This summary plan description (SPD) summarizes the ExxonMobil Medical Plan (the Plan) Aetna Select option. 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.

Open Access Aetna Select Network only option is self-funded. 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.

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

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, you will be able to find the appropriate contact to support your needs.

Information sources

Information sources for the ExxonMobil Medical Plan – Open Access Aetna Select option

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

For claims administration and benefits information

Aetna for medical/surgical, behavioral health and substance use disorder benefits and claims information, including clinical guidelines, benefits predeterminations and providers in the Aetna Select 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)

24 hours a day, 7 days a week

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.

ExxonMobil Benefits Service Center
Phone: 1-800-682-2847 Monday to Friday 8:00 a.m. to 6:00 p.m. (U.S. Eastern Time)
Web: ExxonMobil Benefits Web.
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 employees, retirees, survivors, and their family members.

• EMConnect, the Human Resources Intranet Site — Can be accessed at work by employees.
• ExxonMobil Family, the Human Resources Internet Site — Can be accessed by everyone at www.exxonmobilfamily.com.

Eligibility and enrollment

Eligibility and enrollment details for the ExxonMobil Employee Medical Plan– Open Access Aetna Select option

Most U.S. dollar payroll regular employees of Exxon Mobil Corporation and participating affiliates who work at a location where the Open Access Aetna Select is offered and reside in the Open Access Aetna Select service area are eligible to participate. The service area is determined by the employee's home address zip code.

Generally, you are eligible if:

• You are a regular employee.
• You are working for ExxonMobil after retirement as a regular or non-regular employee
• You are a trainee as described in Key Terms section
• You were an extended part-time employee and enrolled in the Plan on December 31, 2022 as long as you continue to participate in the Plan.

You are not eligible if:

• 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 an expatriate employee.

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. 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 ExxonMobil Benefits Service Center.
• Your totally and continuously disabled child(ren) who is incapable of self-sustaining employment by reason of mental or physical disability that occurred prior to otherwise losing eligibility at age 26 and meets the Internal Revenue Service's definition of a dependent.

More complete definitions of eligible family member and Child appear in the Key terms of this guide and in the definition of Qualified Medical Child Support Order.

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.

Dual Coverage

No one can be covered more than once in the Plan. You and a family member cannot both enroll as employees and elect coverage for each other as eligible family members. If you and your spouse or adult child work for the company and both are eligible for coverage:

• Each of you can be covered as an individual employee, or
• One of you can be covered as the employee 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.

In addition, a marriage between two ExxonMobil employees does not allow enrollment or cancellation in any of the ExxonMobil health plans. In order to change your coverage, you need to wait until you experience a change in status that allows coverage changes or annual enrollment.

How to enroll

As a newly hired or newly eligible employee, you will receive enrollment materials from the ExxonMobil Benefits Service Center. If you wish to enroll, you have 30 days to do so after your start date.

• If you enroll within this 30-day period, coverage begins the first day of employment.
• If you enroll between 31 and 60 days from your date of hire, coverage will be effective the first day of the month following completion of enrollment in ExxonMobil Benefits or through the ExxonMobil Benefits Service Center.

As a current employee, if you are not covered by a medical plan to which ExxonMobil contributes or were previously enrolled, canceled your coverage and wish to re-enroll, you can only do so during the next annual enrollment period or if you experience a qualified change in status. See Change your coverage for additional details.

Classes of coverage

You can choose coverage as an:

• Employee only,
• Employee and spouse,
• Employee and child(ren), or
• Employee and family.

Each class of coverage described in this section has its own contribution rate. Employees contribute to the Plan through monthly deductions from their pay on a pre-tax or after-tax basis.For employees on an approved leave of absence (LOA), the following will apply:

• Military (voluntary): coverage under the Plan will continue for up to 12 months at the employee contribution rate. At the end of the 12 month period, your coverage under the plan will end and you will have the opportunity to elect COBRA. The LOA does not count towards the duration of time you are eligible for COBRA.
• Health/Dependent Care: coverage under the Plan will continue for up to 6 months at the employee contribution rate. At the end of the 6 month period, your coverage under the Plan will end and you will have the opportunity to elect COBRA. The LOA does not count towards the duration of time you are eligible for COBRA.
• Personal Leave: coverage under the Plan will continue for up to 12 months at the employee contribution rate. At the end of the 12 month period, your coverage under the plan will end and you will have the opportunity to elect COBRA. The LOA does not count towards the duration of time you are eligible for COBRA

Changing your coverage 

To make a change to your coverage after your initial enrollment, you must wait until the next annual enrollment period or until you experience a qualified change in status.

