About the Medical Plan
- Information Sources
- Introduction
- Plan at a Glance

Eligibility and Enrollment

Basic Plan Features

The Prescription Drug Program

Mental Health and Chemical Dependency Care

Covered Expenses

Exclusions

Payments

Claims

Partners in Health

Continuation Coverage

Administrative and ERISA Information

Key Terms

Benefit Summary

 

ExxonMobil Medical Plan SPD
POS II "A" and "B" Options
Updated Through 2011

blue square About The Medical Plan

This summary plan description (SPD) summarizes the ExxonMobil Medical Plan (Medical Plan, the Plan). It does not contain all plan details. In determining your specific benefits, the full provisions of the formal plan documents, as they exist now or as they may exist in the future, always govern. You may obtain copies of these documents by making a written request to the Administrator-Benefits. Exxon Mobil Corporation reserves the right to change benefits in any way or terminate the Plan at any time.

The POS II (Point of Service), Aetna Health Maintenance Organization (HMO), and CIGNA HMO options are self-insured. There is no insurance company to collect premiums or underwrite coverage. Instead, contributions from you and ExxonMobil pay all benefits. Prior claims experience and forecasted expenses are used to determine the amount of money needed to pay future benefits. These options are governed by federal laws, not by state insurance laws.

If you enroll in any option other than the POS II "A" or "B" option, you may access an additional SPD for that option. If you do not enroll in any option, you are still eligible for certain Partners in Health program benefits described on page 54.

Applicability to represented employees is governed by collective bargaining agreements and any local bargaining requirements.

blue square Information Sources

When you need information, you may contact:

Claims, Medical POS II Administrator, and Pre-Admission Review — Provides information about claims payment, providers participating in the Medical POS II (Aetna Choice® POS II), claims forms, and benefit pre-determinations. In addition, provides hospital pre-admission review for inpatient medical service, medical case management and pre-certification for skilled nursing care, home health care, private duty nursing, hospice care, and the purchase of durable medical equipment.

Phone Numbers:

Address:

Aetna Member Services
800-255-2386
210-366-2416 (if international, call collect)
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 14586
Lexington, KY 40512-4586

Check DocFind® on Aetna's Web site at www.aetna.com/docfind to locate network providers.

Mental Health and Chemical Dependency Pre-Certification and Mental Health PPO — Provides pre-certification, case management, and information about providers participating in the Mental Health PPO network.

Phone Numbers:

Address:

Magellan Behavioral Health
800-442-4123
801-256-7502 (international, call collect)
24 hours a day, 7 days a week
Magellan Behavioral Health
14100 Magellan Plaza Drive
Maryland Heights, MO 63043

Check Magellan's Web site at www.magellanassist.com for Life Assistance Resource information such as community resources links, health and wellness tips, and behavioral health Internet sites. Once you have accessed this site:

  • Sign in under Member Sign In (new users click on New or unregistered user)
  • Enter toll free number: 800-442-4123 (user id and password not necessary)
  • At this point, you may register or continue as unregistered

Prescription Drug Program — Claims processor for outpatient prescription drugs provided through mail order for long-term prescriptions or a local retail pharmacy for short-term prescriptions.

Phone Numbers:

Addresses:

Medco By Mail – Mail-order Pharmacy:
800-695-4116
800-497-4641 (international, use appropriate country access code depending on country from which you are calling)

Medco By Mail – Mail-order Pharmacy:
P.O. Box 650322
Dallas, TX 75265-0322
For questions regarding Retail Prescriptions – Medco:
800-695-4116
800-497-4641 (international, use appropriate country access code depending on the country from which you are calling)

Non-network and Coordination of Benefits Retail Prescriptions Claims Processing:
Medco
P.O. Box 14711
Lexington, KY 40512
64063-2277

Another way to locate retail network pharmacies and order refills is Medco's Web site at www.medco.com.

Tobacco Cessation Program — Provides support and educational tools to develop quit plans for participants over age 18. To self-enroll contact:

Healthyroads®
877-330-2746
Monday – Friday 7:00 a.m. to 8:00 p.m. (U.S. Central Time)
Or visit www.healthyroads.com

Benefits Administration — Customer Service Representatives can provide specialized assistance. References to Benefits Administration throughout this SPD pertain to either ExxonMobil Benefits Administration or ExxonMobil Benefits Service Center as listed below. Depending on your status (employee, retiree, or survivor), you should contact the appropriate service center.

Employees can enroll/change benefits on the ExxonMobil Me HR Intranet site through Employee Direct Access (EDA) when a change in status occurs. Enrollment forms are also available through ExxonMobil Benefits Administration for those without access to EDA.

Phone Numbers:

Address:

  • Employees call:
    ExxonMobil Benefits Administration/Health Plan Services
    Monday – Friday 8:00 a.m. to 3:00 p.m.
    (U.S. Central Time), except certain holidays
    713-680-5858 (Houston)
    713-680-7070 (international, call collect)
    800-262-2363 (toll free outside Houston)
    262-314-2752 (fax)
ExxonMobil Benefits Administration
ExxonMobil BA BSC USBA 
4300 Dacoma or "BH1" 
Houston, TX 77092
   
  • Retirees and Survivors call:
    ExxonMobil Benefits Service Center
    Monday – Friday 8:00 a.m. to 6:00 p.m.
    (U.S. Eastern Time), except certain holidays
    Toll-Free: 1-800-682-2847
    or 800-TDD-TDD4 (833-8334) for hearing impaired
ExxonMobil Benefits Service Center
PO Box 199540
Dallas, TX 75219-9722 

ExxonMobil Sponsored Sites — Access to plan-related information including claim forms for employees, retirees, survivors, and their family members.

