About the Retiree Medical Plan

This summary plan description (SPD) summarizes the ExxonMobil Retiree Medical Plan (the Plan) Aetna POS II A and B options. 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. You may obtain copies of these documents by making a written request to the Administrator-Benefits. ExxonMobil reserves the right to change benefits in any way or terminate the Plan at any time.  These options are governed by federal laws, not by state insurance laws.

Both Aetna POS II options are self-funded. There is no insurance company to collect premiums or underwrite coverage. Instead, contributions from you and ExxonMobil pay all benefits and expenses. Prior claims experience and forecasted expenses are used to determine the amount of money needed to pay future benefits.

Please read it carefully and refer to it when you need information about how the Plan works.

If you cannot find the answer to your question(s) in this SPD, refer to the Information Sources section, where you will be able to find the appropriate contact to support your needs.

This summary plan description (SPD) summarizes the ExxonMobil Retiree Medical Plan (the Plan) Aetna POS II A and B options. It does not contain all Plan details. The terms and conditions of the Plan are set forth in this SPD, the Plan Document, and the ExxonMobil Benefit Plans Common Provisions.  Together, these documents are incorporated by reference into the Plan Document and constitute the written instruments under with the Plan is established and maintained.  An amendment to one of these documents constitutes an amendment to the Plan.  You may obtain copies of these documents by making a written request to the Administrator-Benefits. ExxonMobil reserves the right to change benefits in any way or terminate the Plan at any time.  Where options are governed by federal laws, they will preempt state and local laws.

Unless otherwise noted, if there is a conflict between a specific provision under the Plan Document, the SPD or other written instrument, the Plan Document controls.  If the Plan Document is silent on a specific issue, then the SPD controls on that issue, except where the SPD refers to a specific written instrument, in which case the specific written instrument will control.  If both the Plan Document, ExxonMobil Benefit Plans Common Provisions, and SPD are silent, the terms of the Plan Document controls. 

Information Sources

Information Sources of the ExxonMobil Retiree Medical Plan – Aetna POS II A and B options

When you need information, you may contact one or more of the following sources. Please read carefully:

For claims administration and benefits information:

Contact Aetna for medical/surgical, behavioral health and substance use disorder benefits and claims information, including clinical guidelines, benefits predeterminations and providers in the Aetna Choice POS II network. Aetna also provides hospital precertification review for inpatient medical, behavioral health and substance use disorder services as well as for certain other medical services, tests, and equipment. Ask to speak to a health advocate nurse for ongoing consultation and referral services.

Contact Express Scripts for pharmacy benefits and claims information, including clinical guidelines, benefits predeterminations, and providers in the Express Scripts pharmacy network. Express Scripts also provides precertification review for certain pharmacy services, medications, and equipment. Ask to speak to a Therapeutic Resource Center (TRC) pharmacist for ongoing consultation and referral services.

Phone numbers and addresses:

Aetna Member Services 
800-255-2386
Monday – Friday 8:00 a.m. to 6:00 p.m. 
(U.S. Central Time), except certain holidays
Automated Voice Response - 24 hours a day, 7 days a week

Aetna 
P. O. Box 981106 
El Paso, TX 79998-1106
To visit Aetna’s website: www.aetna.com

Express Scripts
800-695-4116
800-497-4641 (international, use appropriate country access code depending on country from which you are calling)

Express Scripts Home Delivery
P.O. Box 66577
St. Louis, MO 63166-65777

Direct Reimbursement Claim Form:
Express Scripts
ATTN: Commercial Claims
P.O. Box 14711
Lexington, KY 40512-4711
Direct Reimbursement Claim Forms may also be faxed to: 608 741-5475
To visit Express Scripts website: www.express-scripts.com.

ExxonMobil Benefits Service Center
Toll-Free: 1-800-682-2847 or 800-TDD-TDD4 (833-8334) for hearing impaired
Hours: 8 a.m. to 6 p.m. ET, Monday through Friday, except certain holidays
Address: 
P.O. Box 18025
Norfolk, VA 23501-1867

Effective January 2, 2024, Alight will be the new administrator of ExxonMobil’s health, life insurance, and pension plans. If you need assistance, please contact:

ExxonMobil Benefits Service Center
Phone: 833-776-9966
Hours: 8am – 4pm CST, Monday through Friday, except certain holidays
Your Total Rewards portal: digital.alight.com/exxonmobil

Alight Mobile app  (available through Apple App Store or Google Play)

Address:
Dept 02694, PO Box 64116, The Woodlands, TX, 77387-4116

ExxonMobil sponsored sites - Access to plan-related information including claim forms for 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 Internet Site — Can be accessed by everyone at www.exxonmobil.com/benefits.

Eligibility and enrollment

ExxonMobil Retiree Medical Plan – Aetna POS II A B options

Most U.S. retirees and eligible family members of Exxon Mobil Corporation and participating affiliates are eligible for the Aetna POS II A and B options.

Generally, you are eligible if:

• You are a retiree
• You are a survivor/surviving spouse, which means an eligible family member of a deceased retiree, or employee
• You are a Long Term Disability Retiree and are not eligible for Medicare Part A or B.
• You are a long-term Expatriate with U.S. Company-sponsored green card (also called permanent resident visas or PRVs) who retires/retired at the end of your current U.S. assignment on or after July 1, 2020 and remain in the U.S. with a valid PRV. If you choose not to enroll, there will be no opportunity to enroll at a later point in time during retirement.

You are not eligible for the Retiree Medical Plan if:

• You participate in any other employer medical plan to which ExxonMobil contributes.
• You are eligible for coverage under the ExxonMobil Medical Plan.
• You fail to make any required contribution toward the cost of the Plan.
• You fail to comply with general administrative requirements including but not limited to enrollment requirements.
• You lost eligibility as described under the Loss of eligibility section.
• You are eligible for Medicare as your primary plan.

Eligible family members

You may also elect coverage for your eligible family members including:

• Your spouse. When you enroll your spouse for coverage, you may be required to provide proof that you are legally married.
• Your child(ren) under age 26, even if Medicare eligible. Coverage ends at the end of the month in which they reach age 26. If your situation involves a family member other than your biological or legally adopted child, call the Benefits Service Center.
• Your totally and continuously disabled child(ren)who is over age 26 and  who is incapable of self-sustaining employment by reason of mental or physical disability, that occurred prior to otherwise losing eligibility and meets the Internal Revenue Service's definition of a dependent, and is not eligible to be enrolled in Medicare as their primary medical plan.
• A child or spouse of a Medicare-eligible retiree or survivor enrolled in the Medicare Primary Option (MPO), as long as that spouse or child over age 26 are not eligible to be enrolled in Medicare.

Effective January 1, 2019, a totally and continuously disabled child over age 26 of a retiree, deceased retiree, or deceased employee who is entitled to be enrolled in Medicare as their primary medical plan is not eligible for coverage under the ExxonMobil Retiree Medical Plan, or any other ExxonMobil health plan available to retirees (such as Dental and Vision coverage). 

Refer to Key Terms for definitions of eligible family members, child, suspended retiree, and spouse.

The Administrator-Benefits determination of eligibility is final and no appeals are available, including decisions regarding whether a child age 26 or older meets the clinical definition of totally and continuously disabled. All decisions by Aetna confirming a dependent no longer meets the clinical definition of totally and continuously disabled are final.

Suspended retiree

A person who becomes a retiree due to incapacity within the meaning of the ExxonMobil Disability Plan and who begins long-term disability benefits under that plan, but whose benefits stop because the person is no longer incapacitated is a suspended retiree and not eligible for coverage until the earlier of the date the person:

• Reaches age 55, or
• Begins his or her benefit under the ExxonMobil Pension Plan at which time the person is again considered a retiree and may enroll.

The family members of a deceased suspended retiree will be eligible for coverage under this Plan only after the occurrence of the earlier of the following:

• The date the suspended retiree would have attained age 55; or
• The date a survivor begins receiving a benefit due to the suspended retiree's accrued benefit from the ExxonMobil Pension Plan.

Special eligibility rules

A person who otherwise is not a spouse but who, as a dependent of a former Mobil employee who participated in or received benefits under a Mobil-sponsored plan or program prior to March 1, 2000, is considered an eligible dependent as long as that person's eligibility for coverage as a dependent under a Mobil-sponsored plan would have continued.

Classes of coverage

You can choose coverage as an:

• Individual only (Retiree, Spouse, Surviving Spouse, Surviving Child),
• Retiree and spouse,
• Individual and child(ren), or
• Retiree and family.

There are also classes of coverage for surviving spouses and family members of deceased employees and retirees, and spouses and family members of retirees covered by the Medicare Primary option and Medicare Supplement Plan option.

Each class of coverage described in this section has its own contribution rate. Retirees and survivors receiving monthly benefit checks from ExxonMobil pay by deductions from these checks on an after-tax basis. Other retirees or survivors and participants with continuation coverage pay by check or by monthly draft on their bank account.  You must complete the forms required for payment of contributions within 60 days of enrollment in the Plan.  If you fail to do so, coverage will be retroactively suspended and you will be prevented from enrolling at a future date until you pay past contributions.

Double coverage

No one can be covered more than once in the Retiree Medical Plan. You and a family member cannot both enroll as retirees and elect coverage for each other as eligible family members. If you and your spouse or adult child are both retirees you may both be eligible for coverage. Each of you can be covered as an individual retiree, or one of you can be covered as the retiree and the other can be an eligible family member. Also, if you and your spouse have children, each child can only be covered by one of you.

How to enroll

Retirees have three opportunities to enroll in the ExxonMobil Retiree Medical Plan: 

1. At retirement,
2. If you have waived coverage (see Other Employer Sponsored Coverage – Waiving EMRMP) and later lose coverage under another employer coverage, or
3. When first eligible to be enrolled in Medicare as your primary plan.

There is no opportunity to enroll yourself in the Plan at any other time, including during annual enrollment. If you are under 65 at the time of your retirement or you are about to turn 65 while participating in the Retiree Medical Plan option, and have other employer coverage, you must waive coverage to maintain eligibility (please refer to the Other Employer Sponsored coverage - Waiving EMRMP section).

Eligible family members may be added to your coverage at one of the three enrollment opportunities listed above or if you experience a change in status. Eligible family members cannot be added to your coverage at any other time, including during annual enrollment.

All enrollments must be completed within 60 days of the enrollment event. Coverage is effective the first of the month following receipt of your election by the ExxonMobil Benefits Service Center (EMBSC), except in the case of a birth or adoption of a child when changes will be effective on the date of the birth or adoption.

You can enroll either online or by phone. To enroll online go to www.exxonmobil.com/benefits. To enroll by phone, call the Benefits Service Center at 800-682-2847.

You may be requested to provide documents at some future date to prove that the family members you enrolled were eligible (e.g. marriage certificate, birth certificate). If you fail to provide such requested documents within the required time period, coverage for the family members will be cancelled the first of the following month. If you enroll family members who are not eligible for the Plan, for instance, by covering children who do not meet the eligibility requirements, you may lose eligibility for yourself and your family under all ExxonMobil health plans.

Changing your coverage

You may cancel your coverage at any time; however, you may not re-enroll unless you experience one of the enrollment opportunities listed above. Coverage will be terminated at the end of the month in which your elected change has been received.

Eligible family members may also be removed from your coverage at any time; however, they may not be reinstated unless you experience a corresponding change in status or you wait until one of the enrollment opportunities listed above.

Note: You are required to remove family members who are no longer eligible for coverage at the time of loss of eligibility. To remove an ineligible family member (a divorced spouse for example) you are required to notify the Benefits Service Center within 60 days of the loss of eligibility or your ineligible family members will not be entitled to COBRA benefits continuation. If you fail to notify the Benefits Service Center, you may also lose eligibility for yourself and your family under all ExxonMobil health plans. In addition, you will be required to reimburse the Plans for any claims paid after the loss of eligibility for any ineligible person(s).

Post-Retirement changes in status

If this event occurs...	You may...
Marriage	Add your spouse and any new eligible family members.
Divorce – Retiree and spouse enrolled in ExxonMobil health plans	You are required toremove coverage for your former spouse and any stepchild(ren).
Divorce – Retiree loses coverage under spouse’s health plans	Enroll yourself and add other eligible family members who might have lost eligibility for spouse’s plan.
Gain a family member through birth, adoption or placement for adoption, sole court appointed legal guardian, or sole managing conservator	Add new eligible family members.
Death of a spouse	You must remove coverage for any stepchild(ren) unless you are their court appointed legal guardian or sole managing conservator.
If you have waived coverage and you or a family member loses eligibility under another employer's group health plan	Enroll yourself and add eligible family members.
You lose eligibility because of a change in your employment status, e.g., retiree to rehired employee.	Your Retiree Medical Plan participation will automatically be suspended at the date of rehire and you will be covered under the ExxonMobil Medical Plan.
You gain eligibility because of a change in your employment status, e.g., employee to retiree.	Enroll yourself and add eligible family members.
You change your residence affecting your eligibility to participate in your elected Retiree Medical Plan option	Change your Retiree Medical Plan option.
You or your spouse become entitled to enroll in Medicare as your primary plan	You or your spouse lose eligibility under the Retiree Medical Plan options but may enroll in the Medicare Primary Option.
Your disabled child over age 26 becomes entitled to enroll in Medicare as their primary plan (even if your child is not enrolled yet in Medicare)	You must remove coverage for your child.
Judgment, decree, or other court order requiring you to cover a family member. (e.g. begin a QMCSO)	Add new eligible family members.

 

Other Employer Sponsored coverage – Waiving EMRMP

There are important changes to the ExxonMobil Retiree Medical Plan (EMRMP) relating to waiving coverage. Please read this section carefully, as there may be an impact on your future coverage. Effective January 1, 2023, a new waiver process is in place to provide retirees and eligible family members with the option to waive coverage under the EMRMP when you or your eligible family members choose to participate in other employer-sponsored coverage.  By completing the waiver, you will reserve your right to participate in the EMRMP at a later date upon proof of loss of coverage in the other employer’s plan, as long as the EMRMP is still available at that time. See scenarios below and how the waiver and reservation of rights apply:

How to Waive EMRMP Coverage at the Time of Your Retirement

If you have been actively participating in the ExxonMobil Medical Plan or the ExxonMobil International Medical and Dental Plan at the time of your retirement and you have access to other employer-sponsored coverage through either your own active employment or as a dependent of your spouse’s active employment, you/your spouse can choose to waive EMRMP coverage and reserve your right to participate upon the loss of such other coverage.

You must waive EMRMP coverage no later than 60 days from your retirement effective date. There are 2 ways to waive: you can contact the EMBSC at 1-800-682-2847 and indicate you want to waive, or you may also waive online in the EM Benefits portal by choosing the qualifying event named “Other Employer Sponsored Coverage”. 

In order to enroll at a later date, you and/or your spouse will need to provide proof of loss of coverage and meet the following requirements: 

1.          If you (and/or your spouse) lose other employer-provided coverage and you or your spouse are under 65 years of age, you have 60 days from loss of coverage to enroll in any of the Retiree Medical Plan options (Aetna POS II A or B, Aetna Select, Cigna OAPIN) of the EMRMP.

2.          If you (and/or your spouse) lose coverage and are 65 years of age or over, you or your spouse will have 90 days from loss of coverage to enroll in the Medicare Primary Option (MPO) of the EMRMP. Please refer to section of Eligibility and Enrollment of the Medicare Primary Option for a list of the MPO requirements.  You must meet each of the requirements within the 90 days from the loss of coverage.

If you do not meet all requirements to enroll in the applicable option by the deadlines above, you/your spouse will not be eligible to enroll in the EMRMP at a later date.

How to Waive EMRMP Coverage if you Acquire Other Employer-Sponsored Coverage After Retirement

If after you have begun participating in the EMRMP you acquire other employer sponsored health plan coverage through either your own active employment or as a dependent of your spouse’s active employment, you/your spouse can notify the EMRMP by contacting the EMBSC of your change in status and waive coverage under the EMRMP. There are 2 ways to waive: you can contact the EMBSC at 1-800-682-2847 and indicate you want to waive, or you may also waive online in the EM Benefits portal by choosing the qualifying event named “Other Employer Sponsored Coverage”.  You must waive no later than 60 days from loss of coverage from the EMRMP. 

You/your spouse can then enroll in the EMRMP at a later date when the other employer sponsored health plan ends, with proof of loss of coverage.  As described in subsections 1 and 2, above.

Important note: A waiver form is different from a cancellation form, while the waiver form allows you to preserve your eligibility for future enrollment (if the EMRMP is still an available option at that time), the cancellation form is final and you will no longer be eligible to enroll in any of the EMRMP options at a later date.

Dependent Children/Disabled Dependents

If your dependent child is participating in other-employer sponsored coverage at the time of your retirement or during your retirement and the child is under the age of 26, this children will be eligible upon the proof of loss of coverage to participate in the EMRMP and no waiver form is needed, assuming the child meets eligibility criteria. 

No waiver process is available for dependents who were participating the EMMP or EMRMP as a disabled dependent over the age of 26 and who terminate coverage anytime at or after your retirement.  Once a disabled dependent’s coverage is terminated for loss of eligibility or otherwise, the over age 26 child will not be eligible to participate in the EMRMP at a later date.

Survivor Coverage

If you are a surviving spouse or surviving family member participating in the EMRMP, you are not eligible to waive coverage and reserve your right to participate at a later date when you acquire other employer-sponsored coverage or are hired by ExxonMobil.

Changes at retirement

If you were enrolled in the ExxonMobil Medical Plan, your enrollment and your covered family members will transfer to the ExxonMobil Retiree Medical Plan. If you were enrolled in a Aetna POS II A or B option as an employee, you will maintain claims, deductibles, and out-of-pocket history as a retiree, regardless of whether you choose Aetna POS II A and B. However, as a retiree, you will pay your contributions on an after-tax basis via payroll deduction (if eligible), check, or bank draft.

If you are not covered by a medical plan to which ExxonMobil contributes and would like to enroll in the ExxonMobil Retiree Medical Plan, or if you would like to change your Retiree Medical Plan option, you must do so within 60 days of your retirement date. Coverage is effective the first of the month following receipt of your election by the Benefits Service Center.

Annual enrollment

Each year, during the fall, ExxonMobil offers an annual enrollment period. During this time, you can switch from your current Retiree Medical Plan option to another available option. Changes elected during annual enrollment take effect the first of the following year.

Retirees cannot enroll in health benefitsor add eligible family members during annual enrollment. Eligible family members can only be added to your coverage at one of the enrollment opportunities listed above or if you experience a corresponding change in status. 

Do not wait to remove a family member who loses eligibility; they should be removed as soon as eligibility is lost at the time of loss of eligibility and not at annual enrollment. For consequences for covering an ineligible family member, see Loss of Eligibility.

If you do not want to make any changes, you don’t have to do anything during annual enrollment to continue with your current plan selection for the following year. 

Other situations that may affect your coverage

Change in coverage costs or significant curtailment

If the cost for coverage charged to you significantly increases or decreases during a plan year, you may be able to make a corresponding prospective change in your election, including the cancellation of your election. If you choose to cancel your elected coverage option, you may be able to elect coverage under another Retiree Medical Plan option.