Annual enrollment

Each year, during the fall, ExxonMobil offers an annual enrollment period. During this time, you can switch from your current medical plan option to another available option. This is also the time to make changes to coverage by adding or deleting family members. Changes elected during annual enrollment take effect the first of the following year.

During annual enrollment, changes to your EMMP coverage (option or contributions) do not automatically adjust your coverage or contributions to other plans such as the ExxonMobil Dental Plan, ExxonMobil Vision Plan, or the flexible spending accounts under the ExxonMobil Pre-Tax Spending Plan. Changes to those plans must be made separately.

If you pay your monthly contributions on an after-tax basis and would like to continue making contributions on an after-tax basis for the following year, you must elect to do so each year during annual enrollment and after each change in status. Otherwise, your contributions will be switched to a pre-tax basis beginning the first day of the following year.

Note: You should not wait until annual enrollment to remove a family member who loses eligibility; they should be removed at the time eligibility is lost. For consequences for covering an ineligible family member, see Loss of Eligibility.

Mid-Year changes

Another parent is ordered to provide coverage to your covered child through a QMSCO	Revoke or decrease your election if coverage actually provided	Within 60 days following the date of the event
You are ordered to provide coverage to your eligible child through a QMCSO	Enroll or Increase your election	Within 60 days following the date of the event
Eligible dependent gains eligibility under another employer's plan	If the eligible dependent has or will obtain coverage under the other employer plan, remove them from coverage. You may also cancel coverage for yourself, if health care coverage is obtained through your spouse’s employer plan.	Within 60 days following the date of the event.
A significant change in coverage or cost* of your, your spouse’s plan.     *applies also to a significant increase in health care cost sharing	Make a corresponding prospective change in your election: Change in coverage of this plan: You can cancel your election and be able to elect coverage under another medical plan option.   Change in coverage of your spouse´s plan: you will be able to sign up for medical coverage for yourself and your eligible family members.	Within 60 days following the date of the event.
HIPAA special enrollment provisions
Marriage	Enroll or increase your election because of the newly eligible spouse	Within 60 days following the date of the event.
Gain a family member through birth, adoption or placement for adoption,	Enroll or increase your election because of the newly eligible family member.	You must add the new family member within 60 days even if you already have family coverage. Coverage is effective on the date of birth, adoption, or placement for adoption If you enroll your new family member between 31 and 60 days from the birth or adoption and your coverage level changes, you will pay the cost difference on an after-tax basis until the end of the month in which the enrollment is completed in the ExxonMobil Benefits or though ExxonMobil Benefits Service Center. Beginning the first day of the following month your deduction will be on a pre-tax basis.
You or a family member loses eligibility under another employer's group health plan or other employer contributions cease	Enroll yourself and other family members who might have lost eligibility. This only pertains to the medical plan. Change your level of coverage and change medical plan option.	Check Within 60 days following the date of the event.
The participant or the participant’s dependent becomes eligible for premium assistance under Medicaid or the Children’s Health Insurance Program (CHIP).	You may change your EMMP election for yourself and any eligible family members.	Within 60 days of either: termination of Medicaid or CHIP coverage due to loss of eligibility, or becoming eligible for a state premium assistance program under Medicaid or CHIP coverage. In either case, coverage is effective the first of the month following enrollment through the ExxonMobil Benefits portalor through the ExxonMobil Benefits Service Center phone line.

 

Addition or improvement of medical plan options

If a new 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 medical plan option providing similar coverage or to drop 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 POS II options.  You may also discontinue medical coverage altogether.

Other situations that may affect your coverage

Leave of absence

If you are on an approved leave of absence, you can continue coverage by making required contributions directly to the Plan by check or, if applicable, pre-pay your benefits. If you chose not to continue your coverage while on leave, your coverage ends on the last day of the month in which the cancelation form is received by ExxonMobil Benefits Service Center and you will be required to pay for the entire month's contributions. If you fail to make required contributions while on leave, coverage will end.

If the company should make any payment on your behalf to continue your coverage while you are on leave and you decide not to return to work, you will be required to reimburse the company for required contributions.

If you are on an approved leave of absence and the COBRA Contribution Rate begins, you may continue your coverage by making your required contribution.

