Index

About the Medical Plan

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

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

 

Prescription Drugs
Annual out-of-pocket maximums for prescription drugs			$2,500/individual and $5,000/family
	Retail Co-Pay* ** ***			Medco by Mail
	(up to 34-day supply)	Maximum Per Prescription	3rd+ Retail Refill****	(up to 90-day supply)	Maximum Per Prescription
Generic Drugs	30%	$50	55%	25%	$100
Formulary Brand Drugs	30%	$100	55%	25%	$200
Non-Formulary Brand Drugs	50%	$150	75%	45%	$300

* If using a non-network pharmacy, you pay 100% of the difference between the actual cost and the discounted network cost plus retail co-pays. 
** If your doctor prescribes a brand name drug for which a generic equivalent is available, you will be responsible for paying the generic co-pay and the difference in the cost between the brand name and the generic equivalent. The difference in the cost between the brand name and the generic does not apply to the annual out-of-pocket maximum for prescription drugs. 
*** You must present Medco Prescription Card or Social Security number of participant or benefits will be paid at the non-network level. 
**** Additional 25% coinsurance does not apply to the annual out-of-pocket maximum for prescription drugs.

82

ExxonMobil Medical Plan POS II "A" Option 2010 Summary of Benefits  Plan Code: 1021
Services	POS II Network	Non Network	Out-of-Network Area
Emergency Care	$75 co-pay4 75% coverage	$75co-pay4 75% coverage	$75 co-pay4 75% coverage
Maternity	75% coverage	55% coverage	75% coverage
Chiropractic Care Calendar year limit5	$50 co-pay3 $1,000	55% coverage $1,000	75% coverage $1,000

Services	POS II Network	Non Network	Out-of-Network Area
Mental Health1			Overseas only
Inpatient	$250 deductible 75% coverage Provider initiates precertification	$500 deductible 55% coverage You initiate precertification; $500 penalty for failure to pre-certify inpatient care	$250 deductible 75% coverage You initiate precertification; $500 penalty for failure to pre-certify inpatient care
Outpatient Office Visits	$35 co-pay3	55% coverage	75% coverage
Chemical Dependency1			Overseas only
Inpatient	$250 deductible 75% coverage Provider initiates precertification	$500 deductible 55% coverage You initiate precertification; $500 penalty for failure to pre-certify inpatient care	$250 deductible 75% coverage You initiate precertification; $500 penalty for failure to pre-certify inpatient care
Outpatient	$35 co-pay3	55% coverage	75% coverage

¹ Pre-certification is required for all inpatient care, including mental health and chemical dependency.
² Office co-payment does not apply to complex imagining, chemotherapy, sleep studies, and infusion.
³ Not subject to deductible. 
⁴ Charge applied to hospital deductible if admitted. 
⁵ 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 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 maximums for prescription drugs			$2,500/individual and $5,000/family
	Retail Co-Pay* ** ***			Medco by Mail
	(up to 34-day supply)	Maximum Per Prescription	3rd+ Retail Refill****	(up to 90-day supply)	Maximum Per Prescription
Generic Drugs	30%	$50	55%	25%	$100
Formulary Brand Drugs	30%	$100	55%	25%	$200
Non-Formulary Brand Drugs	50%	$150	75%	45%	$300

* If using a non-network pharmacy, you pay 100% of the difference between the actual cost and the discounted network cost plus retail co-pays. 
** If your doctor prescribes a brand name drug for which a generic equivalent is available, you will be responsible for paying the generic co-pay and the difference in the cost between the brand name and the generic equivalent. The difference in the cost between the brand name and the generic does not apply to the annual out-of-pocket maximum for prescription drugs. 
*** You must present Medco Prescription Card or Social Security number of participant or benefits will be paid at the non-network level. 
**** Additional 25% coinsurance does not apply to the annual out-of-pocket maximum for prescription drugs.

85

ExxonMobil Medical Plan POS II "B" Option
Services	POS II Network	Non Network	Out-of-Network Area
Emergency Care	$75 co-pay4 80% coverage	$75 co-pay4 80% coverage	$75 co-pay4 80% coverage
Maternity	80% coverage	60% coverage	80% coverage
Chiropractic Care Calendar year limit5	$30 co-pay3 $1,000	60% coverage $1,000	80% coverage $1,000

ExxonMobil Medical Plan POS II "B" Option
Services	POS II Network	Non Network	Out-of-Network Area
Mental Health1			Overseas only
Inpatient	$150 deductible 80% coverage Provider initiates precertification	$300 deductible 60% coverage You initiate precertification; $500 penalty for failure to pre-certify inpatient care	$150 deductible 80% coverage You initiate precertification; $500 penalty for failure to pre-certify inpatient care
Outpatient Office Visits	$20 co-pay3	60% coverage	80% coverage
Chemical Dependency1			Overseas only
Inpatient	$150 deductible 80% coverage Provider initiates precertification	$300 deductible 60% coverage You initiate precertification; $500 penalty for failure to pre-certify inpatient care	$150 deductible 80% coverage You initiate precertification; $500 penalty for failure to pre-certify inpatient care
Outpatient	$20 co-pay3	60% coverage	80% coverage

¹ Pre-certification is required for all inpatient care, including mental health and chemical dependency care.
² Office co-payment does not apply to complex imagining, chemotherapy, sleep studies, and infusion.
³ Not subject to deductible.
⁴ Charge applied to hospital deductible if admitted.
⁵ 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 POS II "B" 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.