This provision also applies to a significant increase in plan option deductible or copayment.

If the cost for coverage under your spouse's medical plan significantly increases or there is a significant curtailment of coverage that permits revocation of coverage during a plan year and you drop that coverage, you will be able to sign up for retiree medical coverage for yourself and your eligible family members.

Addition or improvement of plan options

If a new Retiree Medical Plan option is added or if benefits under an existing option are significantly improved during a plan year, you may be able to cancel your current election in order to make an election for coverage under the new or improved option.

Loss of option

If a service area under the Plan is discontinued, you will be able to elect either to receive coverage under another Retiree Medical Plan option providing similar coverage or to cancel medical coverage altogether if no similar option is available. For example, if an option is discontinued, you may elect another option that has service in your area or you may elect to participate in the RMP POS II option. You may also cancel medical coverage altogether.

If a covered family member lives away from home

If you live in a POS II network area and you have a covered family member who lives away from home (for instance, you have a child away at school), your family member's ZIP code determines the level of benefits the Plan pays.

Call Aetna Member Services with your family member's ZIP code to find out if Aetna has a Choice® POS II network in the area. If a network is there, you can contact Aetna Member Services, choose Find a Doctor on Aetna’s member website (www.aetna.com), or launch the Aetna mobile app to identify providers in the area. Here is how benefits are determined:

• If your family member receives care from a network provider, benefits will be paid at the network level.
• If your family member lives in a POS II network area but uses non-network providers, benefits are paid at the non-network level.
• If your family member lives in an area where the POS II network is not available and receives care from a non-network provider, benefits are paid at the out-of-network area level — regardless of whether you live in a network or out-of-network area — if you have notified Aetna of your family member's address.

Upon request, Aetna Member Services will provide an identification card for your family member.

If you or your covered spouse become eligible for Medicare

If you are a retiree, you and your family members who are not eligible for Medicare participate in the Retiree Medical Plan.  When you (as a retiree) or a covered spouse of a retiree becomes eligible for Medicare as your primary plan, you or your spouse will no longer be eligible for the Aetna POS II A/B, Aetna Select, and Cigna OAPIN options in the Retiree Medical Plan, but you or your spouse may be eligible to enroll in the Medicare Primary Option (MPO). If you fail to enroll in the MPO when first eligible or fail to waive coverage due to being enrolled in another employer sponsored health plan, then you or your covered spouse will not be able to enroll at a later time without proof of having other employer provided medical coverage immediately prior to enrollment.

If you die

If you die while enrolled, your covered eligible family members can continue coverage through the Retiree Medical Plan. Eligibility continues for your spouse until your spouse remarries, or becomes eligible for Medicare.  Upon eligibility for Medicare as their primary plan, your spouse can continue coverage through the Medicare Primary Option.

Children of deceased employees or retirees may continue participation in the Retiree Medical Plan as long as they are an eligible family member and are not eligible to be enrolled in Medicare as their primary plan. If your surviving spouse remarries, eligibility for your stepchildren also ends. Special rules may apply to family members of individuals who become retirees due to disability. See Suspended retiree below.

If you become a suspended retiree

If you are a retiree and you would otherwise lose coverage because you have become a suspended retiree under the ExxonMobil Disability Plan, you may continue coverage for yourself and all your family members who were eligible for Medical Plan participation before you became a suspended retiree for either 12 or 18 months.

Coverage continues for 12 months from the date coverage would otherwise end if you received transition benefits under the ExxonMobil Disability Plan. However, if you did not receive transition benefits under the ExxonMobil Disability Plan, coverage continues for 18 months from the date coverage would otherwise end. The cost of this continued coverage is 102% of the combined participant and company contributions

Paying Your Share of Covered Expenses

Payment information for the ExxonMobil Retiree Medical Plan – Aetna POS II A and B options

You and the Plan share costs for covered treatment and services. You pay a fixed copayment for covered items such as a POS II network doctor's office visit and emergency room visits. For other types of care, you must satisfy an annual deductible and if applicable, an inpatient hospital deductible before the Plan starts paying. If you meet your annual out-of-pocket limit, the Plan pays 100% of most covered costs for the rest of that calendar year.

Coinsurance

You share in the cost of most covered expenses. For some services, such as hospital stays, the coinsurance will be a percentage of the cost of the covered service once the deductible has been satisfied. For other services, such as office visits to an EMRMP POS II network provider, the copayment will be a fixed amount. For outpatient prescription drugs, there is a percentage copayment.

• Fixed Copayment - A set amount you pay for covered services or treatments such as POS II doctor's office visits and hospital emergency room visits.
• Percentage Coinsurance - This is your share of the cost of certain covered services or treatments, such as retail and home delivery prescriptions. For medical expenses other than outpatient prescription drugs, once you meet your deductible, you and the Plan share covered costs until you reach your out-of-pocket limit.

Check the Benefits Summary section for each Plan´s coinsurance amounts.

Deductible

The deductible is the amount of covered expenses you must pay each calendar year before the Plan begins sharing the cost. Fixed amount copayments do not apply toward this amount. Outpatient prescription drug percentage copayments are not subject to nor do they count toward the annual deductible.

An additional annual hospital deductible applies to inpatient hospital services.

There are several ways for a family to meet the deductible, including:

• Two covered members of your family each meet the individual deductible.
• One person meets the individual deductible and other members of your family have combined covered charges equaling an individual deductible.
• No one person meets the family deductible, but the combined covered charges of all members of your family equal the family deductible.

Note: A family deductible cannot be met by only one person.

Charges that do not count toward the deductible

• Charges above reasonable and customary levels.
• Charges not covered by the Plan.
• Charge of $500 for failure to pre-certify non- network hospital stays.
• POS II copayments.
• Any outpatient prescription drug percentage copayments.
• Charges for a private hospital room above the cost of the hospital's most common rate for a semiprivate room.

The deductible is applied to your claims in the order Aetna processes them, not when the provider collects the money from you. This means if you pay your deductible to one provider, it may not be applied to your annual deductible if Aetna has received and processed other claims first. Please be sure to always get an itemized bill from your provider and retain proof of your payment.

Check the Benefits Summary section for each Plan´s deductible amounts.

Out-of-Pocket limits

The annual out-of-pocket limit helps protect participants from high medical costs by increasing the reimbursement level when your payments for covered charges reach certain dollar limits. This limit is separate from the limits established for outpatient prescription drugs. In Medical POS II areas, the limit is different depending on whether you use network or non-network providers. Check the Benefits Summary section for each Plan´s Annual Out-of-Pocket Limits.

Family out-of-pocket limit

The family out-of-pocket limits work similarly, but the increased reimbursement then applies to you and all of your covered family members — not just the person who met the individual limit.

Expenses that do not count toward the out-of-pocket limit for either EMRMP POS II option

• Charges above reasonable and customary limits. 
• Charges not covered by the Plan. 
• Charge of $500 for failure to pre-certify a non-network medical, behavioral health or substance use disorder hospital stay.
• Copayments for outpatient prescription drugs.
• Charges for a private hospital room greater than the cost of the hospital's most common rate for a semiprivate room.

No lifetime maximum

There is no maximum lifetime limit on benefits paid by the Plan with the exceptions of the $25,000 lifetime maximum on bariatric surgery for obesity.

Adjustments to billed charges

When providers submit charges for payment, there might be several factors affecting the amount that will be considered eligible for reimbursement including, but not limited to:

• Reasonable and customary limits
• Incidental charges
• No volitional control

 References to these limitations may appear on your Explanation of benefits (EOB). We strongly suggest you contact Aetna Member Services for more information. A predetermination of benefits is strongly recommended before you incur any major or unusual expenses.

Coordination of benefits

Coordination of benefits information for the ExxonMobil Retiree Medical Plan – POS II A and POS II B options

If you have coverage under other group plans, the benefits from the other plans will be taken into account if you have a claim. Other group plans include any other plan coverage provided by:

• Group insurance or any other arrangement of group coverage for individuals, whether or not the plan is insured, and
• No-fault and traditional fault auto insurance, including medical payments coverage provided on other than a group basis, to the extent allowed by law.

Determination of primary plan

To find out if benefits under the EMRMP will be reduced, Aetna must first determine which plan pays benefits first. The determination of which plan pays first is made as follows:

• The plan without a coordination of benefits (COB) provision determines its benefits before the plan that has such a provision.
• The plan that covers a person other than as a dependent determines its benefits before the plan that covers the person as a dependent. If the person is eligible for Medicare and is not actively working, the Medicare Secondary Payer rules will apply. Under the Medicare Secondary Payer rules, the order of benefits will be determined as follows:
  • The plan that covers the person as a dependent of a working spouse will pay first,
  • Medicare will pay second, and
  • The plan that covers the person as a retired employee will pay third.
• Except for children of divorced or separated parents, the plan of the parent whose birthday occurs earlier in the calendar year pays first. When both parents’ birthdays occur on the same day, the plan that has covered the parent the longest pays first. If the other plan doesn’t have the parent birthday rule, the other plan’s COB rule applies.
• When the parents of a child are divorced or separated:
  • If there is a court decree which states that the parents will share joint custody of a child, without stating that one of the parents is responsible for the health care expenses of the child, the parent birthday rule, immediately above, applies.
  • If a court decree gives financial responsibility for the child’s medical, dental or other health care expenses to one of the parents, the plan covering the child as that parent’s dependent determines its benefits before any other plan that covers the child as a dependent.
• If there is no such court decree, the order of benefits will be determined as follows:
  • the plan of the natural parent with whom the child resides,
  • the plan of the stepparent with whom the child resides,
  • the plan of the natural parent with whom the child does not reside, or
  • the plan of the stepparent with whom the child does not reside.
• If an individual has coverage as an active employee or dependent of such employee, and also as retired or laid-off employee, the plan that covers the individual as an active employee or dependent of such employee is primary.
• The benefits of a plan which covers a person under a right of continuation under federal or state laws will be determined after the benefits of any other plan which does not cover the person under a right of continuation.
• If the above rules do not establish an order of payment, the plan that has covered the person for the longest time will pay benefits first.

If it is determined that the other plan pays first, the benefits paid under the EMRMP will be reduced. Aetna will calculate this reduced amount as follows:

• The amount normally reimbursed for covered benefits under the EMRMP,

• Benefits payable from your other plan(s).

If your other plan(s) provides benefits in the form of services rather than cash payments, the cash value of the services will be used in the calculation.

Calculation of Benefits

When the Plan is your primary plan, the Plan will pay your medical claims first, as if there is no other coverage. When the Plan is your secondary plan, the Plan will pay benefits after the primary plan, and that payment amount will be the lesser of:

• What the Plan would have paid if it had been primary, or
• What the Plan would have paid less the primary plan’s payment.

Incorrect computation of benefits

If you believe that the amount of benefit you receive from the ExxonMobil Medical Plan is incorrect, you should notify Aetna in writing or contact Aetna Member Services.  If it is found that you or a beneficiary were not paid benefits you or your beneficiary were entitled to, the Plan or ExxonMobil will pay the unpaid benefits.  (See Claims and Administrative and ERISA information sections.)

Recovery of overpayment

Payments are made in accordance with the Provisions of the Plan.  Whenever payments have been made in excess of the amount necessary to satisfy the provisions of this plan, the Plan has the right to recover these overpayments from any individual (including you, your family members and a provider), insurance company or other entity or organization to whom the excess payments were made—or to withhold payment, if necessary, on future benefits until the overpayment is recovered. The  Administrator-Benefits may also make reasonable arrangements with you for repayment. Whenever payments have been made based on inaccurate, misleading or fraudulent information provided by you or your family member, the Plan will exercise all available legal rights to recover the overpayment, including its right to withhold payment on future benefits or offset future benefits to the extent of the overpayment until the overpayment is recovered.  See Fraud against the plan section. In addition, the Plan has the right to engage an outside collection agency to recover overpayments on the Plan’s behalf if the Plan’s collection effort is not successful. The Plan may also bring a lawsuit to enforce its rights to recover overpayments.

Right of recovery (subrogation and/or reimbursement)

If you or a covered family member receives benefits from this plan as the result of an illness or injury caused by another person, the EMRMP has the right to be reimbursed for those benefits from any settlement or payment you receive from the person who caused the illness or injury. This means the EMRMP may recover costs from all sources (including insurance coverage) potentially responsible for making any payment to you or your covered family member as a result of an injury or illness, including:

• Uninsured motorist coverage,
• Underinsured motorist coverage,
• Personal umbrella coverage,
• Med-pay coverage,
• Workers’ Compensation coverage,
• No-fault automobile coverage, or
• Any first party insurance coverage.

What you need to know

Here are some important points about the right of subrogation:

The Plan has a lien on any payments you receive.

The EMRMP automatically has a lien, to the extent of any benefits it has paid, on any payment you’ve received from a third party, his/her insurer or any other source. The lien is in the amount of benefits paid by Aetna under this plan for treatment of the illness, injury or condition for which the other person is responsible.

Your cooperation is required.

You may not do anything to interfere or affect the EMRMP’s subrogation rights.

You also must fully cooperate with the EMRMP’s efforts to recover benefits it has paid. This includes providing all information requested by the Claims Administrator or its representatives. As part of this process, Aetna may ask you to complete and submit certain applications or other forms or statements. If you fail to provide this information, it will be considered a breach of contract and may result in the termination of your health benefits or the instigation of legal action against you.

You must notify Aetna.

If a lawsuit or any other claim is filed to recover damages due to injuries sustained by you or a covered family member, you must notify Aetna. This must be done within 30 days of the date the notice of the lawsuit or claim is given to a person, including an attorney.

The Plan is paid first.

The EMRMP’s subrogation rights are a first priority claim against all potentially responsible person(s), and must be paid before any other claim for damages.

The Plan is entitled to full reimbursement.

The EMRMP is entitled to full reimbursement first from any payments made by any responsible person(s). This reimbursement must be made, even if the payment is not enough to compensate you or your covered family member in part or in whole for damages. The terms of this plan provision apply and the EMRMP is entitled to full recovery whether or not any liability for payment is admitted by any potentially responsible person(s), and whether or not the settlement or judgment you receive identifies the medical benefits provided by the plan. The EMRMP may be reimbursed from any and all settlements and judgments, even those for pain and suffering or non-economic damages only.

Aetna chooses the court for any legal action.

Any legal action or proceeding with respect to this provision may be brought in any court of competent jurisdiction that Aetna selects. When you receive benefits under this plan, you agree to this rule and waive whatever rights you have by reason of your present or future place of residence.

The Plan is not responsible for your attorneys’ fees.

The EMRMP is not required to participate in or pay attorney fees to the attorney you hire to pursue your claim for damages.

Interpreting this provision.

If there is any question about the meaning or intent of this plan provision or any of its terms, the EMRMP will have the sole authority and discretion to resolve all disputes as to how this provision will be interpreted.

When coverage ends

When coverage ends of the ExxonMobil Retiree Medical Plan – Aetna POS II A and B options

Coverage for you and/or your family members ends on the earliest of the following dates:

The last day of the month in which:

• You die,
• You elect not to participate,
• A family member ceases to be eligible (for example, a child reaches age 26),
• You become a suspended retiree,
• You are no longer eligible for benefits under this Plan (e.g. as a surviving spouse, you re-marry),
• You, as a retiree, or your eligible family member becomes eligible for Medicare and for the Medicare Primary Option; 
• Your former employer  discontinues participation in the Plan,

OR

The date:

• You do not make any required contribution,
• You are rehired by ExxonMobil after retirement as an employee or non-regular employee,
• The Retiree Medical Plan ends,
• You enrolled an ineligible family member and in the opinion of the Administrator-Benefits, the enrollment was a result of fraud or a misrepresentation of a material fact.

You are responsible for ending coverage with the Benefits Service Center when your enrolled spouse or family member is no longer eligible for coverage. To end coverage for your spouse or family member when no longer eligible, contact the ExxonMobil Benefits Service Center. If you do not complete your change within 60 days, any contributions you make for ineligible family members will not be refunded.

Cancellation and Reinstatement Process

Cancellation of EMRMP due to non-payment of premiums:

Cancellations due to non-payment of plan premiums will be prospective, with a 3 month grace period starting 1st month of unpaid contributions, so participants may pay owed contributions within that grace period to avoid cancellation. For example, if retiree has not made payments for their January, February, and March premiums during that 3 month timeframe, coverage will be cancelled effective April 1.

How to Avoid Cancellation due to Nonpayment of Premiums

The ExxonMobil Benefits Service Center (EMBSC) offers the convenience of paying your benefits premiums through either direct debit or deduction from your monthly pension payment (if applicable). To set up either payment method, visit www.exxonmobil.com/benefits:

Direct Debit: click on “Health & Welfare,” then on “More,” and lastly on “Update Premium Payment Information.”

Monthly Pension Payment Deduction: click on “Library,” then on “Documents & Forms,” then on “Forms,” and lastly on “Pension Deduction Authorization Form. Return your completed form to the shown address.

For assistance, call the EMBSC at 1-800-682-2847

Reinstatement of EMRMP:

Once your coverage has been terminated, you can request to be reinstated upon showing good cause.  The EMRMP (or its designee) will review requests for reinstatements on a case-by-case basis. If an individual has been involuntarily disenrolled for failure to pay plan premiums, they may request reinstatement no later than 60 calendar days following the effective date of disenrollment.

Reinstatement for good cause will occur only when:

1. Reinstatement is requested no later than 60 calendar days following the effective date of disenrollment (in the example, 60 days from April 1)
2. The individual has been determined to meet the criteria specified below (i.e., receives a favorable determination); and
3. Within three (3) months of disenrollment for nonpayment of plan premiums, the individual pays in full the plan premiums owed at the time they were disenrolled (in the example, within 3 months from April 1).

If you fail to pay premiums within the grace period, your coverage is terminated, and you fail to show good cause, you and your eligible dependents will not have an opportunity to re-enroll at a future date in the EMRMP. You are still responsible for paying all owed premiums incurred during the grace period in which you were still part of the EMRMP.

Requests for reinstatement must be accompanied by a credible statement (verbal or written) explaining the unforeseen and uncontrollable circumstances causing the failure to make timely payment. An individual may make only one reinstatement request for good cause in the 60-day period. Generally, these circumstances constitute good cause:

• A serious illness, institutionalization, and/or hospitalization of the member or their authorized representative (i.e. the individual responsible for the member’s financial affairs), that lasted for a significant portion of the grace period for plan premium payment;
• Prolonged illness that is not chronic in nature, a serious (unexpected) complication to a chronic condition or rapid deterioration of the health of the member, a spouse, another person living in the same household, person providing caregiver services to the member, or the member’s authorized representative (i.e., the individual responsible for the member’s financial affairs) that occurs during the grace period for the plan premium payment;
• Recent death of a spouse, immediate family member, person living in the same household or person providing caregiver services to the member, or the member’s authorized representative (i.e., the individual responsible for the member’s financial affairs); or
• Home was severely damaged by a fire, natural disaster, or other unexpected event, such that the member or the member’s authorized representative was prevented from making arrangement for payment during the grace period for plan premium;
• An extreme weather-related, public safety, or other unforeseen event declared as a Federal or state level of emergency prevented premium payment at any point during the plan premium grace period. For example, the member’s bank or U.S. Post Office closes for a significant portion of the grace period.