If you were on a leave that meets the requirements of the Family and Medical Leave Act of 1993 (FMLA) or the Uniformed Services Employment and Reemployment Rights Act (USERRA) and your coverage ended, re-enrollment is subject to FMLA or USERRA requirements.

For more information, contact ExxonMobil Benefits Service Center. 

If you retire

If you retire as a regular employee on or after age 55 with 15 or more benefit years of service, you are eligible for the ExxonMobil Retiree Medical Plan (EMRMP) or you may elect COBRA to stay in the ExxonMobil Medical Plan for the duration of COBRA Coverage. If you retire as a regular employee and are Medicare-eligible, you are eligible to enroll in Medicare Primary Option (MPO) option of the EMRMP.

If you decline enrollment in the ExxonMobil Retiree Medical Plan at retirement, you will have limited opportunities to enroll at a later date. See the Summary Plan Description for the EMRMP option of your choice for more information.

If a covered family member lives away from home

Coverage depends on whether the plan option you are enrolled in as an employee offers service in the area where you live. If your covered family member does not live with you (for instance, you have a child away at school), please contact Aetna Member Services to confirm whether service is available where your family member lives. (See Service area in Key terms.)

If you work beyond when you become eligible for Medicare 

If you continue to work for ExxonMobil after you become eligible for Medicare, although you are eligible for Medicare, your ExxonMobil employee coverage remains in effect for you and eligible family members and the ExxonMobil Medical Plan is your primary plan. Medicare benefits, if you sign up for them, will be your secondary benefits. Refer to www.medicare.gov to learn more about Medicare while you are still employed.

If your covered family members become Medicare eligible for any reason

Employees or family members of an employee who become Medicare eligible, either due to age or Social Security disability status, are eligible to participate in any ExxonMobil Medical Plan option as long as the employee remains as a regular employee.

If the employee retires or dies, and coverage is available under the EMRMP:

• Medicare eligible covered spouses must enroll in the Medicare Primary Option, including enrolling in Medicare Parts A and B.
• All eligible dependent children under the age of 26 (including those that are Medicare eligible) and those over the age of 26 who are totally and continuously disabled and not Medicare eligible, may enroll in the Retiree Medical Plan options of the EMRMP.
• Medicare eligible dependent children over the age of 26 are not eligible for coverage under any ExxonMobil Health plan available to retirees.  You may be eligible to elect continuation coverage for your Medicare eligible dependent child under COBRA provisions. See Continuation coverage for details. 

If you die

If you die while enrolled, your covered eligible family members may be eligible for the ExxonMobil Retiree Medical Plan. They are not eligible to continue to participate in the ExxonMobil Medical Plan except through COBRA. Their eligibility continues with the EMRMP for a specified amount of time:

• If you have 15 or more years of benefit service at the time of your death, eligibility continues until your spouse remarries, becomes eligible for Medicare or dies. Upon eligibility for Medicare, your spouse can continue coverage through the Medicare Primary Option.
• If you have less than 15 years of benefit service, eligibility continues for twice your length of benefit service or until your spouse remarries, becomes eligible for Medicare, or dies, whichever occurs first. Upon eligibility for Medicare, your spouse can continue coverage through the Medicare Primary Option.

Children of deceased employees may continue participation as long as they are an eligible family member. If your surviving spouses remarries, eligibility for your stepchildren also ends.

See Continuation Coverage for details.

Coordination of benefits

Coordination of benefits for the ExxonMobil Medical Plan – Open Access Aetna Select option

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 EMMP 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 EMMP will be reduced. Aetna will calculate this reduced amount as follows:

• The amount normally reimbursed for covered benefits under the EMMP,
• 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 EMMP is your primary plan, EMMP will pay your medical claims first, as if there is no other coverage. When EMMP is your secondary plan, EMMP will pay benefits after the primary plan, and that payment amount will be the lesser of:

• What EMMP would have paid if it had been primary, or
• What EMMP 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 Plan Administrator 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 EMMP 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 EMMP 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 EMMP 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 EMMP’s subrogation rights.

