partially, you, your beneficiary, or
designated representative will receive written notice of the decision. The notice will
describe:


The specific reason(s) for the denial; and
The process for requesting an appeal.
Filing a Mandatory Appeal
If your claim is denied, you, your beneficiary, or your designated representative may
appeal the decision to Aetna for medical benefit appeals or to the AdministratorBenefits for prescription drug program appeal. Your written appeal should include the
reasons why you believe the benefit should be paid and information that supports, or
is relevant to, your claim (written comments, documents, records, etc.). Your written
appeal may also include a request for reasonable access to, and copies of, all
documents, records and other information relevant to your claim. In the case of an
urgent care claim, you may request an expedited appeal orally or in writing. You must
submit your written appeal within 180 days from the date of the denial notice.
The review will take into account all comments, documents, records and other
information submitted relating to the claim, without regard to whether such information
was submitted or considered in the initial benefit determination. Aetna or the
Administrator-Benefits will respond to the appeal within 60 days.
If Aetna or the Administrator-Benefits needs additional time to decide on your claim
because of special circumstances, you will be notified within the claim response
period. However, if an extension is requested and granted, the law stipulates that no
additional time must be allowed.
If your appeal is denied, you will receive written notice of the decision. The notice will
set forth in plain language:




The specific reason(s) for the denial and the Plan provisions upon which the
denial is based.
A statement that you are entitled to receive, upon request and free of charge,
reasonable access to, and copies of, all documents, records and other
information relevant to the claim.
A statement of the voluntary appeal procedure and your right to obtain
information about such procedure or a description of the voluntary appeal
procedure.
A statement of your right to bring an action under section 502(a) of the
Employee Retirement Income Security Act (ERISA).
Statute of Limitations
After you have received the response of the mandatory appeal, you may bring an
action under section 502(a) of ERISA without requesting a voluntary appeal. The
statute of limitations or other defense based on timeliness is suspended during the
time that a voluntary appeal is pending. Any such lawsuits must be brought within one
year of the date on which the appeal was denied.
page 47
Filing a Voluntary Appeal
If your appeal is denied, you may then submit a voluntary appeal to the AdministratorBenefits. New information pertinent to the claim is required for the voluntary appeal to
be considered. You must submit your voluntary appeal within 30 days of the denial of
your mandatory appeal. The statute of limitations or other defense based on timeliness
is suspended during the time that a voluntary appeal is pending.
You will be notified within 15 days after your request was received whether the
information was considered new information. If it is determined that there is no new
information pertinent to your claim, you will be notified that your voluntary appeal will
not be considered. If it is determined that there is new relevant information, a decision
will be made within 60 days of the date the Administrator-Benefits receives your
request for a voluntary appeal.
No Implied Promises
Nothing in this SPD says or implies that participation in the Plan is a guarantee of
continued employment with the company.
Future of the ExxonMobil Medical Plan
ExxonMobil has the right to change, suspend, withdraw, amend, modify or terminate
the ExxonMobil Medical Plan or any of its provisions at any time and for any reason. A
change also may be made to required contributions and future eligibility for coverage,
and may apply to those who retired in the past, as well as those who retire in the
future. If any material changes are made in the future, you will be notified. For health
plans, certain rules apply regarding what happens when a plan is changed, terminated
or merged.
Expenses incurred before the effective date of a Plan change or termination will not be
affected. Expenses incurred after a Plan is terminated will not be covered. If a Plan
cannot pay all of the incurred claims and plan expenses as of the date the Plan is
changed or terminated, ExxonMobil will make sufficient contributions to the Plan to
make up the difference.
Your Rights Under ERISA
As a participant in the ExxonMobil Medical Plan, you have certain rights and
protections under the Employee Retirement Income Security Act of 1974 (ERISA).
ERISA provides that as a Plan participant, you shall be entitled to:
Receive Information About Your Plan and Benefits

Examine, without charge, at the office of the Administrator-Benefits and at
other specified locations, such as worksites and union halls, all documents
governing the Medical Plan, including collective bargaining agreements, and a
copy of the latest annual report (Form 5500 Series) filed by the Medical Plan
with the U.S. Department of Labor and available at the Public Disclosure Room
of the Employee Benefits Security Administration.
page 48