There may be situations in addition to those listed above that result in favorable good cause determinations. If an individual presents a circumstance which is not captured in the listed examples, it must meet the regulatory standards of being outside of the member’s control or unexpected such that the member could not have reasonably foreseen its occurrence, and this circumstance must be the cause for the non-payment of plan premiums. The Plan expects non-listed circumstances will be rare.

Examples of circumstances that do not constitute good cause include:

• Allegation that bills or warning notices were not received due to unreported change of address, out of town for vacation, visiting out of town family, etc.;
• Authorized representative did not pay timely on member’s behalf;
• Lack of understanding of the ramifications of not paying plan premiums;
• Could not afford to pay premiums during the grace period; or
• Need for prescription medicines or other plan services.

The ExxonMobil Benefits Service Center is the appointed designee reviewing reinstatement requests and making good cause determinations

Loss of eligibility

Fraud against the Plan

Any act, practice, or omission by a Plan participant that constitutes fraud or an intentional misrepresentation of material fact is prohibited by the Plan, and the Plan may rescind coverage retroactively as a result.  Any such fraudulent statements, including on Plan enrollment forms and in electronic submissions, may invalidate any payment or claims for services and may be grounds for rescinding coverage. Everyone in your family may lose eligibility for Retiree Medical Plan coverage if you file claims for benefits to which you are not entitled. Coverage may also be terminated if you refuse to repay amounts erroneously paid by the Retiree Medical Plan on your behalf or that you recover from a third party. Additionally, coverage may be terminated if you fail to reimburse the Plan for any amount owed to the Plan, or if you receive and fail to report to the Claims Processor any discounts, write-offs or other arrangements with providers that result in misrepresentation of your out-of-pocket costs. Your participation may be terminated if you fail to comply with the terms of the Retiree Medical Plan and its administrative requirements. You may also lose eligibility if you enroll persons who are not eligible, for instance, by covering children who do not meet the eligibility requirements. This includes failing to provide timely notification of when a covered family member loses eligibility, e.g., spouse loses coverage. Termination may be retro-active to the date of coverage.

In the event a retiree is rehired and is eligible for the ExxonMobil Medical Plan (EMMP), the retiree and eligible family members are no longer eligible for the EMRMP and coverage is rescinded for all periods during which the retiree is employed. The rehired retiree and eligible family members will be enrolled retroactively in the EMMP until the earlier of failure to comply with the administrative requirements of the EMMP or re-employment ends.  Any claims paid during such periods of employment under the EMRMP will be reprocessed under the EMMP.

Continuation coverage

Continuation coverage for the ExxonMobil Retiree Medical Plan – Aetna POS II A and B options

Introduction

You are required to be given the information in this section because you are covered under a group health plan (the Retiree Medical Plan). This section contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan under certain circumstances when coverage would otherwise end. 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 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. It can also become available to your spouse and children, if they are covered under the Plan when they would otherwise lose their group health coverage or other rights under the Plan. This section does not fully describe COBRA coverage or other rights under the Plan. For additional information about your rights and obligations under the Plan and under federal law, you should review this SPD or contact the ExxonMobil Benefits Service Center at the telephone numbers or address listed under Benefits Administration in the Contacts for COBRA rights Under the ExxonMobil Retiree Plan section.

Your spouse and your family members may have other options available when they lose group health coverage. For example, they may be eligible to buy an individual plan through the Health Insurance Marketplace.  By enrolling in coverage through the Marketplace, y the costs of monthly premiums may be lower.  Additionally, they may qualify for a 30-day special enrollment period for another group health plan for which they are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

Determination of Benefits Administration Entity to Contact:

• Exxon, ExxonMobil, Mobil, XTO or Superior Oil Retirees, or their Survivors, or their covered family members contact ExxonMobil Benefits (http://www.exxonmobil.com/benefits) or contact the ExxonMobil Benefits Service Center;
• Former Exxon, ExxonMobil or XTO Employees and their covered family members, who have elected and are participating through COBRA, contact the ExxonMobil COBRA Administration.

The contact information for each of these entities is as shown in the Contacts for COBRA Rights Under the ExxonMobil Medical Plan section.

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. Specific qualifying events are listed later in this section.  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.  You, your spouse, and your children could become qualified beneficiaries 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 coverage must pay the entire cost of COBRA coverage (employee plus employer portions) plus a 2% administrative fee.

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 any of the following qualifying events happens:

• The retiree dies,
• You become divorced from the retiree.  Also, if 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 any of the following qualifying events happens:

• The retiree dies,
• The child stops being eligible for coverage under the Plan as a child.

When is COBRA coverage available?

When the qualifying event is the death of a retiree, the Plan will offer COBRA coverage to qualified beneficiaries.  You need to notify the ExxonMobil Benefits Service Center of any other qualifying events.

For the other qualifying events (divorce of the retiree resulting in the spouse or a child losing eligibility for coverage), a COBRA election will be available to you only if you notify the ExxonMobil Benefits Service Center or ExxonMobil COBRA Administration within 60 days after the later of (1) the date of the qualifying event or (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. Current retirees or survivors may give notice of qualifying events by logging onto ExxonMobil Benefits located or by calling eh ExxonMobil Benefits Service Center.

Please note:  Notice is not effective until either a change is made on ExxonMobil Benefits or the proper information is received by the ExxonMobil Benefits Service Center. If notice is not submitted during the 60-day notice period, then all qualified beneficiaries will lose their right to elect COBRA.

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 Plan coverage that lasts between 18-36 months depending on the qualifying event.

Your covered spouse and covered dependent may qualify for up to 36 months of continuation coverage, if they qualify due to one of the following qualifying events:

• You die;
• You and your spouse get a divorce; or
• An enrolled child no longer meets the definition of “child” under the terms of the Plan.

When COBRA Coverage Ends

COBRA coverage can end before the end of the maximum coverage period for several reasons:

• The premium for your continuation coverage is not paid on time.
• If after electing continuation coverage, you become covered by another group health plan, unless the plan contains any exclusions or limitations with respect to any pre-existing condition you or your coverage dependents may have.
• If after electing continuation coverage, you first become eligible for and enroll in Medicare Part A , Part B or both.
• Exxon Mobil Corporation no longer provides group health coverage to any of its eligible employees or eligible retirees.

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 during COBRA

A child born to, adopted by, or placed for adoption with a covered retiree during a period of COBRA coverage is considered to be a qualified beneficiary provided that, if the covered retiree is a qualified beneficiary, the covered retiree 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).

Cost of COBRA coverage

A person who elects continuation coverage may be required to pay 102% of the cost to the Plan to maintain the coverage. A person who elects continuation coverage must pay the required contributions within 45 days from the date coverage is elected retroactively to the date benefits terminated under the Plan.

If you have questions

Questions concerning your plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below.  For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, 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 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 Benefits Service Center 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 Benefits Service Center.

Contacts for COBRA rights under the ExxonMobil Retiree Medical Plan

The following sets out the contact numbers based on your status under the Retiree Medical Plan.  Failure to notify the correct entity could result in your loss of COBRA rights. 

If your status is not listed, call the ExxonMobil Benefits Service Center.

Retirees and their covered family members:
Contact:	Address:
ExxonMobil Benefits Service Center Phone: 1-800-682-2847 Monday – Friday 8:00 a.m. to 6:00 p.m. (U.S. Eastern Time) Web:ExxonMobil Benefits	ExxonMobil Benefits Service Center Address: P.O. Box 18025 Norfolk, VA 23501-1867
Former employees and family members who have elected and are participating through COBRA:
ExxonMobil COBRA Administration Monday - Friday except certain holidays 8:00 a.m. to 7:00 p.m. (U.S. Central Time) 800-526-2720	Wageworks National Accounts Services ExxoMobil COBRA Administration P.O. Box 2968 Alpharetta, GA 30023-2968 Fax: 833-514-6416

Effective January 2, 2024, Alight will be the new administrator of ExxonMobil’s health, life insurance, and pension plans. If you need assistance, please contact:

ExxonMobil Benefits Service Center
Phone: 833-776-9966
Hours: 8am – 4pm CST, Monday through Friday, except certain holidays
Your Total Rewards portal: digital.alight.com/exxonmobil

Alight Mobile app  (available through Apple App Store or Google Play)

Address:
Dept 02694, PO Box 64116, The Woodlands, TX, 77387-4116

Basic Plan features

Basic Plan features for the ExxonMobil Retiree Medical Plan – Aetna POS II A and B options

Both RMP POS II options include the features listed below.

Medically necessary

Expenses are covered under these options only if they are medically necessary. Care is medically necessary if it is a therapeutic procedure, service or supply used in the medical treatment of an injury, disease, or pregnancy, which is generally recognized by the United States medical community as appropriate. Claims are reviewed as submitted, and some or all of any claim or series of services could be denied as not being medically necessary. It also means that experimental and/or investigational procedures, drugs, devices or biological products not proven by long-term clinical studies are generally not covered. See Exclusions for limited exceptions. 

When determining medical necessity, the Administrator-Benefits may consider the Clinical Policy Bulletins (CPBs) published by Aetna, the claims administrator. CPBs are based on objective, credible sources, such as the scientific literature, guidelines, consensus statements and expert opinions. These CPBs may be found on the Aetna website at https://www.aetna.com/health-care-professionals/clinical-policy-bulletins.html.

Precertification

Precertification or preauthorization is a mandatory review of inpatient admissions and select ambulatory procedures and/or services in advance of treatment, to confirm medical necessity based on clinical criteria and benefits eligible under the Plan. If you are using a network provider, the provider will perform the precertification process on your behalf. If you are using a non-network provider, you must initiate the precertification process yourself. Failure to obtain a required precertification for non-network hospitalization services will result in a $500 penalty, even if the services are medically necessary and otherwise covered under the Plan. For more information on precertification for medical/surgical procedures and services, see the National Precertification List on the Aetna member website.

Enhanced clinical review

The Plan also includes a utilization management program, known as Enhanced Clinical Review (ERC), of some diagnostic services (e.g., MRIs, CT Scans, Cardiac Imaging, sleep studies, hip/knee replacement procedures, etc.).

An enhanced clinical review is a mandatory review of select covered services that have equivalent, lower-cost alternatives, to ensure the higher cost service is medically necessary in advance of treatment. If the review is not completed and the treatment is not approved, it will not be covered under the Plan.

Please contact Aetna Member Services to determine if the service your physician has recommended requires enhanced clinical review.

The ECR precertification process applies to Aetna participating providers and facilities. Out of network providers and facilities are subject to retrospective claim reviews to determine if the services meet Aetna medical necessity guidelines.

For emergency inpatient admissions:

Certification must be made within 48 hours following an emergency inpatient admission. If the admission is on a weekend or holiday, notification must be made within 72 hours.

• If you are using POS II network provider, your provider will obtain certification for you.
• You or someone acting on your behalf must call to certify care if you are in a non-network or out-of-network area hospital.

For certain prescription drugs

Your physician must call Express Scripts for precertification of certain prescription drugs. This applies whether you are inside or outside the United States.

In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the Plan will cover another (usually more expensive) drug.

Additionally, as part of Express Scripts’ Advanced Utilization Management (AUM) program, certain targeted drugs will not be covered unless precertified by Express Scripts, based on medical evidence submitted by your physician.

Non-targeted drugs are covered without precertification or prior authorization. Refer to the Prescription drug program section for more details.

Predetermination

A predetermination is an estimate of covered services and benefits payable in advance of treatment. It is not a guarantee of benefits eligible or payment amount. You may request a predetermination for any covered service. In most cases, you may receive an answer over the phone. In other cases, information from your provider may be needed. You or your doctor can also request a predetermination of benefits, in writing, before the service is performed.

Predetermination is recommended for all outpatient surgical procedures. This predetermination may require review by one or more doctors. Be sure to allow time for this review between the predetermination request and the proposed date of the service. By obtaining the written response, you will have more detailed information about the level of reimbursement.

For more information on requesting a predetermination, see the Information sources section at the front of this SPD.

When you call for a benefit predetermination, be ready to provide the following information:

• Primary participant's name and member ID, which can be found on your Aetna ID card,
• Patient's name,
• Complete description of medical services or surgical procedures. If possible, include the diagnosis code(s) and the five-digit Current Procedural Terminology (CPT) codes or the Healthcare Common Procedure Coding System (HCPCS) alpha-numeric codes, which you can get from the provider,
• Provider's complete information including name, address, phone number, and zip code, and
• Provider's proposed fee for each service.

About pregnancy

Federal law mandates that benefit programs such as the ExxonMobil Retiree Medical Plan cover eligible participants for a minimum length of stay for delivery and newborn hospitalizations. Those minimums are 48 hours following a vaginal delivery and 96 hours following a Cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable).

The Plan does not provide breastfeeding support, counseling and equipment for the duration of breastfeeding.

Medical, surgical, behavioral health and substance use disorder Aetna POS II A/B network

The Aetna Choice® POS II network includes a group of physicians, hospitals, and other providers who have met standards for licensing, academic background and service are located throughout the United States. If you use network providers, the Plan pays a larger portion of the covered expenses. Network providers have agreed to negotiated charges which may save you and the Plan money. Other advantages to using Medical POS II network providers for medical, surgical, behavioral heath and substance use disorder care are:

• You pay a copay for most office visits, including diagnostic laboratory and X-rays associated with that office visit. Preventive care office visits are reimbursed at 100%.
• Emergency room physician expenses, in-patient hospital expenses, and outpatient surgery expenses are subject to deductible and coinsurance.
• Other expenses such as home health care, durable medical equipment or complex imaging are reimbursed at the network reimbursement level (either 80% for the Aetna POS II B or 75% for the Aetna POS II A) of a negotiated rate after you meet the annual deductible.
• Your annual out-of-pocket maximum is significantly lower.
• Retiree Medical POS II network providers file claims and handle the hospital preadmission review process for you.
• All negotiated charges are within reasonable and customary limits.

To find Aetna Choice® POS II network providers in your area, choose “Find a Doctor” on the Aetna website or mobile app. If you need further assistance, you can call Aetna Member Services.

Copayment for office visits/lab work when provided by a primary care physician; higher copayment when provided by a specialist.

When you use Retiree Medical POS II network providers for office visits, you are not subject to the annual deductible. You pay a copayment for each office visit, which may  include most related lab work and radiology performed by an RMP POS II network provider.

More extensive tests, including complex imaging (i.e., CT scans, MRI, MRA, PET/SPECT), radiopharmaceutical stress tests, angiography myelography, MUGA scans and sleep studies, and office or out-patient surgery and associated diagnostic lab and xray services are subject to the deductible and coinsurance.

If an injection (other than an injection into a vein or artery) is received in a network doctor's office without an office visit, the copayment will be the actual cost of the injection or the office visit copayment, whichever is less. For infusion therapy and chemotherapy, a fixed copayment only applies to the office visit. All other related services are paid at coinsurance. Allergy serum dispensed by a network doctor is reimbursed at coinsurance after the deductible.

These copayments do not apply to your annual deductible but do apply to your annual out-of-pocket limit. See the explanation beginning in the Payment section for more information about deductibles and copayments.

Is your doctor a network provider?

Call your doctor's office to confirm his or her participation in the Aetna Choice® POS II network. If your doctor is not participating, ask your provider to consider applying to participate. Your doctor can obtain information about becoming a network participant from Aetna's website (www.aetna.com/healthcare-professionals/index.html) or by calling Aetna Credentialing Customer Service at 1-800-353-1232. 

If you live in a POS II network area and use POS II non-network providers

• Your out-of-pocket costs will generally be higher. The Plan's reimbursement level is 60% for the Aetna POS II B and 55% for the Aetna POS II A of reasonable and customary charges, after you satisfy the non-network deductible, and your out-of-pocket expenses will accumulate towards a higher non-network out-of-pocket maximum.
• You must call Aetna to initiate the medical preadmission review process for inpatient treatment and ensure any precertification or preauthorization requirements are completed.
• If your provider or facility charges are above reasonable and customary limits, you are responsible for paying any amounts above reasonable and customary limits in addition to your coinsurance. You may be balance billed by the provider or facility for any amount not reimbursed by Aetna. Refer to section regarding non-volitional use of non-network providers for additional details.
• You are responsible for submitting claims.

If you cannot find a Network Provider (network deficiency)

Sometimes you may have difficulty finding a network provider in your area that is available when you need care. If an Aetna Choice® POS II network provider is not available for medical, surgical, behavioral health and substance use disorder  services, call Aetna Member Services for information on the Plan's alternate network deficiency benefit. If Aetna confirms a network provider is not available for the medical, surgical, behavioral health and substance use disorder services you need, they will authorize use of a designated non-network provider for your care.

Benefits for covered services at a designated non-network provider under the alternate network deficiency benefit will be paid at the In-Network level (either 80% for Aetna POS II B or 75% for Aetna POS II A of reasonable and customary charges) after the plan year deductible has been satisfied, and out-of-pocket expenses for those services will accumulate towards your In-Network out-of-pocket maximum. Copayments will not apply.

If you live outside an Aetna POS II network area (out-of-network area benefits)

If you live outside a designated Aetna POS II network area, benefits for covered services are paid at the out-of-network area benefit level.

You still have access to Aetna Choice® POS II network providers and facilities in your area, within a short driving distance, and while travelling. When you receive care from a network provider or in a network facility, you will be reimbursed at 80% for Aetna POS II B or Aetna 75% for POS II A of the negotiated network rate for inpatient and outpatient services, your network provider will initiate the preadmission review process, and network copayments for primary care and specialist office visits will apply.

If you live outside a Aetna POS II network area and receive care from a non-network provider or in a non-network facility, you will be reimbursed at 80% for POS II B and 75% for POS II A of reasonable and customary charges for similar services in the same area. Network discounts and network copayments do not apply, and you must satisfy the deductible for all covered services other than preventive care. You are also responsible for initiating the medical preadmission review process for inpatient treatment unless you use a network provider.

Most non-network charges fall within reasonable and customary limits. However, you may receive a balance bill for the difference between a non-network provider’s billed charges and what is considered reasonable and customary for covered services in your area. If this happens, call Aetna Member Services. The full or partial balance bill may qualify as an allowable expense eligible for payment by the Plan. This includes balance bills for ambulance services, emergency physicians, radiologists, anesthesiologists, pathologists, hospitalists, neonatologists, and intensivists. It may also include balance bills for scheduled procedures performed by a non-network physician when a network physician is not available. However, if a network physician is available, and you schedule an inpatient or outpatient procedure with a non-network physician, you will be responsible for any billed charges above reasonable and customary limits, which for professional services is set at 200% of Medicare Fee Schedule  of charges for similar services in the same geographic area.

If you live outside a POS II network area, the out-of-pocket maximum for non-network services is the same as the maximum for network services. Once your annual out-of-pocket limit is reached, covered services are reimbursed at 100% of reasonable and customary charges.

Note: You are responsible for payment for services that are not covered by the Plan, including non-medical ancillary services and any balance bill that remains after adjustments for allowable expenses have been made. Payments for services not covered by the Plan do not accumulate towards your annual out-of-pocket limit.

