Index

About Medicare Supplement

Eligibility and Enrollment

The Prescription Drug Program

Other Plan Provisions

Accepting Assignment

Covered Expenses

Exclusions

Coordination of Benefits

Claims

Partners in Health

Continuation Coverage

Administrative and ERISA Information

Key Terms

Benefit Summary
 

blue square 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.

Annual Deductible
Per covered individual		 $300
Out-of-Pocket Maximum
Per covered individual		 $3,000
Medical Individual Lifetime Maximum (Rx does not count towards the maximum, but Rx coverage ends when the maximum is reached) $3,000,000
Medical Services 80% of covered charges less any Medicare payment
Inpatient Hospital Services 80% of covered charges less any Medicare payment
Outpatient Hospital Services 80% of Medicare approved charges less any Medicare payment
Physician Services 80% of covered charges less any Medicare payment

Prescription drugs — Annual out-of-pocket maximums for prescription drugs--$2000/individual and $4000/family

  Retail Co-Pay* ** ***

Medco By Mail
  (up to 34-day supply) 3rd+ Retail Refill**** (up to 90-day supply)
  ($100 max per Rx) ($150 max per Rx)
Generic Drugs 30% 55% 25%
Formulary Brand Drugs 30% 55% 25%
Non-Formulary Brand Drugs 50% 75% 45%
* 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. 
** 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 Prescription Drug Identification Card (Medco Card) or the primary participant's identification number, 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 80% of covered charges less any Medicare payment
Skilled Nursing Facility Charges 80% of covered charges less any Medicare payment
Hospice Care 80% of covered charges less any Medicare payment
Mental Health Treatment 50% of Medicare-approved out patient charges: 80% of inpatient charges less any Medicare payment