You also must fully cooperate with the EMMP’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 EMMP’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 EMMP 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 EMMP 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 EMMP 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 EMMP 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 EMMP 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 for the ExxonMobil Medical Plan – Open Access Aetna Select option

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 terminate employment, retire, or die,  
• You elect not to participate,
• A family member ceases to be eligible (for example, a child reaches age 26),
• You are no longer eligible for benefits under this Plan (e.g., from non-represented to represented where you are no longer eligible for this Plan),
• You terminate employment after being rehired by ExxonMobil as an employee following retirement,
• A Qualified Medical Child Support Order is no longer in effect for a covered family member,
• Your employer discontinues participation in the Plan,

OR

• The date:

• The Plan ends,
• You do not make any required contribution,
• 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 ExxonMobil Benefits Service Center when your enrolled spouse or family member is no longer eligible for coverage. If you do not complete your change within 60 days, any contributions you make for ineligible family members will not be refunded.

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 ExxonMobil Medical coverage, and you may be subject to disciplinary action up to and including termination of employment if you commit fraud against the Plan, for instance, by filing claims for benefits to which you are not entitled. Coverage may also be terminated if you refuse to repay amounts erroneously paid by the ExxonMobil Medical Plan on your behalf or that you recover from a third party. Your participation may be terminated if you fail to comply with the terms of this medical plan and their 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 eligibility due to divorce. 

Extended benefits at termination

You are entitled to extended coverage for as much as a year if you are terminated due to disability with fewer than 15 years of service. This coverage is provided at no cost to you. This is considered a portion of the COBRA continuation period. In order to assure coverage beyond this extension period, you must elect COBRA upon termination of employment.

Several conditions must be met:

• The disability must exist when your employment terminates.
• The extension lasts only as long as the disability continues, but no longer than 12 months.

This extension applies only to the employee who is terminated because of a disability. Continuation coverage for eligible family members may be available through COBRA.

During annual enrollment, changes to your EMMP coverage (option or contributions) do not automatically adjust your coverage or contributions to other plans such as the ExxonMobil Dental Plan, ExxonMobil Vision Plan or the flexible spending accounts under the ExxonMobil Pre-Tax Spending Plan. Changes to those plans must be made separately during annual enrollment.

Continuation of coverage

Continuation of coverage for the ExxonMobil Medical Plan – Open Access Aetna Select option

Introduction

You are required to be given the information in this section because you are covered under a group health plan (the 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 Medical Plan section.

You, your spouse and your family members may have other options available when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace.  By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs.  Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you 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:

• Current ExxonMobil and XTO Employees or their covered family members should use ExxonMobil 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 an employee, you will be entitled to elect COBRA, if you lose your coverage under the Plan because either one of the following qualifying events happens:

• Your hours of employment are reduced, or
• Your employment ends for any reason other than your gross misconduct.

If you are the spouse of an employee, you will be entitled to elect COBRA if you lose coverage under the Plan because any of the following qualifying events happens:

• Your spouse dies,
• Your spouse's hours of employment are reduced,
• Your spouse’s employment ends for any reason other than his or her gross misconduct,
• You become divorced from your spouse.  Also, if your spouse (the employee) 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 employee’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 parent-employee dies,
• The parent-employee's hours of employment are reduced,
• The parent-employee's employment ends for any reason other than his or her gross misconduct, or
• The child stops being eligible for coverage under the Plan as a child.

When is COBRA coverage available?

When the qualifying event is the end of employment or reduction of hours of employment or death of the employee, 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 employee 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 employees may give notice of qualifying events by logging onto ExxonMobil Benefits located on the Employee Connect intranet site or contacting the 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 employees 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.

You, your spouse and covered dependents may qualify for up to 18 months of continuation coverage, if you qualify due to one of the following qualifying events:

• Your employment ends for any reason other than termination for gross misconduct;
• Your work hours are reduced and you are no longer eligible to participate in the Plan; or
• Unpaid Leave of Absence.

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.

Second qualifying event extension COBRA coverage

If your family experiences another qualifying event while receiving COBRA coverage as a result of the covered employee’s termination of employment or reduction of hours (including COBRA coverage during a disability extension as described above), the covered spouse and children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given the COBRA Administrator. This extension may be available to the spouse and any children receiving COBRA coverage if the employee or former employee dies, gets divorced, or if the covered child stops being eligible under the Plan as a child. This extension is not available under the Plan when a covered employee becomes entitled to Medicare after his or her termination of employment or reduction of hours.  This extension due to a second qualifying event is available only if you notify the correct benefits administration entity within 60 days of the date of the second qualifying event.