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or you’re treated by an out-of-network provider at an in-network hospital, or ambulatory surgical center or by an air ambulance provider, you are protected from surprise billing or balance billing.

Your ID cards

Your cards identify you as a plan participant when you receive services from in-network providers or when you receive emergency services at non-network facilities. Always carry your ID cards with you and show them each time you get covered services from a provider, including your prescription drug card (Express Scripts).

If your cards are lost or stolen, please notify Aetna and Express Scripts immediately.

Health Management programs

Details on ExxonMobil's Health management programs

24-Hour nurse line

Trained, licensed nurses are available by telephone at 1-800-556-1555, 24 hours a day, 7 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 not covered under the Plan (see Exclusions). The nurse may refer you to a Health Advocate for a more detailed conversation if you face a health risk or serious medical condition.

Health Advocacy Program

The Health Advocate Program provides direct support to you, your family, and your treating physician(s) in the management of specific health care needs, at no cost to you. The Health Advocate staff consists of registered nurses, supported by a medical director. Once you begin working with a Health Advocate, the nurse will work personally with you as long as you need support.

Health Advocates will assist you to coordinate a wide array of health care-related support and educational services. As situations require, your Health Advocate will assist you with admission, counseling, inpatient advocacy, discharge planning and home counseling. The nurse will also act as your proactive partner, working directly with you to help you navigate the health care delivery system by assisting with the coordination and management of your health care needs and collaborating with others involved in your treatment.

Some of the condition management programs available include but not limited to Coronary artery disease (CAD), heart failure, diabetes –adult and pediatric, asthma –adult and pediatric, chronic obstructive pulmonary disease (COPD), chronic lower back pain, osteoporosis / osteoarthritis and peripheral artery disease.  Contact Aetna to check if your chronic condition can be managed through the Health Advocate program.

Aetna Maternity Program

The Aetna Maternity Program provides free support and resources to help you have a healthy pregnancy. The program provides useful information about early labor symptoms, genetic counselling and screening, preeclampsia prevention and education and resources on caring for a newborn.

If your pregnancy is considered at-risk, nurse managers will be available to help you manage the risk, identify symptoms and understand treatment options.

Contact aetna.com for additional information.

Cancer Management Program

As a part of your coverage under this plan, Health Advocacy nurses are available to assist with newly diagnosed cancer, undergoing active treatment for cancer, or a recurrence, at no cost to you. The Health Advocacy team will support you in your cancer journey with case management and provide you with information on the many resources available to you including a personal navigator with experience in cancer diagnosis and treatments, who will provide you with personalized support whenever you need it, genetic counseling to help guide your treatment and assess your risk of developing other forms of cancer, and an extensive online cancer support center.

If you would like to receive support from a Health Advocate, call 800-255-2386.  

Musculoskeletal Conditions Support

As a part of your coverage under this plan, Hinge Health offers musculoskeletal conditions support at no cost to you, with programs relating to care for different joint and muscle pain needs, for example:

• Prevention (at risk): specific exercises and education
• Acute (recent injury): physical therapy video visits for every body part
• Chronic (high risk): exercise, education and behavioral change
• Surgery (pre & post rehab): pre and post rehabilitation continuity of care

Learn more about this program at www.hingehealth.com/exxonmobil or call 855-902-2777

Expert Medical Opinion Services

If you or a family member receive a diagnosis or treatment plan requiring complex medical care, you have access to expert medical opinion services through 2ndMD. Specialists who are recognized experts in their field will review medical records related to the diagnosis and provide an opinion on the recommended treatment, including a detailed report you can share with your physician or Health Advocate nurse. Expert opinion consults are available at no additional cost to you and can be accessed through a mobile application, web portal, or phone. Call 866-410-8649 or www.2nd.md/aetna to initiate services.

Omada Programs for Diabetes, Hypertension, and Prevention (Weight Management)

Omada programs are available to eligible members (meeting certain medical criteria) via the application at www.omadahealth.com/exxonmobil. The programs offer real-time tips, health care equipment and support from care team coaches and specialists, and can help members feel better, manage medication and potentially reduce out-of-pocket health care costs.

Centers of Excellence, Institutes of Quality and Institutes of Excellence

Centers of Excellence (COE), Institutes of Quality (IOQ) and Institutes of Excellence (IOEs) are nationally recognized facilities for the treatment of certain conditions or the delivery of certain procedures where high-level knowledge and expertise provide better care and more likely positive outcomes.

COEs/IOQs/IOEs are not available for all diseases and all conditions or procedures relevant to a disease state. For instance, there are IOQs for bariatric, cardiac, orthopedic and applied behavioral analysis (ABA), while there are IOEs for transplant support and pediatric congenital heart Surgery and COEs for cardiac, cancer and some pediatric specialties. More information can be found at Aetna Institutes. If you would like to learn more about different COE/IOE options, you will need to contact the 24-hour nurse line and ask to be put in contact with a Health Advocate who will be able to discuss different options with you.

Participation in a COEs/IOQs/IOEs program is voluntary, and designed to direct participants to nationally recognized facilities with more positive outcomes. A COEs/IOQs/IOEs -recommended treatment plan, however, must meet the Retiree Medical Plan provisions for medically necessary care in order for claims to be eligible for reimbursement.

Whenever clinically appropriate, you will be referred to a local COEs/IOQs/IOEs. If access to a clinically appropriate COEs/IOQs/IOEs requires the patient to travel 100 or more miles, the Retiree Medical Plan will reimburse reasonable transportation costs for you and a caregiver. The Plan will also provide a per diem for you and a caregiver to cover lodging and other expenses. If you become hospitalized, only your caregiver will receive the per diem, because food and lodging are already provided as part of the hospital charge. The per diem amounts are established by the Administrator-Benefits.

If you decide not to use a COEs/IOQs/IOEs, you will not incur additional out-of-pocket costs for choosing another hospital in the Plan's network. However, you must obtain Comprehensive Infertility Services and Advanced Reproductive Technologies at an Aetna-designated Institute of Excellence in order for the services to be covered.

2023 Benefit summary

Benefits summary of the ExxonMobil Retiree Medical Plan – Aetna POS II A and B options

Please note: These charts provide only a brief summary of benefits under the RMP Aetna POS II A and B options. They are not intended to include all provisions. Non-network and out-of-network area benefits are subject to reasonable and customary limits.

ExxonMobil Retiree Medical Plan / POS II A option 2023 Summary of Benefits / Plan Code: 1021
Service Area: Worldwide POS II Group Number:476599 Member Services:800-255-2386 Provider Website:www.aetna.com Choice® POS II

 

Services	POS II Network	Non-Network	Out-of-Network Area
Annual Deductible (Individual/Family)	$500 / $1000	$700 / $1400	$500 / $1000
Out-of-Pocket Maximum (Individual/Family)	$4,500 / $9,000	$18,000 / $36,000	$4,500 / $9,000
Individual Lifetime Maximum	Unlimited	Unlimited	Unlimited
Separate Lifetime Maximum for Bariatric Surgery	$25,000	$25,000	$25,000
Inpatient Hospital Services for Medical¹, Behavioral Health and Substance Use Disorder treatment	$300 deductible 75% coverage	$600 deductible 55% coverage	$300 deductible 75% coverage
Precertification Reference the AetnaNational Precertification List for a list of procedures requiring precertification	Provider initiates	You initiate; $500 penalty for failure to precertify inpatient care	You initiate; $500 penalty for failure to precertify inpatient care
Outpatient Surgery and Associated Diagnostic Lab and X-ray Services	75% coverage	55% coverage	75% coverage

 

Physician Services*	POS II Network	Non-Network	Out-of-Network Area
Surgeon/Hospital Doctor Visits	75% coverage	55% coverage	75% coverage
Office Visit (including most diagnostic lab and X-ray services)²	Primary care: $40 copay³ Specialist: $60 copay³	55% coverage	75% coverage
Preventive Care (including most diagnostic lab and X-ray services)² *Physician services include Behavioral Health providers. PCP selection is not required.	100% coverage	100% coverage	100% coverage

 

Services	POS II Network	Non-Network	Out-of-Network Area
Emergency Care	$100 copay4 75% coverage	$100 copay4 75% coverage	$100 copay4 75% coverage
Maternity	75% coverage	55% coverage	75% coverage
Chiropractic Care Calendar Year Limit5	$60 copay $1,000	55% coverage $1,000	75% coverage $1,000
Precertification is required for all inpatient care, including behavioral health and substance use disorder. Excludes MRI, CAT scan, PET/Spect, Muga Scan, Thallium stress test, Angiography and Myelography. Not subject to deductible. Charge applied to hospital deductible if admitted. Applies to all chiropractic expenses regardless of network status of provider.

IMPORTANT NOTE: This chart provides only a brief summary of benefits under this option. It is not intended to include all ExxonMobil Retiree Medical POS II A option provisions.

Prescription Drugs
Annual out-of-pocket maximum for prescription drugs:	$2,500 per individual / $5,000 per family

 

	Short-Term Retail CoPay* ** ***		Express Scripts, Accredo, or Smart90 Pharmacy**
	(up to 34-day supply)	Maximum Per Prescription	(up to 90-day supply)	Maximum Per Prescription
Generic Drugs	30%	$60	25%	$120
Preferred**** Brand Drugs	30%	$130	25%	$260
Non-Preferred Brand Drugs	50%	$200	50%	$400

* If using a non-network pharmacy, you pay 100% of the difference between the actual cost and the discounted network cost plus retail copays.

** 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 full 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 Express Scripts or Medco Prescription Card or Social Security number of participant or benefits will be paid at the non-network level.

**** Preferred means Express Scripts’ formulary of preferred prescription drugs. Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits. However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program. If the specialty medication being purchased qualifies for copay assistance and is included in the drug list linked here, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program. If you choose not to enroll in the program, a 30% coinsurance with no maximum will apply, and any amount you pay will not count towards your Deductible or Out-of-Pocket Maximums.

ExxonMobil Retiree Medical Plan / Aetna POS II B option 2023 Summary of Benefits / Plan Code: 1022
Service Area: Worldwide POS II Group Number:476599 Member Services:800-255-2386 Provider Website:www.aetna.com Choice® POS II

 

Services	POS II Network	Non-Network	Out-of-Network Area
Annual Deductible (Individual/Family)	$300 / $600	$600/ $1200	$300 / $600
Out-of-Pocket Maximum (Individual/Family)	$3,000 / $6,000	$15,000 / $30,000	$3,000 / $6,000
Individual Lifetime Maximum	Unlimited	Unlimited	Unlimited
Separate Lifetime Maximum for Bariatric Surgery	$25,000	$25,000	$25,000
Inpatient Hospital Services for Medical¹, Behavioral Health and Substance Use Disorder treatment	$200 deductible 80% coverage	$400 deductible 60% coverage	$200 deductible 80% coverage
Precertification Reference the Aetna National Precertification List for a list of procedures requiring precertification	Provider initiates	You initiate; $500 penalty for failure to precertify inpatient care	You initiate; $500 penalty for failure to precertify inpatient care
Outpatient Surgery and Associated Diagnostic Lab and X-ray Services	80% coverage	60% coverage	80% coverage

 

Physician Services*	POS II Network	Non-Network	Out-of-Network Area
Surgeon/Hospital Doctor Visits	80% coverage	60% coverage	80% coverage
Office Visit (including most diagnostic lab and X-ray services)²	Primary care: $25 copay³ Specialist: $40 copay³	60% coverage	80% coverage
Preventive Care (including most diagnostic lab and X-ray services)²	100% coverage	100% coverage	100% coverage

 

Services	POS II Network	Non-Network	Out-of-Network Area
Emergency Care	$100 copay4 80% coverage	$100 copay4 80% coverage	$100 copay4 80% coverage
Maternity	80% coverage	60% coverage	80% coverage
Chiropractic Care Calendar Year Limit5	$40 copay3 $1,000	60% coverage $1,000	80% coverage $1,000
Precertification is required for all inpatient care, including behavioral health and substance use disorder. Excludes MRI, CAT scan, PET/Spect, Muga Scan, Thallium stress test, Angiography and Myelography. Not subject to deductible. Charge applied to hospital deductible if admitted. Applies to all chiropractic expenses regardless of network status of provider.

IMPORTANT NOTE: This chart provides only a brief summary of benefits under this option. It is not intended to include all Retiree Medical POS II A Option provisions.

This information is applicable to all non-represented employees participating in the Medical Plan. Applicability to represented employees is governed by local bargaining requirements.

Prescription Drugs
Annual out-of-pocket maximum for prescription drugs:	$2,500 per individual / $5,000 per family

 

	Short-Term Retail Copay* ** ***		Express Scripts, Accredo, or Smart90 Pharmacy**
	(up to 34-day supply)	Maximum Per Prescription	(up to 90-day supply)	Maximum Per Prescription
Generic Drugs	30%	$50	25%	$100
Preferred**** Brand Drugs	30%	$125	25%	$250
Non-Preferred Brand Drugs	50%	$200	50%	$400

* If using a non-network pharmacy, you pay 100% of the difference between the actual cost and the discounted network cost plus retail copays.
** 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 full 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 Express Scripts or Medco Prescription Card or Social Security number of participant or benefits will be paid at the non-network level.

**** Preferred means Express Scripts’ formulary of preferred prescription drugs. Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits. However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program. If the specialty medication being purchased qualifies for copay assistance and is included in the drug list linked here, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program. If you choose not to enroll in the program, a 30% coinsurance with no maximum will apply, and any amount you pay will not count towards your Deductible or Out-of-Pocket Maximums.

Eligible health services under your plan

Your benefits on the ExxonMobil Retiree Medical Plan- POS II A and B options.

Although a specific service may be listed as a covered benefit, it may not be covered unless it is medically necessary for the prevention, diagnosis or treatment of your illness or condition. Refer to the Key Terms section for the definition of medically necessary.

Certain services must be pre-certified by Aetna. Your in-network provider is responsible for obtaining this approval.

Preventive care

Preventive care services will be covered at 100%. If you use a non-network provider or live in a location where there is not a Medical POS II network, reasonable and customary charges for covered preventive care services will continue to apply. Preventive care services covered at 100% (for either network or non-network providers) include the following:   

Routine physical exams

Eligible health services include office visits to your physician or other health professional for routine physical exams.

Preventive care immunizations

Eligible health services include immunizations for infectious diseases recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

Immunizations/vaccinations obtained outside of a physician's office or hospital:

• Some immunizations can also be obtained or administered at in-nework retail pharmacies, using the Aetna ID card at an Aetna network pharmacy, or the Express Scripts ID card at an Express Scripts network pharmacy.

During the emergency period, the ExxonMobil Retiree Medical Plan has covered COVID-19 vaccines/boosters at no cost to members. Starting May 12, 2023, these will be included as a preventive vaccine (such as the annual flu shot), which are also available to members at no cost. If you receive a vaccine at a non-network provider, you will be reimbursed at 100% (this is subject to Aetna’s definition of reasonable and customary limits, where you may be reimbursed at a lower amount than what the vaccine costs you).

Well woman preventive visits

Eligible health services include your routine:

• Well woman preventive exam office visit to your physician, PCP, obstetrician (OB), gynecologist (GYN) or OB/GYN. This includes pap smears. A routine well woman preventive exam is a medical exam given for a reason other than to diagnose or treat a suspected or identified illness or injury.
• Preventive care breast cancer (BRCA) gene blood testing by a physician and lab.
• Preventive breast cancer genetic counseling provided by a genetic counselor to interpret the test results and evaluate treatment.
• Screening for diabetes after pregnancy for women with a history of diabetes during pregnancy.
• Screening for urinary incontinence.

Preventive screening and counseling services

Eligible health services include screening and counseling by your health professional for some conditions. These are obesity, misuse of alcohol and/or drugs, use of tobacco products, sexually transmitted infection counseling and genetic risk counseling for breast and ovarian cancer.

Routine cancer screenings

Eligible health services include the following routine cancer screenings:

• Mammograms
• Prostate specific antigen (PSA) tests
• Digital rectal exams
• Fecal occult blood tests
• Sigmoidoscopies
• Double contrast barium enemas (DCBE)
• Colonoscopies which include removal of polyps performed during a screening procedure, and a pathology exam on any removed polyps
• Lung cancer screenings

If you need a routine gynecological exam performed as part of a cancer screening, you may go directly to a network provider who is an OB, GYN or OB/GYN.

Prenatal care

Eligible health services include your routine prenatal physical exams as Preventive Care, which is the initial and subsequent history and physical exam such as:

• Maternal weight
• Blood pressure
• Fetal heart rate check
• Fundal height

You can get this care at your physician's, OB's, GYN's, or OB/GYN’s office. Services are only paid at 100% if network providers are used.

Comprehensive lactation support and counseling services

Eligible health services include comprehensive lactation support (assistance and training in breast feeding) and counseling services during pregnancy or at any time following delivery for breast feeding. The plan will cover this counseling only from a certified lactation support provider.

Breast feeding durable medical equipment

Eligible health services include renting or buying durable medical equipment you need to pump and store breast milk. Contact Aetna for additional details.

Family planning services – female contraceptives

Eligible health services include family planning services such as:

• Counseling services: provided by a physician, OB, GYN, or OB/GYN on contraceptive methods.
• Devices: contraceptive devices (including any related services or supplies) when they are provided by, administered or removed by a physician during an office visit.
• Voluntary sterilization: charges billed separately by the provider for female voluntary sterilization procedures and related services and supplies. This also could include tubal ligation and sterilization implants.

Important note:

Lactation support, Breastfeeding durable medical equipment and contraceptive services are covered at 100% only through in-network providers.

To receive preventive care benefits, the doctor's bill must indicate that the service is preventive in nature. If you are found to have a condition requiring additional treatment, the additional covered services will be paid after you meet any remaining annual deductible.

Physicians and other health professionals

Physician services

Physician services include: non-routine office visits with your physician, such as your primary care physician, during both office and non-office hours - including Telemedicine, non-routine home visits, treatment for illness and injury and injections, including routine allergy desensitization injections in your physician´s office, with or without physician encounter.

Telemedicine

Telemedicine services are available via phone, web, or mobile app, 24 hours/day, 7 days/week through the Plan’s designated service provider (Teladoc). Teladoc’s health care professionals can evaluate, diagnose, and treat non-emergency medical and behavioral health conditions, such as cold/flu symptoms, stomach aches, common childhood illnesses, dermatology support, depression, stress, and anxiety. To register for services, call 855-835-2362 or visit www.Teladoc.com/Aetna.

Hospital and other facility care

Hospital care

The types of hospital care services that are eligible for coverage include:

• Room and board charges up to the hospital’s semi-private room rate.
• Services of physicians employed by the hospital.
• Operating and recovery rooms.
• Intensive or special care units of a hospital.
• Administration of blood and blood derivatives, but not the expense of the blood or blood product.
• Radiation therapy.
• Cognitive rehabilitation.
• Speech therapy, physical therapy and occupational therapy.
• Oxygen and oxygen therapy.
• Radiological services, laboratory testing and diagnostic services.
• Medications.
• Intravenous (IV) preparations.
• Discharge planning.
• Services and supplies provided by the outpatient department of a hospital.

