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ExxonMobil Medicare
Supplement Plan SPD Updated Through 2008
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 2008 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.
Information Sources
When you need information, you may contact:
Prescription Drug Program - Claims processor for outpatient prescription drugs provided through mail order for long-term prescriptions or a local retail pharmacy for short-term prescriptions.
Phone Numbers:
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Address:
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- Medco By Mail - Mail-order Pharmacy:
800-695-4116
800-497-4641 (international, use appropriate country access code depending on country from which you are calling)*
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- Medco By Mail - Mail-order Pharmacy:
P.O. Box 650322
Dallas, TX 75265-0322
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- For questions regarding Retail Prescriptions - Medco:
800-695-4116
800-497-4641 (international, use appropriate country access code depending on the country from which you are calling)*
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- Non-network and Coordination of Benefits Retail Prescriptions Claims Processing:
Medco
P.O. Box 14711
Lexington, KY 40512 64063-2277
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*To be able to reach this international access line for Medco, 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 Medco's Web site at www.medco.com.
All Other Medical — The Claims
Administrator provides claim forms, claims payment information
and advance approval for in-home skilled-nursing care.
Claims processor for all medical expenses except outpatient prescriptions.
Phone Numbers:
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Address:
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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
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Aetna
P.O. Box 14586
Lexington, KY 40512
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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:
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Address:
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- 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
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ExxonMobil Benefits Service Center
P. O. Box 1014
Totowa, NJ 07512-1014
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ExxonMobil Sponsored Sites — Access to plan-related information
including claim forms for employees, retirees, survivors, and their family members.
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ExxonMobil Me, the Human Resources Intranet Site —
Can be accessed at work by employees.
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ExxonMobil Family, the Human Resources Internet Site —
Can be accessed from home by everyone at www.exxonmobilfamily.com.
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Retiree Online Community Internet Site — Can be accessed from home by
retirees
and survivors only at
www.emretiree.com.
- ExxonMobil Benefits Service Center at ACS
Internet Site —
Can be accessed from home by everyone at www.exxonmobil.com/benefits.
Introduction
The ExxonMobil Medicare Supplement Plan referred to as the Plan in this SPD is
a medical plan for retirees, survivors and their dependents who are 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 Medco
are paid fees to provide services such as processing claims, answering questions, and managing
the pharmacy network and Medco By Mail, the mail-order pharmacy service. Neither Aetna nor Medco
has any responsibility for funding benefits under the Plan.
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.
- An Index to help you locate specific items.
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.
Plan at a Glance
Eligibility
Retirees and their dependents who are 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 two 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.
Other Plan Provisions
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 pays up to $3,000,000 in benefits for the lifetime of each
covered person. The Plan covers some items Medicare may not —
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 17.
Accepting Assignment
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 24.
Covered and Excluded Expenses
The Plan provides benefits for many, but not all, types of treatment, care
and services. See page 26 for
Covered Expenses and page 29 for Exclusions.
Coordination of Benefits
The Plan treats Medicare coverage as another group plan for purposes
of coordinating benefits. See page
31.
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 33.
Partners in Health
Tools and resources are available to you and your dependents to help you better manage your health care. The health portal, health risk
assessment and 24-hour nurse line are available to all Plan participants. See
page 36.
COBRA
Your dependents who lose eligibility may continue medical coverage for a limited time
in certain circumstances. See page
38.
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 42.
Key Terms
This is an alphabetized list of words and phrases, with their definitions,
used in this SPD. See page 48.
Benefit Summary
Key features of the Plan and Medicare are highlighted. See page
54.
Index
You can use this to locate specific topics described in this SPD.
See page 56.
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