Obtain, upon written request to the Administrator-Benefits, copies of
documents governing the operation of the Medical Plan, including collective
bargaining agreements, and copies of the latest annual report (Form 5500
Series) and updated summary plan description. The administrator may require
a reasonable charge for the copies.
Receive a summary of the Medical Plan's annual report. The AdministratorBenefits is required by law to furnish each participant with a copy of this
summary annual report.
Prudent Actions by Medical Plan Fiduciaries
In addition to creating rights for Medical Plan participants, ERISA imposes duties upon
the people who are responsible for the operation of the employee benefit plan. The
people who operate the Medical Plan, called "fiduciaries" of the Medical Plan, have a
duty to do so prudently and in the interest of you and other Medical 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 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 Medical Plan documents or the latest
summary annual report from the Medical 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 Administrator-Benefits to provide the materials and pay you up to
$110 a day until you receive the materials, unless the materials were not sent
because of reasons beyond the control of the administrator.
If you have a claim and an appeal for benefits, which are denied or ignored, in
whole or in part, you may file suit in a federal court. Such lawsuit must be filed
in the United States District Court for the Southern District of Texas, Houston,
Texas, or in the United States District Court for the federal judicial district
where the employee currently works. If a retiree or terminee, the suit must be
filed in the last location worked prior to termination of employment.
Beneficiaries must also file in the same federal judicial district that the
employee or retiree would be required to file. Any such lawsuits must be
brought within one year of the date on which an appeal was denied. 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 Medical Plan, you should contact Aetna Member
Services via the telephone number on your ID card, or call Benefits Administration. If
you have any questions about this statement or about your rights under ERISA, or if
you need assistance in obtaining documents from the Administrator-Benefits, 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.
page 49
Federal Notices
Grandfathered Plan Intent
Exxon Mobil Corporation believes that the ExxonMobil Medicare Supplement Plan
(EMMSP) is a "grandfathered health plan" under the Patient Protection and Affordable
Care Act (PPACA). As permitted by the Affordable Care Act, a grandfathered health
plan can preserve certain basic health coverage that was already in effect on March
23, 2010. Grandfathered plan options under the EMMSP may not include all consumer
protections of the Affordable Care Act that apply to other plans.
Questions regarding which protections apply to the EMMSP and what might cause the
EMMSP to change from grandfathered health plan status can be directed to the Plan
Administrator at Administrator-Benefits, P.O. Box 2283, Houston, Texas 77252-2283.
You may also contact the Employee Benefits Security Administration, U.S.
Department of Labor at 1-866-444-3272
or www.dol.gov/ebsa/healthreform. This
website has a table summarizing which protections do and do not apply to
grandfathered health plans.
Women's Health and Cancer Rights Act of 1998
If you have a mastectomy, at any time, and decide to have breast reconstruction,
based on consultation with your attending physician, the following benefits will be
subject to the same percentage co-payment and deductibles which apply to other plan
benefits:




Reconstruction of the breast on which the mastectomy was performed;
Surgery and reconstruction of the other breast to produce a symmetrical
appearance; and
Prostheses and
physical complications in all stages of mastectomy, including lymphedema.
The above benefits will be provided subject to the same deductibles, co-payments and
limits applicable to other covered services.
If you have any questions about your benefits, please contact Aetna Member
Services.
Coverage for Maternity Hospital Stay
Under federal law, the Plan may not restrict benefits for any hospital length of stay in
connection with childbirth for the mother or newborn child to less than 48 hours
following a vaginal delivery, or less than 96 hours following a cesarean section, or
require that a provider obtain authorization from the Plan for prescribing a length of
stay not in excess of the above periods. The law generally does not prohibit an
attending provider of the mother or newborn, in consultation with the mother, from
discharging the mother or newborn earlier than 48 or 96 hours, as applicable.
Key Terms
Program
Covered Expenses
Exclusions
Accepts Assignment
A physician who accepts Medicare assignment agrees to accept no more
than the Medicare-approved amount as total payment for a service.
Close Window
Approved Amount
The amount on which Medicare bases its payments for a particular
service.
Close Window
Benefit Period
A period beginning when you enter a hospital and ending after you have
remained out of the hospital (or a skilled-nursing facility) for 60
consecutive days.
Close Window
Benefit Service
Generally, all the time from the first day of employment until you leave the
company's employment. Excluded are:
Close Window
Claims
Partners in Health