Alternatives to hospital stays

Outpatient surgery and physician surgical services

Eligible health services include services provided and supplies used in connection with outpatient surgery performed in a surgery center or a hospital’s outpatient department.

Home health care

Eligible health services include home health care provided by a home health care agency in the home, but only when all of the following criteria are met:

• You are homebound.
• Your physician orders them.
• The services take the place of your needing to stay in a hospital or a skilled nursing facility, or needing to receive the same services outside your home.
• The services are a part of a home health care plan.
• The services are skilled nursing services, home health aide services or medical social services, or are short-term speech, physical or occupational therapy.
• If you are discharged from a hospital or skilled nursing facility after a stay, the intermittent requirement may be waived to allow coverage for continuous skilled nursing services. See the schedule of benefits for more information on the intermittent requirement.
• Home health aide services are provided under the supervision of a registered nurse.
• Medical social services are provided by or supervised by a physician or social worker.

Home health care services do not include custodial care.

Hospice care

Eligible health services include inpatient and outpatient hospice care when given as part of a hospice care program.

Outpatient private duty nursing

Eligible health services include private duty nursing care provided by an R.N. or L.P.N. for non-hospitalized acute illness or injury if your condition requires skilled nursing care and visiting nursing care is not adequate.

Residential treatment facility

This is an institution that:

• Specializes in the treatment of psychological and social disturbances that are the result of behavioral health or substance use disorder conditions;
• Provides a sub-acute, structured, psychotherapeutic treatment program under the supervision of physicians;
• Provides 24-hour care, in which the patient lives in an open setting; and
• Is licensed as a residential treatment center in accordance with the laws of the appropriate legally authorized agency.

Skilled-nursing care

Skilled-nursing care is covered if medically necessary. Nursing care that helps a person meet personal needs and daily living activities, such as bathing, dressing, eating or administering oral medication, even if ordered by a physician and performed by a licensed medical professional, is considered custodial and is not a covered expense eligible for benefits. Also, charges for a private-duty nurse in a hospital or an extended-care facility are not covered.

Skilled nursing facility

The types of skilled nursing facility care services that are eligible for coverage include:

• Room and board, up to the semi-private room rate
• Services and supplies that are provided during your stay in a skilled nursing facility

Skilled care

Skilled care involves nursing or rehabilitation services that can be provided only by licensed medical professionals. For example, intravenous feeding is a skilled service.

Emergency services and urgent care

In case of a medical emergency

Go to the nearest hospital for treatment. Benefits for emergency care (as a result of emergency outpatient treatment or an emergency admission to a hospital following emergency outpatient treatment received at the same hospital) are paid at the network reimbursement level for both network and non-network providers. However, the network reimbursement level for emergency care by non-network providers is only payable until the patient is determined able to be safely transferred to a network facility.

If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. If a participant goes to a hospital emergency room for an Emergency Medical Condition, any medical provider can be utilized (Aetna Participating Provider  or non Participating Provider) and the emergency room copay/coinsurance will apply.

Reimbursement for emergency services

When you go to the emergency room, you are subject to a deductible. If you are admitted as an inpatient to the hospital following emergency outpatient hospital treatment, the deductible amount will apply to your separate inpatient hospital deductible. See the Benefit summary.

Reimbursement for non-emergency services

If you go to a non-network emergency room and your condition is determined to be non-emergency, then the expense may be subject to the non-network level of reimbursement (either 60% for the Aetna POS II B or 55% for the Aetna POS II A), after the plan year deductible has been satisfied

In case of an urgent condition

Your physician may direct you to an Urgent Care Center as an alternative to a hospital emergency room when he or she feels it is appropriate to do so. If you or a family member receive care at a network urgent care center, you will pay the applicable copay, equal to the specialist physician copay under your plan option, and the Plan pays the remaining charges.  If you live in a network area, and you use a non-network urgent care center, you will be reimbursed at the non-network level (either 60% for the Aetna POS II B or 55% for the Aetna POS II A), after the plan year deductible has been satisfied.  If you live in an out of network area, you will be reimbursed at the out of network area level (either 80% for the Aetna POS II B or 75% for the Aetna POS II A) after you have met your deductible.

Care while traveling

For non-emergency care, call Aetna Member Services to identify a nearby Medical POS II network provider, choose Find a Doctor on Aetna 's website (aetna.com) or launch the Aetna mobile app.

If a covered family member lives away from home

If you live in a Medical POS II network area and you have a covered family member who lives away from home (for instance, you have a child away at school), your family member's ZIP code determines the level of benefits the Plan pays.

Call Aetna Member Services with your family member's ZIP code to find out if Aetna has a Choice® POS II network in the area. If a network is there, you can contact Aetna Member Services, choose Find a Doctor on Aetna’s member website (www.aetna.com), or launch the Aetna mobile app to identify providers in the area. Here is how benefits are determined:

• If your family member receives care from a network provider, benefits will be paid at the network level.
• If your family member lives in a Medical POS II network area but uses non-network providers, benefits are paid at the non-network level.,

Protections against surprise bills: out-of-Network Provider Exceptions

Services rendered by a non-Participating Provider are subject to special payment rules described below when:

1. You receive emergency services for an Emergency Medical Condition.
2. You receive services by a non-Participating Provider in an In-Network facility.
3. You receive covered air ambulance services.

1. You receive emergency services for an Emergency Medical Condition. In this case, the cost share will be based on the recognized amount calculated in accordance with ERISA § 716. The cost share will not be greater than the amount that would have been charged if such services were provided by an In-Network Provider. If you receive these services, the Out-of-Network Providers cannot Balance Bill you.
2. You receive certain items and services by an out-of-Network Provider in an In-Network facility. In this case, the cost share will generally be based on the recognized amount calculated in accordance with ERISA § 716. The cost share will generally not be greater than the amount that would have been charged if such services were provided by an In-Network Provider. If you receive these services, the out-of-Network Providers cannot Balance Bill you, unless you give written consent.
3. You receive covered air ambulance services. In this case, the cost sharing will be based on the lesser of the qualifying payment amount (calculated in accordance with ERISA § 716) or the billed amount for the services. The cost share requirements will be the same requirements that would apply if the services were provided by an In-Network Provider of air ambulance services. If you receive these services, the out-of-Network Providers cannot Balance Bill you.

When Balance Billing isn’t allowed, you also have the following protections:

• You are only responsible for paying your share of the cost, such as the copayments and coinsurance, that you would pay if the provider or facility was in-network. Your health plan will pay out-of-network providers and facilities directly.
• You’re never required to give up your protections from balance billing. You also don’t have to get care out-of-network. You can choose a provider or facility in your plan’s network.

You are protected from Balance Billing for:

• Emergency services
  If you have an Emergency Medical Condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount. This includes copayments and coinsurance. You can’t be Balance Billed for these emergency services. This includes services you may get after you’re in stable condition. The exception is if you give written consent and give up your protections not to be Balanced Billed for these post-stabilization services.
• Certain services performed by an out of network provider at an in-network hospital or ambulatory surgical center
  When you get services from certain out-of-network providers at an in-network hospital or ambulatory surgical center, those out-of-network providers may not Balance Bill you or ask you to sign a written notice and consent form that allows Balance Billing. You pay only your plan’s in-network cost sharing amount. This applies to anesthesia, assistant surgeon, emergency medicine, hospitalist, intensivist service, laboratory, neonatology, pathology, or radiology.
  
  If you get other services from any other out-of-network providers at in-network hospital or ambulatory surgical center, these out-of-network providers can’t Balance Bill you, unless you sign a written notice and consent form that allows Balance Billing and are provided with a good faith estimate of your costs from the hospital or ambulatory surgical center before services are given. If you sign the notice and consent form, you can be Balance Billed for out-of-network services. You are not required to sign the notice and consent form. You may seek care from an available in-network provider.
• Air Ambulance

When you receive medically necessary air ambulance services from an out-of-network provider, your cost share will be the same amount that you would pay if the service was provided by an in-network provider.  Any cost sharing will be based on rates that would apply if the services were supplied by an in-network provider.

Some states have surprise bill/balance billing laws.  These laws apply to fully insured plans and may have impact to some self-funded plans, including state government or municipal plans and church plans.

Your health plan generally must:

• Cover emergency services without requiring you to get approval for services in advance (prior authorization).
• Cover emergency services by out-of-network providers.
• Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
• Count any amount you pay for emergency services or out-of-network services toward your out-of-pocket limit.

How to handle services supplied based on inaccurate provider directory information?

If you relied on inaccurate information from our provider directories or website or that we verbally provided, we hold you harmless. For example, if you received services from a provider that you believed was in-network based on inaccurate information showing that the provider was in-network, but your claim was paid as out-of-network. In these situations, contact us and we will review the claim. After review, you may be responsible only for your in-network cost share.

Specific conditions

Autism spectrum disorder

Eligible health services include the services and supplies provided by a physician or behavioral health provider for the diagnosis and treatment of autism spectrum disorder.

Family planning services – other

Eligible health services include certain family planning services provided by your physician such as voluntary sterilization for males.

Gender affirming surgery

Gender affirming surgery is considered medically necessary when certain criteria are met. Please refer to Aetna's Clinical Policy Bulletins for more information about the criteria relating to gender affirming surgery.

Insulin and diabetic supplies

Insulin and diabetic supplies are covered under the prescription drug plan through Express Scripts.  They can be obtained through a retail pharmacy or through home delivery by paying your required coinsurance.  In those rare instance where insulin or diabetic supplies are received in a doctor’s office, outpatient facility or hospital setting, they are covered as a medical expense.

Maternity and related newborn care

Eligible health services include prenatal and postpartum care and obstetrical services related to the pregnancy of a covered child, but not those related to the child born to the family member.

After your child is born, eligible health services include:

• 72 hours of inpatient care in a hospital after a vaginal delivery
• 120 hours of inpatient care in a hospital after a cesarean delivery
• A shorter stay, if the attending physician, with the consent of the mother, discharges the mother or newborn earlier

Obesity (Bariatric) surgery

Eligible health services include obesity surgery, which is also known as “weight loss surgery.” Obesity surgery is a type of procedure performed on people who are morbidly obese, for the purpose of losing weight. Obesity is typically diagnosed based on your body mass index (BMI). To determine whether you qualify for obesity surgery, your doctor will consider your BMI and any other condition or conditions you may have. In general, obesity surgery will not be approved for any member with a BMI less than 35.

Your doctor will request approval in advance of your obesity surgery. The plan will cover charges made by a provider for the following outpatient weight management services:

• An initial medical history and physical exam
• Diagnostic tests given or ordered during the first exam
• Outpatient prescription drug benefits included under the Outpatient prescription drugs  section

Health care services include one obesity surgical procedure. However, eligible health services also include a multi-stage procedure when planned and approved by the plan. Your health care services include adjustments after an approved lap band procedure. This includes approved adjustments in an office or outpatient setting.

You may go to any of our network facilities that perform obesity surgeries.

Oral and maxillofacial treatment (mouth, jaws and teeth)

Covered services include the following when provided by a physician, dentist and hospital:

• Dental work required by an accidental injury to sound, natural teeth or the mouth
• Cutting out:
  • Cysts, tumors, or other diseased tissues
  • Cutting into gums and tissues of the mouth.
  • Only when not associated with the removal, replacement or repair of teeth
• Oral surgery and related procedures covered under the Aetna POS II plan options are reimbursed at 75% for the Aetna POS II A and 80% for the Aetna POS II B, regardless of the provider’s network participation.
• Treatment of temporomandibular disorders, sometimes referred to as TMJ/TMD, including splints and orthotics, when preauthorized by Aetna. This includes diagnosis and surgical treatment of the jaw and cranio-mandibular joint resulting from an accident, trauma, congenital or developmental defect, or pathology.

Reconstructive surgery and supplies

Eligible health services include all stages of reconstructive surgery by your provider and related supplies provided in an inpatient or outpatient setting only in the following circumstances:

• Your surgery reconstructs the breast where a necessary mastectomy was performed, such as an implant and areolar reconstruction. It also includes surgery on a healthy breast to make it symmetrical with the reconstructed breast, treatment of physical complications of all stages of the mastectomy, including lymphedema and prostheses.
• Your surgery is to implant or attach a covered prosthetic device.
• Your surgery corrects a gross anatomical defect present at birth. The surgery will be covered if:
  • The defect results in severe facial disfigurement or major functional impairment of a body part.
  • The purpose of the surgery is to improve function.
• Your surgery is needed because treatment of your illness resulted in severe facial disfigurement or major functional impairment of a body part, and your surgery will improve function.

Transplant services

Eligible health services include transplant services provided by a physician and hospital.

This includes the following transplant types:

• Solid organ
• Hematopoietic stem cell
• Bone marrow
• CAR-T and T-Cell receptor therapy for FDA approved treatments

Network of transplant facilities

The amount you will pay for covered transplant services is determined by where you get transplant services. You can get transplant services from:

• An Institutes of Excellence™ (IOE) facility Aetna designates to perform the transplant you need
• A Non-IOE facility

Your cost share will be lower when you get transplant services from the IOE facility Aetna designates to perform the transplant you need. You may also get transplant services at a non-IOE facility, but your cost share will be higher.

The National Medical Excellence Program® will coordinate all solid organ, bone marrow and CAR-T and T-Cell therapy services and other specialized care you need.

Important note: If there is no IOE facility for your transplant type in your network, the National Medical Excellence Program® (NME) will arrange for and coordinate your care at an IOE facility in another one of our networks.  If you don’t get your transplant services at the IOE facility we designate, your cost share will be higher.

Many pre and post-transplant medical services, even routine ones, are related to and may affect the success of your transplant. While your transplant care is being coordinated by the NME Program, all medical services must be managed through NME so that you receive the highest level of benefits at the appropriate facility. This is true even if the covered service is not directly related to your transplant.

Gene Therapy Benefits

For certain gene therapy medications, the Embarc Gene Therapy Protection program allows members to receive life-changing medications with no out of pocket drug costs. As of January 1, 2023, included medications are Luxturna®️, Zolgensma®️, Zynteglo®️, and Skysona®️ and Hemgenix®️. Express Scripts will be performing the prior authorization requests and your clinician can request a review as needed by contacting Express Scripts at 1-800-753-2851. Additional medications may be added pending FDA approval and program changes.

Cost share for associated medical claims, i.e. related inpatient stays, would still apply. Due to the rare nature of these medications and limited network access, medical claims associated with the administration of an Express Scripts-authorized gene therapy medication will be considered non-volitional, which means they will be covered and adjudicated at the in-network level.

Questions about medical claims should still be directed to Aetna.

Specific therapies and tests 

Diagnostic complex imaging services 

Eligible health services include complex imaging services by a provider, including:

• Computed tomography (CT) scans
• Magnetic resonance imaging (MRI) including Magnetic resonance spectroscopy (MRS), Magnetic resonance venography (MRV) and Magnetic resonance angiogram (MRA) 
• Nuclear medicine imaging including Positron emission tomography (PET) scans

Complex imaging for preoperative testing is covered under this benefit. Some services may require precertification.

Diagnostic lab work and radiological services

Eligible health services include diagnostic radiological services (other than diagnostic complex imaging), lab services, and pathology and other tests, but only when you get them from a licensed radiological facility or lab.

COVID-19 diagnostic tests (both administered in doctor’s offices or at pharmacies) and over-the-counter (OTC) COVID-19 tests have been covered by the Plan during the emergency period. Starting May 12, 2023, COVID-19 tests performed in doctor’s offices or at a pharmacy will be covered at the appropriate cost share for diagnostic tests.  Please see the Benefit Summary for detailed information on cost share for diagnostic tests.  

Starting May 12, 2023, COVID-19 OTC tests will not be covered at point of sale, but members that participate in the Health Care Flexible Spending Account (HC FSA) may request reimbursement for those tests, as long as they are considered eligible medical expenses. Inclusion of COVID-19 OTC tests as an eligible HC FSA expense is subject to IRS guidance, which may change in the future.

Chemotherapy 

Eligible health services for chemotherapy depends on where treatment is received. In most cases, chemotherapy is covered as outpatient care. However, your hospital benefit covers the initial dose of chemotherapy after a cancer diagnosis during a hospital stay. 

Chelation therapy

Chelation therapy is covered when considered medically necessary in the treatment of any of the diseases/disorders listed in Aetna Coverage Policy Bulletins.

Oral-motor therapy

Oral-motor therapy is covered when considered medically necessary in the treatment of any of the diseases/disorders listed in Aetna Coverage Policy Bulletins

Outpatient infusion therapy 

Eligible health services include infusion therapy you receive in an outpatient setting including but not limited to a free-standing outpatient facility, the outpatient department of a hospital, a physician in the office or a home care provider in your home. 

Outpatient radiation therapy 

Eligible health services include the following radiology services provided by a health professional: 

• Radiological services
• Gamma ray
• Accelerated particles
• Mesons
• Neutrons
• Radium
• Radioactive isotopes

Short-term cardiac and pulmonary rehabilitation services 

• Cardiac rehabilitation: includes cardiac rehabilitation services you receive at a hospital, skilled nursing facility or physician’s office, but only if those services are part of a treatment plan determined by your risk level and ordered by your physician. 
• Pulmonary rehabilitation: includes pulmonary rehabilitation services as part of your inpatient hospital stay if it is part of a treatment plan ordered by your physician.

Short-term rehabilitation services 

Short-term rehabilitation services help you restore or develop skills and functioning for daily living.

Eligible health services include short-term rehabilitation services your physician prescribes. The services have to be performed by:

• A licensed or certified physical, occupational or speech therapist 
• A hospital, skilled nursing facility, or hospice facility 
•  A home health care agency
• A physician

Short-term rehabilitation services have to follow a specific treatment plan.

Outpatient cognitive rehabilitation, physical, occupational, and speech therapy 

Eligible health services include: 

• Physical therapy, but only if it is expected to significantly improve or restore physical functions lost as a result of an acute illness, injury or surgical procedure.
• Occupational therapy (except for vocational rehabilitation or employment counseling), but only if it is expected to:
• Significantly improve, develop or restore physical functions you lost as a result of an acute illness, injury or surgical procedure, or
• Relearn skills so you can significantly improve your ability to perform the activities of daily living.
• Speech therapy, but only if it is expected to:
• Significantly improve or restore the speech function or correct a speech impairment as a result of an acute illness, injury or surgical procedure, or
• Improve delays in speech function development caused by a gross anatomical defect present at birth.
• Cognitive rehabilitation associated with physical rehabilitation, but only when:
• Your cognitive deficits are caused by neurologic impairment due to trauma, stroke, or encephalopathy and 
• The therapy is coordinated with us as part of a treatment plan intended to restore previous cognitive function.

If you or your provider anticipates that your current course of therapy may exceed 25 visits, have your physician or therapist submit medical records with each physical therapy claim. Claims for therapy service beyond the 25th visit are subject to medical review. Additional information will be required. Claims will not be paid if the service is found not to be medically necessary or rendered in connection with an IEP (Individualized Education Program) in a school setting. Visit limits do not apply to behavioral health services.