  • ExxonMobil Me, the Human Resources Intranet Site — Can be accessed at work by employees.
  • ExxonMobil Family, the Human Resources Internet Site — Can be accessed from home by everyone at www.exxonmobilfamily.com.
  • Retiree Online Community Internet Site — Can be accessed from home by retirees and survivors only at www.emretiree.com.
  • ExxonMobil Benefits Service Center at ACS Internet Site — Can be accessed from home by everyone at www.exxonmobil.com/benefits.

blue square Introduction

The ExxonMobil Medical Plan is made up of POS II options and HMO options, including both self-insured and fully-insured HMOs. This SPD is a summary of your benefits under the POS II options only. It does not contain all the details about the POS II options nor does it contain any information about the HMO options. If you enroll in any option other than the POS II options, you may access an SPD for that option. Even if you do not enroll in any option, you are still eligible for certain Partners in Health program benefits described on page 54.

The POS II is a network of physicians, hospitals, and other health care providers whose credentials have been reviewed by the network manager and who have agreed to provide their services at negotiated rates. The POS II "A" and "B" are different plan designs utilizing the same network.

The network for medical care covered under the POS II option – referred to as the Medical POS II in this SPD – is offered by Aetna. Aetna Life Insurance Company (Aetna) is the network manager and claims administrator for the Medical POS II.

Aetna does not render medical services or treatments.  Neither the Plan nor Aetna is responsible for the health care that is delivered by providers participating in the Medical POS II (Aetna Choice® POS II) and those providers are solely responsible for the health care they deliver. Providers are not the agents or employees of the Plan or Aetna.

The PPO for mental health and chemical dependency care covered under the POS II options – referred to as the Mental Health PPO (MHPPO) in this SPD – is managed by Magellan Behavioral Health.

The POS II options offer you the ability to use physicians and other health care providers that are part of a network. You can generally reduce your out-of-pocket expenses by using network providers.

If you elect the POS II "A" or "B" option and you live outside one of the network areas, you are provided benefits on an out-of-network area basis. However, if you live within the network area and choose to use a non-network provider, specific limitations apply to the benefits you are provided.

These tools help you find specific information quickly and easily:

  • Plan at a Glance, a user's guide highlighting plan basics.
  • Charts and tables throughout this SPD provide information, examples and highlights of plan provisions, including Benefit Summary charts on pages 80-85
  • References to places where you can get more information.
  • A list of Key Terms containing definitions of some words and terms used in this SPD. Terms are underlined and linked for easy identification.

A careful reading of this SPD will help you understand how the POS II option works so you can make the best use of the plan provisions. You may obtain additional information through the sources shown on pages 1-3.

blue square Plan at a Glance

Enrolling
You may enroll yourself and your eligible family members within 60 days of hire or within 60 days of a subsequent change-in-status or at Annual Enrollment. See page 7.

Basic Plan Features
The Medical Plan covers medically necessary and preventive care. You can save money and time if you use a provider who participates in the POS II network. When you receive care through the POS II network, the provider files claims and obtains necessary pre-certifications, expenses are within reasonable and customary limits, and the negotiated rates generally lower your out-of-pocket costs. See page 19.

The Prescription Drug Program
The Medical Plan offers you two cost-saving ways to buy prescription drugs – at a local participating network pharmacy for short-term prescriptions and through a mail-order program for long-term prescriptions. See page 26.

Mental Health and Chemical Dependency Care
The Plan provides for mental health and chemical dependency care through Magellan's nationwide mental health PPO. All non-network inpatient care must be pre-certified. See page 32.

Covered and Excluded Expenses
The Medical Plan provides benefits for many, but not all, types of treatment, care and services. See Covered Expenses on page 37 and Exclusions on page 42.

Payments
You and the Medical Plan share costs for covered treatment and services. You pay a fixed co-payment for covered items such as a POS II network doctor's office visit and most related lab work. For other types of care, you must first satisfy a deductible before the Medical Plan begins paying. If you meet your annual out-of-pocket limit, the Medical Plan pays 100% of most covered costs for the rest of that calendar year. See page 44.

Claims
POS II network providers file claims for you. You are responsible for ensuring that claims for non-network care are filed. See page 52.

Partners in Health
Tools and resources are available to you and your family members to help you better manage your health and health care. The health portal (Internet site), health assessment and 24-hour nurse line are available to everyone. Participants who are enrolled in the POS II option, Aetna HMO or CIGNA HMO options and who meet certain qualifications have access to several programs — Health Advocate, Disease Management and Centers of Excellence Programs — to help access the best available treatment. See page 54.

Consolidated Omnibus Budget Reconciliation Act 1985 (COBRA)
You and your family members who lose eligibility may continue medical coverage for a limited time under certain circumstances. See page 57.


Administrative and ERISA Information
This Plan is subject to rules of the federal government, including the Employee Retirement Income Security Act of 1974, as amended (ERISA), not state insurance laws. See page 62.

Key Terms
This is an alphabetized list of words and phrases, with their definitions, used in this SPD. These words are underlined and linked throughout the SPD for easy identification. See page 69.

Benefit Summaries
Brief summaries of benefits for the POS II "A" and "B" options. See pages 80-85.