Information

Key Terms
Benefit Summary

Unauthorized absences;
Leaves of absence of over 30 days (except military leaves or
leaves under the Federal Family and Medical Leave Act);
Certain absences from which you do not return;
Periods when you work as a non-regular employee or as a
special-agreement person, in a service station, car wash, or carcare center operations; or
When you are covered by a contract that requires the company to
contribute to a different benefit program, unless a special
authorization credits the service.
Clinical Psychologist
A person specializing in clinical psychology who is licensed or certified by
an appropriate governmental authority. If there is no licensing or
certification in a particular area, he or she must be a member or fellow of
the American Psychological Association.
Close Window
Co-Payment and Co-Insurance
The portion of covered expenses you pay. For some services the coinsurance will be a percentage of the cost of the service once the
deductible has been satisfied. For outpatient prescription drugs there is a
percentage co-payment.
Close Window
page 51
Covered Charges or Covered Expenses
Expenses that are eligible for reimbursement under the Plan. Some
expenses must be Medicare-approved to be covered. All expenses must
meet Plan requirements including medical necessity.
Close Window
Custodial Care
Care primarily helping meet personal needs and daily living activities
such as walking, bathing, dressing, eating and giving medicine. Neither
Medicare nor the Plan covers custodial care, even if ordered by a
physician and provided by a licensed professional.
Close Window
Deductibles
The amount of covered expenses you incur before a plan begins to pay.
Medicare and the Plan have separate and different deductibles.
Close Window
Disability
You may qualify for Social Security and Medicare by virtue of a disability,
even if you are less than age 65.
Close Window
Eligibility Rule for Participants of the Comprehensive Medical
Expense Benefit Plan of Mobil Oil Corporation and the Superior Oil
Medical Plan
If you or your family members were participating in the Comprehensive
Medical Plan of Mobil Oil Corporation on March 31, 2004, and you were
Medicare eligible, you are a participant in the Plan effective April 1, 2004.
In addition, individuals who became your eligible family members (e.g.,
marriage) after March 31, 2004, are eligible.
Close Window
Eligible Family Members
Eligible family members are generally:
Close Window






The spouse of an eligible retiree;
The surviving spouse, who has not remarried, of a deceased
eligible retiree;
The surviving spouse, who has not remarried, of a deceased
employee;
The child of an eligible retiree;
The child, whose surviving parent has not remarried, of a
deceased employee or eligible retiree; or
A person who becomes an eligible family member of an
ExxonMobil eligible retiree by marriage after becoming eligible for
Medicare. To participate in the Plan under this provision, prior
group health coverage is not required. However, the person must
be added as a covered family member within 30 days of
becoming eligible.
page 52
Eligible Retiree
In the Plan, an eligible retiree is a person who:





Close Window
Retired with retiree status from ExxonMobil;
Retired with retiree status from Exxon;
Retired with retiree status from Mobil or Superior Oil;
Is a former Exxon employee who retired with retiree status from
ExxonMobil; or
Is a former Mobil employee who retired with retiree status from
ExxonMobil.
Retirees of Station Operators, Inc. doing business as ExxonMobil
Company Operated Retail Stores (CORS) are not eligible for coverage
under this plan.
Experimental or Investigational
A medical treatment or procedure, or a drug, device, or biological
product, is experimental or investigational if any of the following apply:



Close Window
The drug, device, or biological product cannot be lawfully
marketed without approval of the U.S. Food and Drug
Administration (FDA); and, approval for marketing has not been
given at the time it is furnished; Note: Approval means all forms of
acceptance by the FDA.
Reliable evidence shows that it is the subject of ongoing phase I,
II, or III clinical trials or under study to determine its maximum
tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as
compared with the standard means of treatment or diagnosis; or
Reliable evidence shows that the consensus of opinion among
experts regarding the drug, device, or biological product or
medical treatment or procedure, is that further studies or clinical
trials are necessary to determine its maximum tolerated dose, its
toxicity, its safety, its efficacy or its efficacy as compared with the
standard means of treatment or diagnosis. Reliable evidence shall
mean only:
 Peer reviewed, published reports and articles in the
authoritative medical and scientific literature;
 The written protocol or protocols used by the treating
facility or the protocol(s) of another facility studying
substantially the same drug, device, or biological product
or medical treatment or procedure; or
 The written informed consent used by the treating facility
or by another facility studying substantially the same drug,
device, or medical treatment or procedure.
Explanation of Benefits
A statement summarizing charges and payments for medical services
including the amount paid by Medicare or the Plan, and amounts
remaining to be paid.
Close Window
Home-Health Care
Medically necessary care and equipment provided at home by a
Medicare-certified agency on a part-time or intermittent basis by skilled
nurses, home-health aides, occupational, physical or speech therapists
and those providing medical social services.
Close Window
page 53
Hospital
An institution which is engaged primarily in providing medical care and
treatment of sick and injured persons on an inpatient basis at the
patient's expense which is:



Close Window
Accredited by the Joint Commission on Accreditation of Hospitals;
A hospital, psychiatric hospital or a tuberculosis hospital, as those
terms are defined in Medicare (or as may be amended by
Medicare in the future), which is qualified to participate and
eligible to receive payments under and in accordance with the
provisions of Medicare; or
An institution which:
 maintains on its premises diagnostic and therapeutic
facilities for surgical and medical diagnosis and treatment
of sick and injured persons by or under the supervision of
a staff of duly qualified physicians;
 continuously provides on its premises twenty four hour a
day nursing service by or under the supervision of
registered graduate nurses; and
 functions continuously with organized facilities for
operative surgery on its premises.
Limiting Charge
The maximum amount (currently 115% of 95%, or 109.25% of the
Medicare-approved amount) a physician may require a Medicare
beneficiary to pay for a covered service if the physician does not accept
assignment.
Close Window
Medically Necessary or Medical Necessity
Services or supplies that are: legal; ordered by a physician or clinical
psychologist; safe and effective in treating the condition for which
ordered; part of a course of treatment generally accepted by the
American medical community; of a proper quantity, frequency and
duration for treating the condition for which ordered; not redundant when
combined with other services and supplies used to treat the condition for
which ordered; not experimental, meaning unproven by long-term clinical
studies; and for the purpose of restoring health or extending life.
Close Window
Mental Health Condition
Neurosis, psychoneurosis, psychopathy, psychosis, or mental or
emotional disease or behavioral disorder or disturbance with a diagnosis
code from the American Psychiatric Association, Diagnostic and
Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV), or its
successor publication, and which is otherwise covered by Medicare. Such
a condition will be considered a mental health condition, regardless of
any organic or physical cause or contributing factor.
Close Window
Non-Custodial
See skilled-nursing care.
Close Window
Nurse
A registered graduate nurse (RN), a licensed vocational nurse (LVN), or a
licensed practical nurse (LPN).
Close Window
Other Services and Supplies
Services and supplies provided by a hospital or skilled-nursing facility
required to treat a patient. Excluded are fees for room and board and
fees charged by physicians, private-duty or special nursing services.
Close Window
page 54
Outpatient Prescription Drug
A prescription drug or medicine obtained through either a retail pharmacy
or through a mail order prescription service (including insulin and
associated diabetic supplies if acquired through a prescription). A
prescription drug or medicine, including injections, obtained or
administered in a physician's office or in a hospital are not considered
outpatient prescription drugs.
Close Window
Part A
That part of Medicare which pays certain hospital and skilled-nursing
facility bills.
Close Window
Part B
That part of Medicare which pays certain physician and other medical
bills.
Close Window
Part C
That part of Medicare that provides Medicare Advantage plans.
Close Window
Part D
That part of Medicare which pays certain outpatient prescription drug
bills.
Close Window
Physician
"Physician" means a person acting within the scope of his or her license
and holding the degree of Doctor of Medicine (M.D.), Doctor of
Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of Podiatry
(D.P.M.), Doctor of Optometry (O.D.), or Doctor of Chiropractic (D.C.), or
who is duly licensed as a Physician Assistant or Nurse Practitioner.
Close Window
Primary Participant
The participant whose Social Security number or Aetna Member
Identification Number is used for identification purposes. The primary
participant is the retiree, survivor or individual who elected COBRA
coverage. Covered family members use the primary participant's Social
Security number or Aetna Member Identification Number to access all
benefits.
Close Window
page 55
Reasonable and Customary
An amount which is less than or equal to the most common charge for a
particular medical service or supply in a particular geographic area. The
Plan bases its payments on the lesser of the actual amount charged, the
reasonable and customary amount, or the Medicare limiting charge,
except when the provider accepts assignment under Medicare (then the
Medicare-approved amount is used).
Close Window
Reserve Days
A Medicare term for available benefits after you use 90 days of hospital
coverage in any benefit period. You have a lifetime maximum of 60
reserve days.
Close Window
Retiree
Generally, a person at least 55 years old who retires as a regular
employee with 15 or more years of benefit service and who has not
thereafter recommenced employment as a covered employee or a nonregular employee. Retiree status may also be attained by someone who
is retired by the company and entitled to long-term disability benefits
under the ExxonMobil Disability plan after 15 or more years of benefit
service, regardless of age.
Close Window
Employees who terminate while non-regular (including extended parttime employees) are not eligible for retiree status regardless of age or
service.
Room and Board
Room, board, general-duty nursing and any other services regularly
furnished by the hospital as a condition of being hospitalized. It does not
include professional services of physicians or private-duty nursing.
Close Window
Skilled-Nursing Care
Care requiring services only licensed medical professionals can provide