Outpatient physical, occupational, and speech therapy 

Eligible health services include: 

• Physical therapy (except for services provided in an educational or training setting), if it is expected to develop any impaired function.
• Occupational therapy (except for vocational rehabilitation or employment counseling), if it is expected to develop any impaired function.
• Speech therapy (except for services provided in an educational or training setting or to teach sign language) is covered provided the therapy is to:
• Restore speech after a demonstrated previous ability to speak is lost or impaired,
• Improve or develop speech after surgery to correct a birth defect which impaired or would have impaired the ability to speak, or
• Improve, develop, or maintain speech impaired as a result of delayed development, including autism spectrum disorder, down syndrome, cerebral palsy, fetal alcohol syndrome, and muscular dystrophy. (See Speech Therapy under Exclusions. Submission of a proposed treatment plan for a benefit predetermination is strongly recommended.)

Other services

Acupuncture

Eligible health services include manual or electro acupuncture consistent with Aetna Coverage Policy Bulletins.  Limited to a 10 visit max per year..

Chiropractic services

Chiropractic services will be covered only when performed by a licensed doctor or chiropractic who is acting within the scope of their license, up to $1,000 per person per year (benefits paid for acupuncture and supplies billed by a doctor of chiropractic are not included in the $1,000 annual maximum).

Ambulance service

Eligible health services include transport by professional ground ambulance services:

• To the first hospital to provide emergency services.
• From one hospital to another hospital if the first hospital cannot provide the emergency services you need.
• From a hospital to your home or to another facility if an ambulance is the only safe way to transport you.
• From your home to a hospital if an ambulance is the only safe way to transport you. Transport is limited to 100 miles.

Your plan also covers transportation to a hospital by professional air or water ambulance when:

• Professional ground ambulance transportation is not available.
• Your condition is unstable, and requires medical supervision and rapid transport.
• You are travelling from one hospital to another and
• The first hospital cannot provide the emergency services you need, and
• The two conditions above are met.

Eligible health services include routine patient costs otherwise covered by the Plan that are associated with participation in phases I-IV of Approved Clinical Trials (as further defined inKey Terms) (i.e., clinical trials that are federally funded and certain drug trials) to treat cancer or other Life-Threatening Conditions, as determined by Aetna and as required by law. These costs will be subject to the Plan’s otherwise applicable cost-sharing requirements and limitations and do not include items that are provided for data collection or services that are clearly inconsistent with widely accepted and established standards of care or otherwise payable or reimbursable by another party.

Durable medical equipment (DME)

Durable medical equipment (DME) when medically necessary, prescribed by a physician for the treatment of an illness or injury. Some DME may require preauthorization from Aetna. For more information on precertification, see the National Precertification List on the Aetna member website. Replacement, repair and maintenance are only covered for purchased DME if:   

• It cannot be repaired
• Repairs would be more expensive than purchasing or renting replacement equipment   
• The attending physician recommends replacement because of a change in the patient’s physical condition   

Coverage includes:

• One item of DME for the same or similar purpose.
• Repairing DME due to normal wear and tear. It does not cover repairs needed because of misuse or abuse.
• A new DME item you need because your physical condition has changed. It also covers buying a new DME item to replace one that was damaged due to normal wear and tear, if it would be cheaper than repairing it or renting a similar item.

Your plan only covers the same type of DME that Medicare covers. But there are some DME items Medicare covers that your plan does not. We list examples of those in the exclusions section.

Extended-care facilities

An extended-care facility provides skilled-nursing services and rehabilitation care. Extended-care facility charges are covered expenses if these conditions are met:

• The inpatient stay must be medically necessary, and
• The inpatient stay has been pre-certified.

Reimbursement is based on the facility charge or daily room and board rate of the hospital from which the patient transferred, whichever is less.

Hearing aids and exams

Benefits are provided up to a maximum of $2,500 after the deductible and coinsurance are paid for one or more hearing aids every rolling five year period, which also includes the repair of a hearing aid. However, shipping and handling charges and routine maintenance such as battery replacement are not covered. The amount allowed is subject to reasonable and customary limits but not negotiated rates. There are no Medical POS II preferred providers for hearing aids and related materials. The member will be responsible for the difference between the billed and allowable amount regardless of provider participation.

You may be able to maximize your benefit through the Amplifon Hearing Health Care (formerly HearPo) Discount Program,  the Hearing Care Solutions Discount Program or LifeMart. 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-of-pocket expenses could be lower. To find a participating hearing discount center location, visit www.aetna.com and select "Hearing Discount Locations". To compare costs, please call Amplifon Hearing Health Care at 1-877-301-0840 or Hearing Care Solutions at 1-866-344-7756 and identify yourself as an Aetna member. To browse LifeMart discounts, register on their website via the link on the Aetna Member Website.

Non-routine/non-preventive care hearing exams

Eligible health services for adults and children include charges for an audiometric hearing exam for evaluation and treatment of illness, injury or hearing loss.

Prosthetic devices

Braces, crutches and prostheses required because of an injury or disease. Coverage is generally limited to the purchase price.

Coverage includes:

• Repairing or replacing the original device you outgrow or that is no longer appropriate because your physical condition changed
• Replacements required by ordinary wear and tear or damage
• Instruction and other services (such as attachment or insertion) so you can properly use the device

Behavioral health and substance use disorder care

Behavioral health and substance use disorder care for the Retiree Medical Plan - POS II A and B Options

Behavioral Health coverage

Covered services include the treatment of behavioral health disorders provided by a hospital, psychiatric hospital, residential treatment facility, physician, or behavioral health provider including:

• Inpatient room and board at the semi-private room rate (your plan will cover the extra expense of a private room when appropriate because of your medical condition), and other services and supplies related to your condition that are provided during your stay in a hospital, psychiatric hospital, or residential treatment facility
• Outpatient treatment received while not confined as an inpatient in a hospital, psychiatric hospital, or residential treatment facility, including:

• Office visits to a physician or behavioral health provider such as a psychiatrist, psychologist, social worker, or licensed professional counselor (includes telemedicine consultation)
• Individual, group, and family therapies for the treatment of behavioral health disorders
• Other outpatient behavioral health treatment such as:
  • Partial hospitalization treatment provided in a facility or program for behavioral health treatment provided under the direction of a physician
  • Intensive outpatient program provided in a facility or program for behavioral health treatment provided under the direction of a physician
  • Skilled behavioral health services provided in the home, but only when all of the following criteria are met:
    • You are homebound
    • Your physician orders them
    • The services take the place of a stay in a hospital or a residential treatment facility, or you are unable to receive the same services outside your home
    • The skilled behavioral health care is appropriate for the active treatment of a condition, illness, or disease
  • Electro-convulsive therapy (ECT)
  • Transcranial magnetic stimulation (TMS)
  • Psychological testing
  • Neuropsychological testing
  • Observation
  • Peer counseling support by a peer support specialist

Substance use disorder treatment

Covered services include the treatment of substance related disorders provided by a hospital, psychiatric hospital, residential treatment facility, physician, or behavioral health provider as follows:

• Inpatient room and board, at the semi-private room rate (your plan will cover the extra expense of a private room when appropriate because of your medical condition), and other services and supplies that are provided during your stay in a hospital, psychiatric hospital, or residential treatment facility.
• Outpatient treatment received while not confined as an inpatient in a hospital, psychiatric hospital, or residential treatment facility, including:
  • Office visits to a physician or behavioral health provider such as a psychologist, social worker, or licensed professional counselor (includes telemedicine consultation)
  • Individual, group, and family therapies for the treatment of substance related disorders
  • Other outpatient substance related disorders treatment such as:
    • Partial hospitalization treatment provided in a facility or program for treatment of substance related disorders provided under the direction of a physician
    • Intensive outpatient program provided in a facility or program for treatment of substance related disorders provided under the direction of a physician
    • Ambulatory or outpatient detoxification which include outpatient services that monitor withdrawal from alcohol or other substances, including administration of medications
• Observation
• Peer counseling support by a peer support specialist

Behavioral health important note: A peer support specialist serves as a role model, mentor, coach, and advocate. They must be certified by the state where the services are provided or a private certifying organization recognized by Aetna. Peer support must be supervised by a behavioral health provider.

Precertification

All inpatient and residential treatment for behavioral health and substance use disorder care must be pre-certified. The health care provider is responsible for obtaining pre-certification for network care. The participant is responsible for obtaining required pre-certifications for services at non-network facilities; if pre-certification for inpatient care is not obtained, a $500 penalty will be assessed for failure to pre-certify inpatient care at a non-network facility.

Prescription drug program

Prescription drug program information for the ExxonMobil Retiree Medical Plan - Aetna POS II A and B options

The Plan contains a prescription drug program that offers you two cost-saving ways to buy outpatient prescription drugs. You may buy your prescriptions through:

• A network of local participating retail pharmacies for short-term prescriptions.
• Express Scripts Pharmacy, and participating Smart90 retail pharmacies (Walgreens, CVS) the home delivery pharmacy for long-term or maintenance prescriptions.
• Express Scripts Specialty Pharmacy, Accredo, for prescriptions requiring special handling.

Please note, a dose or doses of prescription medication or injections given at the time of treatment in a doctor’s office is covered under the POS II Medical Plan as a part of the medical service rendered. Self-administered or take home use prescription medication may be covered under your prescription drug benefit and you must submit claims separately to Express Scripts for reimbursement.

Refer to the Summary of Benefits for details on the costs per prescription

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. The Plan generally provides benefits for up to a 34-day supply. See Special provisions for more information.

You have the choice of filling your prescriptions at:

• A local in-network retail pharmacy (part of Express Scripts' extensive network of pharmacies), where you will pay your share of the discounted cost, and there are no claims to file.
• A non-network retail pharmacy of your choice, where you will pay the full price and file a claim for partial reimbursement of the cost.

The in-network retail network pharmacy

You may call Express Scripts, check the Express Scripts website (www.express-scripts.com), or use the Express Scripts mobile app to locate an in-network retail pharmacy near you. When you fill a prescription, you must identify yourself as a member of Express Scripts’ retail pharmacy program to maximize your savings.

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 blood pressure, you will pay an additional 25% copayment. The additional 25% copayment does not apply to your annual prescription drug out-of-pocket maximum.

How to obtain your prescription or a refill

• Refills can be obtained if prescribed and needed. You must have generally used 75% of the previous prescription, based on the dosage prescribed, before you can refill and receive plan benefits.
• To receive the discounted price, present your prescription and either your prescription drug identification card or the primary participant's identification number at an in-networknetwork retail pharmacy. See the definition for primary participant.
• The pharmacist enters the prescription and the primary participant's Social Security number or ID number into the pharmacy's computer system to confirm:

• That the participant or family member is covered,
• That it is a covered prescription, and
• The prescription's cost share.
• No claim filing is necessary.

The term Primary Participant refers to the participant whose identification number is used. The primary participant is the retiree or 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 identification number after the date they enroll as a COBRA participant.

Using a Non-Network Pharmacy or Not Showing Your Express Scripts or Medco ID Card

You are not eligible for a discounted price if you have your prescription filled at a non-network retail pharmacy or fail to show your prescription drug ID card at a in-network retail pharmacy. You may print out a temporary ID card if you have registered for access to your personal account on the Express Scripts website at www.express-scripts.com.

• You pay the full price of the prescription at the time of purchase.
• You must submit a completed Direct Reimbursement Claim Form to Express Scripts within two years following purchase. You may obtain a claim form by accessing the ExxonMobil Family Internet site or by contacting 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 the discounted cost of the prescription (the ineligible cost),
  PLUS
• Your percentage copayment portion of the discounted cost.

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, a heart condition or blood pressure. The Plan generally provides benefits for up to a 90-day supply. See Special provisions for more information.

How to get started with Express Scripts Pharmacy

If you need maintenance medication immediately, ask your doctor for two prescriptions — one for an immediate supply to be filled at a local retail pharmacy and a second for an extended supply to be ordered through the home delivery pharmacy. You can also fill maintenance medications at a Smart90 retail pharmacy (Walgreens, CVS).

Home delivery pharmacy prescriptions

With Express Scripts Pharmacy, you save money and have the convenience of home delivery. Ask the doctor to write a prescription for up to a 90-day supply with appropriate refills. Enclose your original prescription(s) and payment of your percentage copayment in an envelope. If you are paying by check or money order, you may obtain a calculation of your percentage copayment from the Express Scripts Web site or by calling Express Scripts directly. If you are paying by credit card, Express Scripts will deduct the appropriate percentage copayment and you will receive notification of the deduction with your medication. 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.

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 generally used 75% of the previous prescription based on the prescribed dosage.

Whether you fill prescriptions through Express Scripts Pharmacy or at a local retail pharmacy:

• Your payments and copayments under the outpatient prescription drug benefits do not apply toward your deductible for other benefits under the Plan.
• Your prescription drug payments and copayments do not apply toward your annual medical out-of-pocket limit.
• Your prescription drugs annual out-of-pocket maximum is $2,500 for each individual in your family, or $5,000 for your entire family.
• The additional cost for purchasing brand-name prescription drugs when a generic is available, as well as the full cost for purchasing subsequent refills of maintenance medication after the third fill obtained at retail pharmacies that are not part of the Smart90 network (Walgreens, CVS), will not count toward your annual out-of-pocket maximum.

Comparing retail pharmacy with Express Scripts Pharmacy

This example shows how you can save money by purchasing long-term medications through either the Express Scripts home delivery, or a Smart90 retail pharmacy.

At a in-network Retail Pharmacy			Through Express Scripts, or Smart90 retail pharmacy
$108.00	Cost of formulary preferred brand name drug (30-day supply)		$324.00	Cost of formulary preferred brand name drug (90-day supply)
x 30%	Percentage copayment		x 25%	Percentage copayment
$32.40	Your copayment		$81.00	Your copayment
You pay $32.40, or $97.20 for 3 purchases.			You pay $81.00

By purchasing a 90-day supply of this prescription through home delivery, 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% copayment for the third and any subsequent refills from a participating retail pharmacy. Actual savings may be greater..

Covered prescriptions

The prescription drug program covers drugs, medicines, and supplies that are:

• Obtainable only with a physician's prescription or are specifically covered expenses (see Covered expenses),
• Approved by the U.S. Food and Drug Administration for the specific diagnosis,
• Medically necessary, and
• 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 dispense only generics that 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 copayment amount will depend on which medication you select.

If you purchase the brand name drug, you are responsible for paying the generic drug percentage copayment PLUS the full difference in cost between the generic drug and the brand name drug. This difference in cost will not count toward your annual prescription drug out-of-pocket maximum.

Here is an example from the POS II B option 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.

	Generic	Brand
Prescription cost	$ 50.00	$ 200.00
Copayment (30% of the cost of generic drug)	$ 15.00	$ 15.00
Difference in cost with available generic*	$ 0.00	$ 150.00
Total cost	$ 15.00	$ 165.00

If you purchase the brand name drug:

• Your copayment will be $15 + $150 (difference in cost) = $165
• The additional $150 does not count toward your annual prescription drug out-of-pocket maximum.

Available alternatives

Sometimes, a generic drug or a less expensive brand name drug which provides the same therapeutic effect 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 percentage copayment.

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 home delivery 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 monitoring service may 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.

Your doctor makes the final decision about any change in your prescription or course of treatment.

Special provisions

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 of buying 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.
• For most prescriptions, 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.
• During natural disasters, you may be able to replace lost or damaged medications without having used 75% of the previous prescription.

Specialty medications

Specialty medications, including injectables and infusions for rheumatoid arthritis and other inflammatory conditions, require special handling and may be administered in a hospital, clinic, doctor’s office, or in your home. Some specialty medications, like most oncology drugs administered in a hospital setting, are covered under the medical benefit administered by Aetna. Other specialty medications are covered under the prescription drug program administered by Express Scripts. If you have questions about starting a specialty medication, call Aetna member services and ask to speak to a Health Advocate nurse.

Specialty medications administered by Express Scripts are filled through their specialty pharmacy, Accredo, and can be delivered to hospitals, clinics, doctor’s offices, or to a home health care provider. Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits. However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program. If the specialty medication being purchased qualifies for copay assistance and is included in the drug list linked here, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program. If you choose not to enroll in the program, a 30% coinsurance with no maximum will apply, and any amount you pay will not count towards your Deductible or Out-of-Pocket Maximums.

Advanced Utilization Management

In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the Plan will cover another (usually more expensive) drug.  Prior authorization and preferred drug step therapy rules are designed to encourage the use of effective, lower-cost drugs.

As part of Express Scripts’ Advanced Utilization Management (AUM) program, certain targeted drugs will not be covered unless precertified by Express Scripts, based on medical evidence submitted by your physician. In addition, some therapies will be monitored for appropriate pharmacogenomic parameters, and oral oncology medications will be limited to ensure appropriate use. Please visit www.express-scripts.com to more information about your medications and if they require a coverage review.  If you have a question regarding a drug on the AUM program list, contact Express Scripts at the number listed in the Information Sources section of this SPD.

Preferred drug step therapy rules

Preferred drug step therapy rules are used for certain therapeutic classes of drugs, to encourage the use of effective, lower-cost drugs initially by excluding some targeted medications from coverage unless prior authorization is provided by Express Scripts. Therapeutic classes include: proton pump inhibitors, sleep agents, depression, osteoporosis, respiratory, cardiovascular, triptans, glaucoma, diabetes, respiratory allergy/asthma, anti-inflammatory and rheumatoid arthritis, growth hormone, stimulants for Attention Deficit Hyperactivity Disorder (ADHD), prostate therapy drugs, topical steroids, and stroke prevention. 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 classes, 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

Prior authorization rules apply to certain therapeutic classes of drugs; therapies in this section will be monitored for appropriate use, including pharmacogenomics parameters in some cases.  These classes include 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 classes, contact Express Scripts. You will be notified directly by Express Scripts if you are affected by these rules.

Therapeutic Resource Centers

Plan participants and their physicians may receive outreach calls from Express Scripts Therapeutic Resource Center (TRC) pharmacists or healthcare specialists to offer personal over-the-phone guidance as well as other health management tools. You can also ask to speak to a TRC pharmacy specialist when you call Express Scripts.

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.

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 clinical data available at that time.

Coordinating benefits for prescriptions

The Medical Plan coordinates benefits with any other group medical plan under which you or your family members are covered, which is described in more detail in Coordination of benefits in the Payments section of this SPD. This information is provided to the prescription drug network.

Exclusions

Exclusions for the ExxonMobil Retiree Medical Plan – Aetna POS II A and B options

Although the Plan covers many types of treatments and services, it does not cover all of them. Exclusions shall be interpreted and applied consistently with Clinical Policy Bulletins published by Aetna. These bulletins can be accessed on the Aetna website at www.aetna.com. See Basic Plan features for more information.

No benefits are payable under the Plan ( POS II A and B) for any charge incurred for:

General exclusions

• Any claim submitted past the claim-filing deadline.
• Any expense incurred before you or your family members became covered under this option (except children less than 31 days old).
• Any expenses that exceed reasonable and customary limits.
• Any procedure, treatment or other type of coverage prohibited under federal, state, local or other applicable law.
• Charges for missed appointments, and/or completion of claim forms are excluded by the Plan

Physicians and other health professionals

• Any expense not recommended and approved by a physician acting within the scope of his or her license.
• Any program or service performed in a nonconventional setting, even if the services are performed by a licensed provider, including: spas/resorts, outdoor learning or leadership programs; wilderness, camp, or ranch programs; academic, vocational, or recreational settings.
• Experimental or investigational drugs or treatments for a particular diagnosis.
• Periodic physical examinations paid for by the company.
• Treatment not specifically covered or meeting the Plan's requirements for medically necessary for the care or treatment of a particular disease, injury, or pregnancy, even when medical provider has recommended/prescribed the services

Hospital and other facility care

• Cosmetic surgical procedures, treatments or hospital stays, except for those that are primarily for the purpose of restoring a bodily function or surgery, which is medically necessary. 
• Custodial care or maintenance care, even if ordered by a physician.
• In-hospital expenses for non-medical items, such as a telephone or television set.
• Private-duty nursing, except as defined in the Covered expenses section.
• Private room rate above the hospital's most common semiprivate room rate, except when medically necessary.
• Stay in a facility that is primarily a school, place of rest, or nursing home.

Specific conditions

• Applied Behavior Analysis (ABA) for Autism spectrum disorder conditions.
• Bariatric surgery expenses for the treatment of morbid obesity in excess of the $25,000 lifetime maximum.
• Chelation therapy.
• Chiropractic services for therapeutic purposes in excess of $1,000 per person per year and any maintenance chiropractic care.
• Concierge or annual fees.  Any portion not related to medical care (such as a private waiting room, same-day appointments, extended time with physician) is excluded.
• Dental charges except as specifically provided in the Covered Expenses section.
• Drugs or vitamins that are available over the counter, even if prescribed by a physician (referred to as legend vitamins, except prenatal vitamins, Rocaltrol).
• Fertility benefits provided by Progyny.
• Foot orthotics and other supportive devices for feet with the exception of some types of foot braces, even if prescribed by a physician.
• Laser-assisted in situ keratomileusis (LASIK), photorefractive keratectomy (PRK), and other similar or related procedures to improve visual acuity. Revision or repeated treatment of surgery is not covered.
• Non-therapeutic or elective abortions.
• Nutritional programs, weight programs, and related food supplements, except for physician expenses and lab costs for treatment of morbid obesity, and for nutritional counseling performed by a licensed nutritionist or dietician, consistent with Aetna's Clinical Policy Bulletins.
• Nutritional supplements, even if prescribed by a physician, except for treatment of phenylketonuria (PKU). 
• Outpatient prescription drugs in excess of the allowed supply (34 days for retail and 90 days for home delivery) per fill or refill.
• Routine eye examinations, eyeglasses, contact lenses, and orthoptics.
• Self-treatment
• Services primarily of an educational nature or in an educational setting, including but not limited to services for developmental reading disorders, developmental arithmetic disorders, developmental language disorders or developmental articulation disorders.
• Some prescription medications including injections, billed by and provided in an outpatient hospital or Doctor's office, are not covered under Aetna, but may be covered under the prescription drug program administered through Express Scripts.
• Wigs or hairpieces for androgenic alopecia (male pattern baldness).
• Treatment of injuries received or illnesses contracted while on military assignment and covered by a government medical plan.
• Treatment of occupational illnesses or injuries sustained in situations covered by workers' compensation or a similar law.
• Transportation or travel expenses other than emergency transportation service by professional ambulance, transportation costs to travel to a COE/IOE, if the distance is over 100 miles, and for Organ, Tissue and Bone Marrow Transplants.
• Voluntary sterilization reversal procedures (including any services for infertility related to voluntary sterilization and its reversal).

Medical Claims and Appeals

Filing claims for the ExxonMobil Retiree Medical Plan – Aetna POS II A II B options

For most of your network claims for benefits, you do not need to submit a claim. This will be done automatically for you by the network provider. However for some network providers and out of network providers you will be required to file a claim for benefits.

All claims and appeals for benefits should be directed to the appropriate claims fiduciary. Eligibility claims should be directed to the Administrator-Benefits.

How to file a Claim for benefits

If your providers do not file claims for benefits for you, follow the instructions on the claim forms, which are available at the Healthcare forms and useful links section of the ExxonMobil Family Internet site.

If you need to file a claim:

• Submit a completed claim form with necessary documentation within 12 months from the date the expense was incurred.
• Aetna will send you an explanation of benefits (EOB) for each claim. The EOB shows what service was performed, how much the provider charged, and what the covered charge was under the Plan. It shows if copayment was involved, as well as the calculation used to determine your benefit.
• Keep the explanation of benefits for your records.
• You can review your EOB by going to Aetna's website at www.aetna.com and following the instructions.

For prescription drug claims, refer to Short-term prescriptions in the Prescription Drug Program section.

Effective January 1, 2023, non-emergent care outside the U.S. will no longer be covered.

If you paid for medical care received when traveling or working outside the United States prior to January 1, 2023, you have up to 12 months to request reimbursement by submitting an itemized bill along with a claim form. If the original bills are in a foreign language or paid in a foreign currency, you should obtain an English translation, if possible, of the services rendered and the claims administrator will convert the bill to U.S. dollars as of the date of service. Covered expenses are payable at an out-of-network schedule. 

If you were enrolled in POS II A and B plan options by December 31, 2022 you will be grandfathered and thus allowed to process non-emergent claims outside the US.

Initial Claim Review and Decision

When you file a claim, the claims administrator reviews the claim and makes a decision to either approve or deny the claim (in whole or in part). You will receive a written notice of the claim decision within the time limits described in the chart that follows. Those time limits are based on the type of claim and whether you submit a proper claim, including all necessary information. 

Urgent, Pre-Service and Post-Service claims

Time limits
Urgent care claim	Pre-service claim		Post-service claim
If the initial claim is properly completed:
Notice will be given to you not later than 72 hours after receiving the initial claim.         Notice of initial benefits decision 24 hours in the case of a concurrent claim, if you request to extend the authorized treatment at least 24 hours before the existing authorization ends	Notice will be given to you not later than 15 days after receiving the initial claim, unless an extension, up to 15 days, is necessary due to matters beyond the control of the plan. You will be notified within the initial 15 days if an extension is needed. In the case of a concurrent claim, you will be notified in advance of any reduction or termination of treatment so you may appeal the decision		Notice will be given to you not later than 30 days after receiving the initial claim, unless an extension, up to 15 days, is necessary due to matters beyond the control of the plan. You will be notified within the initial 30 days if an extension is needed. In the case of a concurrent claim, you will be notified in advance of any reduction or termination of treatment so you may appeal the decision
If the initial claim is not properly completed:
Notice will be given to you as soon as possible (but no more than 24 hours after Aetna receives the claim). You will have up to 48 hours to provide the additional information.	Notice will be given to you 15 days of receipt of the claim.   You will have up to 45 days to provide the additional information.		Notice will be given to you 30 days of receipt of the claim.   You will have up to 45 days to provide the additional information.
If additional information is required:
The Plan´s benefit determination will be given to you not later than 48 hours after receiving additional information or upon the expiration of your 48-hour deadline to provide such information to complete the claim, whichever is earlier.		The Plan´s benefit determination will be given to you not later than 15 days after receiving your additional information or upon the expiration of your 45-day deadline to complete the claim, whichever is earlier.

 

Claim denial and reconsideration

If all or part of a claim is denied, Aetna will provide you with a written explanation supporting the denial.

For Concurrent Care Claims, Aetna will send you written notification of an affirmative benefit determination. For other types of claims, you may only receive notice if Aetna makes an adverse benefit determination.

Adverse benefit determinations are decisions Aetna makes that result in denial, reduction, or termination of a benefit or the amount paid for it. It also means a decision not to provide a benefit or service.

Adverse benefit determinations can be made for one or more of the following reasons:

• The individual is not eligible to participate in the Plan, or
• Aetna determines that a benefit or service is not covered by the Plan because:
• it is not included in the list of covered benefits,
• it is specifically excluded,
• a Plan limitation has been reached, or
• it is not medically necessary.

How to Appeal an Adverse Benefit Determination

Aetna will send you a written notice of an adverse benefit determination that will include the reason for the decision and will explain what steps you must take if you wish to appeal. The Plan provides for two levels of appeal plus an option to seek External Review of the adverse benefit determination. Appeals should be filed within 180 days from the date of the notice of Adverse Benefit Determination.

The following chart summarizes some information about how level one and level two appeals are handled for different types of claims. In certain situations, such as natural disasters and pandemics, the time frames shown may be extended. Please contact Aetna member services for more information.  

 

 

External review of Aetna’s final appeal determinations

If the Level One and Level Two appeals uphold the original adverse benefit determination, you may have the right to pursue an external review of your claim.

An external review is a review by an independent physician, with appropriate expertise in the area at issue, of claim denials and denials based upon lack of medical necessity, a rescission of coverage, or an adverse determination for surprise bills (medical and air ambulance bills, including a determination of whether an adverse determination is subject to surprise billing provisions) or the experimental or investigational nature of a proposed service or treatment. You may request a review by an external review organization (ERO) if:

• You have received notice of the denial of a claim by Aetna, and
• Your claim was denied because Aetna determined that the care was not medically necessary or was experimental or investigational, and

You must submit the Request for External Review Form to Aetna within four months of the date you received the final claim denial letter. The form must be accompanied by a copy of the final claim denial letter and all other pertinent information that supports your request.

Aetna will contact the External Review Organization that will conduct the review of your claim. The External Review Organization will select an independent physician with appropriate expertise to perform the review. In rendering a decision, the external reviewer may consider any appropriate credible information submitted by you with the Request for External Review Form, and will follow the applicable plan’s contractual documents and plan criteria governing the benefits. You will generally be notified of the decision of the External Review Organization within 45 days of Aetna’s receipt of your request form and all necessary information. An expedited review is available if your physician certifies (by telephone or on a separate Request for External Review Form) that a delay in receiving the service would jeopardize your health. Expedited reviews are decided within 3-5 calendar days after Aetna receives the request.

You are responsible for the cost of compiling and sending the information that you wish to be reviewed by the External Review Organization to Aetna. Aetna is responsible for the cost of sending this information to the External Review Organization.

Nonalienation of Benefits 

No benefit, right or interest of any Covered Person under the Plan shall be subject to anticipation, alienation, sale, transfer, assignment, pledge, encumbrance, charge, garnishment, execution or levy of any kind, either voluntary or involuntary, including any liability for, or subject to, the debts, liabilities or other obligations of such person; and any attempt to anticipate, alienate, sell, transfer, assign, pledge, encumber, charge, garnish, execute or levy upon, or otherwise dispose of any right to benefits payable hereunder or legal causes of action, shall be void.  Notwithstanding the foregoing, the Plan may choose to remit payments directly to health care providers with respect to covered services, if authorized by the Covered Person, but only as a convenience to Covered Persons.  Health care providers are not, and shall not be construed as, either “participants” or “beneficiaries” under this Plan and have no rights to receive benefits from the Plan or to pursue legal causes of action on behalf of (or in place of) Covered Persons under any circumstances.

This provision in this SPD is deemed to be notice to any and all individuals to whom notice may be required, and no additional notice of the above provisions is needed for a provider or otherwise.

Uncashed Checks 

If a check to a Participant for benefits under the Plan remains uncashed for 5 years after issue, amounts attributable to such check shall remain in the Plan until the time the participant has requested these funds.

End of the COVID-19 emergency periods (National Emergency (NE) and Public Health Emergency (PHE)

The COVID-19 “Outbreak Period” was anticipated to end 60 days after the end of emergency period. During that period, certain deadlines for the events outlined below were paused. The regular deadline timing for these events will resume starting on July 10, 2023. As these extended deadlines are applied on a case-by-case basis and if you have a question about the appropriate deadline for a particular claim or appeal, please contact the carrier (Aetna, Cigna, Express Scripts) directly for further assistance.

• Enrolling in a health plan upon a special enrollment event
• Electing COBRA continuation of coverage
• Making COBRA premium payments
• Notifying the plan of a COBRA qualifying event or determination of disability
• Filing an initial benefit claim or appeal of an adverse benefit determination for disability, retirement and other plans
• Filing an initial benefit claim, appeal of an adverse benefit determination and external review of certain claims for health plans

For example, assume that you experienced a COBRA qualifying event on March 1, 2023.  Ordinarily, you would have a 60-day election period, or until April 30, 2023, to elect COBRA continuation coverage.  However, the “outbreak period” pauses these deadlines until July 10, 2023.  As a result, the 60-day election period will not start to run until July 11, 2023, and you will have 60 days from July 11, 2023, or until September 8, 2023, to elect COBRA continuation coverage. You are still responsible for premium payments for the entirety of the period that you are covered (beginning with your qualifying event), even if your election deadline was adjusted due to the emergency period.

Administrative and ERISA information

Administrative and ERISA information for the ExxonMobil Retiree Medical Plan – Aetna POS II A and B options

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 Retiree Medical Plan.

Plan sponsor and participating affiliates

The ExxonMobil Retiree Medical Plan is sponsored by:

Exxon Mobil Corporation
22777 Springwoods Village Parkway
Spring, TX 77389

All of Exxon Mobil Corporation's divisions and most of the major U.S. affiliates participate in the ExxonMobil Retiree Medical Plan. A complete list of participating affiliates is available from the Administrator-Benefits upon written request.

Basic plan information

Plan name

ExxonMobil Medical Plan
This SPD describes the POS II A and B options.

Plan sponsor and participating affiliates

The ExxonMobil Retiree Medical Plan is sponsored by:

Exxon Mobil Corporation
22777 Springwoods Village Parkway
Spring, TX 77389

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.

Plan numbers

The ExxonMobil Retiree Medical Plan is identified with government agencies under two numbers: the Employer Identification Number, 13-5409005, and the Plan Number (PN), 540.

Plan administrator

Various aspects of the Plan are administered by various parties. The Administrator of the Plan shall have the full power to control and manage all aspects of the Plan in accordance with its terms and all applicable laws. The Administrator may allocate or delegate its responsibilities for the administration of the Plan to others and employ others to carry out or give advice with respect to its responsibilities under the Plan, including administrative services of the following nature: Claim Administration; Cost Containment; Financial; Banking and Billing Administration. Benefits provided under this plan are funded by ExxonMobil.

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).

For appeals of eligibility or enrollment issues Administrator-

Benefits P.O. Box 18025
Norfolk, VA 23501-1867

Effective January 2, 2024, Alight will be the new administrator of ExxonMobil’s health, life insurance, and pension plans. If you need assistance, please contact:

ExxonMobil Benefits Service Center
Phone: 833-776-9966
Hours: 8am – 4pm CST, Monday through Friday, except certain holidays
Your Total Rewards portal: digital.alight.com/exxonmobil

Alight Mobile app  (available through Apple App Store or Google Play)

Address:
Dept 02694, PO Box 64116, The Woodlands, TX, 77387-4116

For service of legal process:

Corporation Service Co.
211 East 7th Street, Suite 620
Austin, Texas 78701-3218

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 Retiree Medical Plan in its application to any participant or beneficiary, and to decide any and all claim appeals.

NOTE: Effective January 1, 2021, no appeals of eligibility will be available regarding decisions that a  dependent child no longer meets the clinical definition of totally and continuously disabled. All decisions by  Aetna confirming a dependent no longer meets the clinical definition of totally and continuously disabled are final.

Type of plan

The ExxonMobil Retiree Medical Plan is a welfare plan under ERISA providing medical benefits.

Plan year

The plan year is the calendar year.

Plan funding

The Plan is funded through participant and company contributions. Each year, ExxonMobil determines the rates of required participant contributions to the ExxonMobil Retiree Medical Plan. These rates are based on past and projected plan experience. Participant contributions are paid to a Trustee who manages the funds under the terms of a Trust Agreement between ExxonMobil and the Trustee. The Trustee for the EMRMP Plan is:

The Northern Trust Company
50 S. LaSalle
Chicago, IL 60675

Claims administrator

The claims administrator provides information about claims payment. The claims administrator is Aetna for medical and behavioral health and substance use disorder claims and Express Scripts for prescription drug claims.

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 Retiree Medical Plan

ExxonMobil has the right to change, suspend, withdraw, amend, modify or terminate the 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. If all claims and expenses are paid and there is still money in ExxonMobil's book reserve established for the purpose of making contributions toward the cost of retirees' health care coverage, ExxonMobil will determine what to do with the excess amount in view of the purposes of the plans.

Your rights under ERISA

As a participant in the ExxonMobil Retiree 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 ExxonMobil Retiree Medical Plan, and a copy of the latest annual report (Form 5500 Series) filed by the ExxonMobil Retiree Medical Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.
• Obtain, upon written request to the Administrator-Benefits, copies of documents governing the operation of the ExxonMobil Retiree Medical Plan, 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 Plan's annual financial report. The Administrator-Benefits is required by law to furnish each participant with a copy of this summary annual report.

Prudent actions by ExxonMobil Retiree Medical Plan fiduciaries

In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called fiduciaries of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one can 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 the Plan documents or the latest summary annual report from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the 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. 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 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 the ExxonMobil Retiree Medical Plan, you should contact Aetna Member Services via the telephone number on your ID card, or call the Benefits Service Center. 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.

Federal Notices

Federal Notices for the ExxonMobil Retiree Medical Plan – Aetna POS II A B options

A note regarding the ExxonMobil Retiree Medical Plan

The Retiree Medical Plan (RMP) is a retiree only plan. A retiree only health plan is exempt from all the insurance mandates of the PPACA and HIPAA portability. As a retiree only plan the RMP will not include the consumer protections of PPACA that apply to the other 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 copayment 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,
• Prostheses, and
• Services for physical complications in all stages of mastectomy, including lymphedema.

The above benefits will be provided subject to the same deductibles, copayments 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

List of key terms in the Retiree Medical Plan - POS II A and B options

Approved Clinical Trial

A phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life- threatening disease or condition and meets any of the following three conditions:

1. Federally funded trials. The study or investigation is approved or funded (which may include funding through in-kind contributions) by one or more of the following:
• The National Institutes of Health.
• The Centers for Disease Control and Prevention.
• The Agency for Health Care Research and Quality.
• The Centers for Medicare & Medicaid Services.
• Cooperative group or center of any of the entities described in clauses (a) through (d) or the Department of Defense or the Department of Veterans Affairs.
• A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants.
• Any of the following if certain conditions are met:
• The Department of Veterans Affairs.
• The Department of Defense.
• The Department of Energy.
• The study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration; or
• The study or investigation is a drug trial that is exempt from having such an investigational new drug application.
The conditions for this clause (g) are that the study or investigation has been reviewed and approved through a system of peer review that the Secretary of Health and Human Services determines: to be comparable to the system of peer review of studies and investigations used by the National Institutes of Health, and assures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review.


2. The study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration; or
3. The study or investigation is a drug trial that is exempt from having such an investigational new drug application.

Balance Bill

The difference between the Plan’s reimbursement for out-of-Network services and what the Provider charges. 