in the home or in a skilled-nursing facility. Both Medicare and the Plan
cover such care when prescribed by a physician and determined to be
medically necessary. These types of services are sometimes called noncustodial nursing care.
Close Window
Skilled-Nursing Facility
A Medicare-approved institution meeting government-prescribed
standards for skilled-nursing care or skilled-rehabilitation services. The
Plan covers only Medicare-approved skilled-nursing facilities.
Close Window
Skilled Rehabilitation Services
Services only licensed rehabilitation professionals can provide. Both
Medicare and the Plan cover such care when prescribed by a physician
and determined to be medically necessary.
Close Window
Spouse; Marriage
All references to marriage shall mean a marriage that is legally
recognized under the laws of the state or other jurisdiction in which the
marriage takes place, consistent with U.S. federal tax law. All references
to a spouse or a married person shall refer to individuals who have such
a marriage.
Close Window
Survivor/Surviving Spouse
A surviving unmarried spouse of a deceased ExxonMobil regular
employee or retiree.
Close Window
About
Medicare
Supplement
Eligibility and
Enrollment
The
Prescription
Drug Program
Benefit Summary
The following pages provide a brief summary of the ExxonMobil Medicare Supplement
Plan amounts, and how payments are determined.
The Plan provides benefits up to the Plan's reimbursement level when combined with
Medicare. This means that Medicare's payments are subtracted from the Plan's
benefits and any difference is paid by the Plan. For more information, check the
Medicare Web site at www.medicare.gov.
Other Plan
Provisions
Accepting
Assignment
Covered
Expenses
Annual Deductible
Per covered individual
$300
Out-of-Pocket Maximum
Per covered individual
$3,000
Medical Individual Lifetime Maximum
Unlimited
Exclusions
Medical Services
80% of covered charges less any
Medicare payment
Coordination
of Benefits
Inpatient Hospital Services
Medicare payment
Outpatient Hospital Services
80% of Medicare approved charges
less any Medicare payment
Physician Services
Medicare payment
Claims
Partners in
Health
Continuation
Coverage
Administrative
and ERISA
Information
Key Terms
Benefit
Summary
Prescription drugs — Annual out-of-pocket maximums for prescription drugs-$2,500/individual and $5,000/family.
Retail Co-Pay* ** ***
(up to 34Maximum
3rd+ Retail (up to 90-day Maximum
day supply)
Per
Refill****
supply)
Per
Prescription
Prescription
Generic
30%
$ 50
55%
25%
$ 100
Drugs
Formulary
30%
$ 115
55%
25%
$ 200
Brand
Drugs
Non50%
$ 170
75%
45%
$ 300
Formulary
Brand
Drugs
* If using a non-network pharmacy, you pay 100% of the difference between the actual
cost and the discounted network cost plus retail co-pays.
page 57
** If your doctor prescribes a brand name drug for which a generic equivalent is
available, you will be responsible for paying the generic copay and the difference in the
cost between the brand name and the generic equivalent. The difference in the cost
between the brand and the generic does not apply to the annual out-of-pocket
maximum for prescription drugs.
*** You must present your Express Scripts Prescription Card or Social Security number
of the primary participant or benefits will be paid at the non-network level.
**** Additional 25% coinsurance does not apply to the annual out-of-pocket maximum
for prescription drugs.
Care Outside of the U.S.
80% of the covered charge
Home Health Care
80% of Medicare-approved charges
less any Medicare payment
Blood
Medicare payment
Skilled Nursing Facility Charges
Medicare payment
Hospice Care
Medicare payment
Mental Health Treatment
80% of reasonable and customary
charges less any Medicare payment
58
Claims Examples:
Claim 1
Eligible
Expenses
Medicare
Approved
Amount
Medicare
Deductible
Medicare
Coinsurance
$150
$147
$0.60
Medicare Paid based
Amount
True Out of Amount Paid by
on 80% benefit after
Applied to Pocket Expense EMMSP After
Medicare Part B
EMMSP Annual
Applied to
Medicare's
deductible ($147
Deductible
$3000 Annual Payment and
applied)
Out of Pocket
Applicable
Please reference your
Maximum
Yearly Plan
Medicare Handbook for
Deductible and
current
Coinsurance is
deductible/coinsurance
Applied
for the expenses
incurred
$2.40 ($150 - $147 =
$3.00 x80%)
Claim 2
$200
$0
$40
$160 ($200 x 80%)
Claim 3
$2,250
$0
$450
$1800 ($2250 x 80%)
Claim 4
Claim 5
$13,400
$1,000
$17,000
$0
$0
$147
$2,680
$200
$3,370.60
Paid By
Participant
$150.00
$147.60
$0.00
$147.60
$150.00
$40.00
$0.00
$40.00
$0.00
$450.00
$0.00
$450.00
$0.00
$2,362.40
$317.60
$2,362.40
$0.00
$0.00
$200.00
$0.00
$300
$3,000
$517.60
$3,000.00
$10,720 ($13,400 x
80%)
$800 ($1000 x 80%)
$13,482.40
EMMSP Plan
Benefit
Calculation:
Medicare's
Approved
Amount - Plan
Deductible Annual Plan
Coinsurance Medicare Paid =
Plan benefit
Payment
$150 applied to
deductible = $0
plan paid
$200 - $150
applied
deductible = $50
x 80% = $40 $160 Medicare
Paid = $0 plan
paid
$2250 x 80% =
$1800 - $1800
Medicare paid =
$0 plan paid
$13,400 x 80% =
$10,720
$3000 plan out
of pocket
maximum met at
$11037.60 $10,720
Medicare paid =
$317.60 plan
paid
$1000 x 100%
annual out of
pocket met =
$1000 - $800
Medicare
payment = $200
plan paid
$517.60
59
Page left intentionally blank
60
Page left intentionally blank

ExxonMobil Medicare Supplement Plan

Transcription

Similar documents

verdugo hills 11-11-15

SAVE 50%

STATEMENT OF PATIENT PRIVACY RIGHTS

Patient Forms

PDF - National Union of Public and General Employees

ameriflex - Montville.net

Saebo Long Term Care Program

Key Changes with Health Reform - The National Association of State

For Loving Couples - Encore Patented Vacuum Therapy for Erectile

mpbanneroct12.pub (Read-Only) - The Meeting Place Senior Center