Behavioral 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 (5th ed. 2013) (DSM-V), or its successor publication, and which is appropriately treated by the Behavioral health Network. Such a condition will be considered a behavioral health condition, regardless of any organic or physical cause or contributing factor.

Behavioral health provider

A person, including a psychiatrist, psychologist, psychiatric nurse or social worker, therapist, or other clinician with at least a master's degree, who provides inpatient or outpatient treatment for a behavioral health condition, who is licensed in the state of practice and who is acting within the scope of that license (if applicable). If the person is not subject to a licensing requirement, the person must provide treatment consistent with that which would be provided by the type of providers listed above.

Benefit service

Generally, all the time from the first day of employment until you leave the company's employment. Excluded are:

• Unauthorized absences,
• Leaves of absence of over 30 days (except military leaves or leave 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, as a special agreement person, in a service station, car wash, or car-care 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.

Benefit predetermination

The review of proposed treatment or services before the expense is incurred to determine if, and to what extent, charges will be covered by the Plan. 

Case management

Review provided by medical professionals who consult with the patient and/or care providers to determine effective, cost-efficient ways to treat illnesses and utilize plan benefits.

Change in status

Life or work event that allows you to make changes to your elections during the plan year.

Child

A person under age 26 who is:

• A natural or legally adopted child of a retiree,
• A grandchild, niece, nephew, cousin, or other child related by blood or marriage over whom a retiree, or the spouse of a retiree (separately or together) is the sole court appointed legal guardian or sole managing conservator,
• A child for whom the retiree has assumed a legal obligation for support immediately prior to the child's adoption by the regular employee or retiree, or
• A stepchild of a retiree.

Child does not include a foster child.

Claims administrator / processor

Aetna Life Insurance Company, or affiliates, for claims other than outpatient prescription drugs, and Express Scripts for retail and home delivery of outpatient prescription drugs.

Claims fiduciary

For the purpose of section 503 of Title 1 of the Employee Retirement Income Security Act of 1974, as amended (ERISA), the claims fiduciary is the person with complete authority to review all denied claims for benefits under the Plan. Each claims fiduciary has the right to adopt reasonable policies, procedures, rules and interpretations of the Plan to promote orderly and efficient administration. A claims fiduciary may not act arbitrarily and capriciously, which would be an abuse of its discretionary authority.

Concurrent care claims

Concurrent claims are any claims that involve an ongoing approved course of treatment. Typically, concurrent claims will be handled as either a pre-service claim or urgent care claim, depending on the circumstances.

Copayments and coinsurance

Your share of covered services (including out-patient prescription drugs) and behavioral health and substance use disorder expenses. For some services, such as hospital stays, the coinsurance will be a percentage of the cost of the service once the deductible has been satisfied. For other services, such as routine office visits to a POS II provider, the copayment will be a fixed amount. For outpatient prescription drugs there is a percentage copayment up to a per-prescription maximum.

Covered medical expense

• For treatment of injury or sickness — a medically necessary expense incurred by a covered person that is not excluded from coverage;
• For treatment of behavioral health or substance use disorder — a medically necessary expense that is certified in advance of actual treatment or an out-of-network inpatient treatment, that is provided according to the terms of the Plan, and that is not otherwise excluded from coverage.

Covered person

Any person identified on the books of the employer as a retiree, eligible family member, or survivor who:

• Complies with the established enrollment requirements and makes any required contributions,
• In the case of a retiree, family member, or survivor, is not eligible for Medicare, and
• Is not eligible for any other medical plan to which ExxonMobil contributes on their behalf.

Custodial care

Care that helps meet personal needs and daily living activities. Such care, even if ordered by a doctor and performed by a licensed medical professional such as a nurse, is not covered by the Plan. Examples are:

• Routine patient care such as changing dressings, periodic turning and positioning in bed
• Administering oral medications
• Care of a stable tracheostomy (including intermittent suctioning)
• Care of a stable colostomy/ileostomy
• Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or continuous) feedings
• Care of a bladder catheter (including emptying/changing containers and clamping tubing)
• Watching or protecting you
• Respite care, adult (or child) day care, or convalescent care
• Institutional care. This includes room and board for rest cures, adult day care and convalescent care
• Help with walking, grooming, bathing, dressing, getting in or out of bed, toileting, eating or preparing foods
• Any other services that a person without medical or paramedical training could be trained to perform
• Any service that can be performed by a person without any medical or paramedical training

Deductible

The amount of covered expenses you must pay each calendar year before the Plan begins sharing the cost. Fixed amount copayments do not apply toward this amount. Outpatient prescription drug copayments are not subject to nor do they count toward the annual deductible. The deductible is applied to your claims in the order Aetna processes them, not when the provider collects the money from you. This means if you pay your deductible to one provider, it may not be applied to your annual deductible if Aetna has received and processed other claims first. Please be sure to always get an itemized bill and retain proof of your payment, should you need to recover money from your provider.

Emergency

Means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson (including the parent of a minor child or the guardian of a disabled individual), who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

• Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
• Serious impairment to bodily function, or
• Serious dysfunction of any bodily organ or part.
• With respect to emergency services furnished in a hospital emergency department, the Plan does not require prior authorization for such services if you arrive at the emergency medical department with symptoms that reasonably suggest an emergency condition, based on the judgment of a prudent layperson, regardless of whether the hospital is an in-network provider.
• The Plan covers medically necessary emergency services including the following:
• Initial services. A medical screening examination within the capability of a hospital emergency department or freestanding independent emergency department, including ancillary services routinely available in the emergency department, to determine whether an “emergency medical condition” exists.

Post-stabilization services. Additional services covered under the plan that are furnished by a nonparticipating provider or nonparticipating emergency facility after a participant or beneficiary is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which the initial services were provided. 

Eligible family members

Eligible family members are generally your:

• Spouse.
• A child who is described in any one of the following paragraphs (1) through (3):
• (1) has not reached the end of the month during which age 26 is attained, or
• (2) is totally and continuously disabled and incapable of self-sustaining employment by reason of mental or physical disability, provided the child:
• (a) meets the Internal Revenue Service's definition of a dependent, and
• (b) was covered as an eligible family member under this Plan or the ExxonMobil Medical Plan immediately prior to the birthday on which the child's eligibility would have otherwise ceased, and
• (c) met the clinical definition of totally and continuously disabled before such birthday and continues to meet the clinical definition through subsequent periodic reassessment reviews, and
• (d) is not eligible to be enrolled in Medicare as their primary medical plan, or
• (3) is recognized under a qualified medical child support order as having a right to coverage under this Plan.

A child who was disabled but who no longer meets the requirements of paragraph two above, ceases to be an eligible family member 60 days following the date on which the applicable requirement is not met.

Please note: An eligible retiree's parents are not eligible to be covered.

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:

• 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 (EOB)

The summary you receive after your claim is processed. Codes referred to on the EOB are explained on the document.

Extended-care facility

An institution that meets the following criteria:

• Provides 24 hour skilled nursing care and related services for the rehabilitation of injured or sick persons.
• Has policies developed with the advice of and subject to the review of professional personnel to cover nursing care and related services.
• Has a physician, a registered professional nurse or a medical staff responsible for the execution of such policies.
• Requires that every patient be under the care of a physician and makes a physician available to furnish medical care in an emergency.
• Maintains clinical records on each patient and has appropriate methods for dispensing drugs and biologicals.
• Provides for periodic review by a group of physicians to examine the need for admissions, adequacy of care, duration of stay and the medical necessity of continuing confinement of patients.
• Is licensed pursuant to law or is approved by an appropriate authority as qualifying for licensing.
• Does not include a place that is primarily for custodial care.

ExxonMobil Retiree Medical Plan (EMRMP)

The Plan sponsored by Exxon Mobil Corporation which provides medical benefits for eligible retirees, survivors and their family members, and includes the Retiree Medical Plan (RMP) ), the Medicare Primary Option (MPO), and the Medicare Supplement Plan (or MSP).

Hospital

An institution which:

• Is licensed as a hospital (if licensing is required),
• Is operated pursuant to law for the care and treatment of sick and injured persons,
• Provides 24 hour nursing care and has facilities both for diagnosis and surgery, except in the case of a hospital primarily concerned with the treatment of chronic diseases, and
• Is not a hotel, rest home, nursing home, convalescent home, place for custodial care, or home for the aged.

For purposes of this definition, hospital shall also mean, with respect to treatment of substance use disorders, a treatment facility, residential facility, or a clinic licensed or approved for such treatment by the appropriate authority for the jurisdiction in which the facility or clinic is located.

Incidental charges

Aetna’s current standards for incidental charges are based on the Current Procedural Terminology (CPT) codes and guidelines authored and revised by the American Medical Association since 1966. CPT coding has become the most widely accepted format, by both government and private health insurance programs, in reporting physician procedures. CPT coding furnishes health care providers with a uniform system to accurately describe medical services. CPT coding guidelines explain that services commonly carried out as an integral component of a total service or procedure should not be reported as a separate procedure.

When a claim is submitted with multiple CPT codes, Aetna uses the CPT guidelines to determine whether the charges should be considered as separate costs or if the charges are typically considered as one cost. If Aetna determines that the charges should have been submitted together under one CPT code, the separate charges would be considered incidental to the primary procedure, and the amount allowed for reimbursement would be the amount for the primary procedure.

Example: Your provider administers an immunization and submits separate charges: one for the medication administered in the immunization and another for administering the shot. In most cases, an immunization should be submitted for payment using one CPT code. If it is submitted as two separate charges, Aetna uses the CPT guidelines and pays only one CPT code for the cost of the medication. The charge for administering the shot is considered to be incidental and is not paid.

Network providers have agreed to accept incidental charges reductions; however, you are responsible for incidental expenses when you use a non-network provider or if you have signed a statement in the provider’s office saying you will be responsible for incidental charges.

Multiple surgeries (including bilateral procedures)

When multiple surgeries are performed, a health industry standard calculation method is used to reflect the cost savings that accompany services rendered during the same operative session. Contact Aetna Member services for additional details on the amounts allowed.

Multiple imaging diagnostic tests

When certain multiple imaging diagnostic tests (e.g., MRIs, CT scans, ultrasounds) are performed on the same date of service, the amount allowed for reimbursement is 100% of the fee schedule (network) or reasonable and customary charge (non-network) for the first diagnostic test and 50% for subsequent tests ordered during a single encounter. 

Medical necessity or medically necessary

• Legal,
• Ordered by a physician for medical treatment,
• Reasonably required for the treatment or management of the condition for which it is ordered, and
• Commonly and customarily prescribed by the United States medical community as treatment or management of the condition for which it is ordered.

The Administrator-Benefits has the exclusive and final authority to determine if a service or supply is medically necessary.

Medical precertification

Certification obtained prior to a hospital inpatient stay (including behavioral health and substance use disorder) to give notice of inpatient admission and the proposed care. If you do not precertify hospital stay, you will be responsible for the first $500 of eligible expenses. Refer to the Aetna National Precertification list for details of services requiring precertification.

Medicare

The term Medicare means the program of medical care benefits provided under Title XVIII of the Social Security Act of 1965 as amended. Prescription drug coverage under the ExxonMobil Medical Plan is considered creditable coverage and the Notice of Creditable Coverage is provided annually. 

No volitional control

Charges incurred if you had no volitional control in determining the provider will be reimbursed at 80% after the deductible for the EMRMP POS II B and 75% after the deductible for the EMRMP POS II A option, as though a network provider was used.

Non-network charges incurred through the use of a network facility for radiologists, anesthesiologists, pathologists, neonatologists, intensivists, will also be reimbursed at 80% after the deductible for the EMRMP POS II B and 75% after the deductible for the EMRMP POS II A option, as though a network provider was used. However, charges incurred through the use of a non-network facility for non-network radiologists, anesthesiologists, pathologists, neonatologists, intensivists, and hospitalists continue to be reimbursed as non-network.

Reimbursement to non-network providers will be limited to a reasonable and customary amount, rather than billed charges. In the event you are billed for any balance at a network facility or in an emergency situation at a non-network facility, by a non-network physician, you may submit the balance to Aetna for additional processing. Only amounts that are above the reasonable and customary fee schedule will be considered for additional reimbursement. Charges for services not covered by the Plan will not be reprocessed. If you do and you are enrolled in the automatic rollover process to your Health Care Flexible Spending Account (HCFSA), an overpayment from the HCFSA may result from the additional processing. You should contact Aetna to discuss options to return the overpaid HCFSA funds back into the account. 

Network

Providers and facilities that participate in the Retiree Medical POS II network available under the RMP POS II option.

Non-network

Providers and facilities located in the Retiree Medical POS II but which do not participate in a network available under this Plan.

Nurse

A registered graduate nurse (RN), a licensed vocational nurse (LVN), or a licensed practical nurse (LPN). 

Out-of-network area

Geographic areas that do not fall within the medical POS II or behavioral health and substance use disorder PPO network.

Out-of-pocket limit 

The amount of covered medical expenses you pay in one year before the Plan begins paying 100%. The RMP POS II A and B options have different out-of-pocket limits. The out-of-pocket limit is accumulated in the order Aetna processes the claims. After the out-of-pocket limit is reached, the Plan pays 100% of most covered expenses for the remainder of that year. Certain expenses that you pay do not apply to the out-of-pocket limit. The annual deductible and your percentage copayments for eligible expenses apply to the out-of-pocket limit. The following charges do not apply to the out-of-pocket limit:

• Charges above reasonable and customary limits
• Charges not covered by the Plan
• Charge of $500 for non-compliance with medical pre-admission review process
• Charge of $500 for failure to precertify inpatient non-network and out-of-network behavioral health or substance use disorder services
• Copayments for outpatient prescription drugs
• Charges for a private hospital room above the cost of the hospital's most common rate for a semiprivate room

Outpatient prescription drug

A prescription drug or medicine obtained through either a retail pharmacy or through a mail service prescription program (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.

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 an orthoptist, a physician assistant or nurse practitioner. Primary Care Physician means a Physician engaged in general practice, family practice, internal medicine, pediatrics or obstetrics/gynecology who provides basic health services to covered persons.

Predetermination

A written predetermination request will result in a detailed response as to whether a treatment or service is covered under the Retiree Medical Plan and whether the proposed cost is within R&C limits, thus ensuring all parties are aware of the financial consequences, providing all circumstances described in the request remain unchanged. Please note that a predetermination, either verbal or written, is not a guarantee of payment, as claims are paid based on the actual services rendered and in accordance with Plan provisions.

Pre-service claims

Requests for approval required before medical care, such as preauthorization or a decision on whether a treatment or procedure is medically necessary. 

Primary participant

The term primary participant refers to the participant whose identification number is used. The primary participant is the retiree, survivor or an individual who elected COBRA coverage. Covered family members use the primary participant's identification number to access all medical benefits.

Private duty nursing

Continuous, substantial, and complex in-home nursing care requiring services that can only be provided by a licensed medical professional, has been prescribed by a treating physician, provided on an hourly basis and is determined to be medically necessary. Private duty nursing provides more individual and continuous skilled care than the care that can be provided in a skilled nurse visit through a home health agency.

Reasonable and customary limits

Allowable amounts for services are determined by reasonable and customary (R&C) limits.

Aetna uses the industry-wide standard for R&C limits. Aetna’s network is based on a percentage of the Medicare allowable rate or on reasonable & customary limits for the geographical area as determined by Aetna. For professional services, R&C limit is set at 200% of Medicare Fee Schedule of charges for similar services in the same geographic area.

R&C limits apply only to non-network providers and services.

Example: A non-network provider charges $80 for a particular medical procedure, the reasonable and customary limit is $30, and the network provider charge is $25. Only $30 of the $80 charge will be allowed for payment. At the 60% benefit level for the EMRMP POS II B option, the Plan will pay $18 and you will be responsible for paying $12 plus the $50 difference between the reasonable and customary limit and the non-network charge for a total of $62. If you used a Medical POS II provider, you would be charged only the network-negotiated rate of $25 at the 80% network reimbursement level for the EMRMP POS II B option. You would have paid only $5 for the same service.

Retiree

Generally, a person at least 55 years old who retires as a regular employee with 15 or more years of benefit service or 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.

Retirees who have been rehired as regular or non-regular employees are not eligible for the ExxonMobil Retiree Medical Plan.

Retiree Medical Plan (RMP)

One of the parts of the ExxonMobil Retiree Medical Plan which provides medical benefits for Pre-Medicare eligible retirees, survivors and their family members. It includes Retiree Medical Plan POS II option (as described in this SPD) and other self-funded options.

Retiree Medical Plan POS II Option (Point of Service) 

A network of established physicians, hospitals and other medical care providers whose credentials have been screened according to Aetna's standards and who have agreed to provide their services at negotiated rates. The Retiree Medical Plan POS II is a network specifically selected by the Plan — it is part of Aetna's Choice® POS II. This network is referred to in this SPD as the Retiree Medical POS II.

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.

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.

Surgical procedure

This term refers to the following:

• A cutting operation
• Suturing a wound
• Treating a fracture
• Reduction of a dislocation
• Radiotherapy (excluding radioactive isotope therapy) if used in lieu of a cutting operation for removal of a tumor
• Electrocauterization
• Diagnostic and therapeutic endoscopic procedures
• Injection treatment of certain conditions
• Laser treatments

Note: Minor procedures such as biopsies or removal of moles or warts, even if performed in a doctor's office, are considered surgery.

Survivor/ surviving spouse

A surviving unmarried spouse or child of a deceased ExxonMobil regular employee or retiree.

Suspended retiree

A person who becomes a retiree due to incapacity within the meaning of the ExxonMobil Disability Plan and who begins long-term disability benefits under that plan, but whose benefits stop because the person is no longer incapacitated. A person remains a suspended retiree until the earlier of the date the person:

• Reaches age 55, or
• Begins his or her benefit under the ExxonMobil Pension Plan, at which time the person is again considered a retiree.

The family members of a deceased suspended retiree will be eligible for coverage under this Plan only after the occurrence of the earlier of the following:

• The date the suspended retiree would have attained age 55, or
• The date a survivor begins receiving a benefit due to the suspended retiree's accrued benefit from the ExxonMobil Pension Plan.

Urgent care 

Conditions or services that are non-preventative or non-routine and needed in order to prevent the serious deterioration of a person's health following an unforeseen illness, injury or condition. Urgent care includes conditions that could not be adequately managed without immediate care or treatment but do not require the level of care provided in an emergency room. Treatment of such a condition outside of an emergency room is paid according to the network status of the provider or facility. For example, out-of-network urgent care furnished by an out-of-network provider or facility is reimbursed at the out-of-network benefit level.

Urgent care claims

Special kind of pre-service claim that requires a quicker decision because your health would be threatened if the plan took the normal time permitted to decide a pre-service claim. If a physician with knowledge of your medical condition tells the plan that a pre-service claim is urgent, the plan must treat it as an urgent care claim.

Visit

The scope of “visit” to a participating health care facility includes: the furnishing of equipment and devises, telemedicine services, imaging services, laboratory services, and preoperative and postoperative services, regardless of whether the provider furnishing such items or services is at the facility. This applies to OON emergency services and non-emergency services by OON ancillary providers in participating facilities. 

Year 

Calendar year, January 1 through December 31.