Disability extension of 18-month COBRA continuation coverage

The 18-month continuation period may be extended for you and your covered family members if the Social Security Administration determines that you or another family members, who is a qualified beneficiary, is disabled at any time during the first 60 days of continuation coverage.  If all of the following requirements are met, coverage for all family members who are qualified beneficiaries as a result of the same qualifying event can be extended for up to an additional 11 months (for a total of 29 months):

• This extension is available only for qualified beneficiaries who are receiving COBRA coverage because of a qualifying event that was the covered employee’s termination of employment or reduction of hours.
• The disability must have started at some time before the 61st day after the covered employee’s termination of employment or reduction of hours
• A copy of the Notice of Award from the Social Security Administration is provided to the COBRA Administrator (ExxonMobil Benefits Service Center) within 60 days the latest of (a) the date of the Social Security disability determination; (b) the date of the qualifying event (i.e., the termination of employment or reduction of hours); (c) the date on which you lost or would lose coverage under the plan as a result of the qualifying event; or (d) the date on which the you were informed, through the furnishing of the SPD or COBRA initial notice, of both the responsibility to provide the notice of disability determination and the plan's procedures for providing such notice to the administrator.
• If the disabled qualified beneficiary elects continuation coverage, you must pay an increased premium of 150 percent of the monthly cost of Plan coverage that’s continued, beginning with the 19^th month of continuation coverage.

Extension Due to Medicare Eligibility

Coverage may also last up 36 months for a covered spouse or covered dependent when loss of coverage is the result of a qualifying event that is the end of the employee’s employment or the reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event.  In this case, COBRA coverage under the Plan for qualified beneficiaries (other than the employee) may last until up to 36 months after the date of the employee’s Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA coverage for his spouse and children who lost coverage as a result of his termination can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). This COBRA coverage period is available only if the covered employee becomes entitled to Medicare within 18 months BEFORE termination or reduction of hours.

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 come eligible for and enroll in Medicare Part A, Part B or both.
• You extend coverage for up to 29 months due to a qualified beneficiary’s disability and there has been a final determination by the Social Security Administration that the qualified beneficiary is no longer disabled. In this case, continuation coverage will end on the first of the month that begins more than 30 days after the final determination o by the Social Security Administration that the qualified beneficiary is no longer disabled. This will be the case only if the qualified beneficiary has been covered by continuation coverage for at least 18 months.
• 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 employee during a period of COBRA coverage is considered to be a qualified beneficiary provided that, if the covered employee is a qualified beneficiary, the covered employee 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 employee. To be enrolled in the Plan, the child must satisfy the otherwise-applicable Plan eligibility requirements (for example, regarding age).

Alternate recipients under QMCSOs

A child of the covered employee who is receiving benefits under the Plan pursuant to a qualified medical child support order (QMCSO) received by ExxonMobil during the covered employee's period of employment with ExxonMobil is entitled to the same rights to elect COBRA as an eligible child of the covered employee.

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, unless the person is entitled to extended coverage due to disability. If the person becomes entitled to such extended coverage due to disability, the person may be required to contribute up to 150% of contributions after the initial 18-month's coverage until coverage ends. 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 ExxonMobil 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.

Contacts for COBRA rights under the ExxonMobil Medical Plan

The following sets out the contact numbers based on your status under the ExxonMobil 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 for help.

Employees 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 ExxonMobil COBRA Administration WP.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

Information on Basic Plan features of the ExxonMobil Medical Plan – Open Access Aetna Select option works

The Plan generally covers only Medically necessary care and services.

Plan participants have access to a network of participating Primary Care Physicians (PCPs), specialists and hospitals that meet Aetna’s requirements for quality and service. These providers are independent physicians and facilities that are monitored for quality of care, patient satisfaction, cost-effectiveness of treatment, office standards and ongoing training.

Although not required, each participant in the Plan is encouraged to select a network Primary Care Physician (PCP) when they enroll.  When choosing a PCP, use the aetna.com website to select an individual physician. Your PCP serves as your guide to care in today's complex medical system and will coordinate and monitor your overall care or may provide treatment. They may also refer you to other network providers.

Participants may update their PCP by calling Member Services or through aetna.com.

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 procedures, drugs, devices or biological products not proven by long-term clinical studies are generally not covered. See Exclusions: What your plan doesn’t cover for limited exceptions.

When determining medical necessity, Clinical Policy Bulletins (CPBs) published by Aetna, the claims administrator may be used.

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 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.

For more information on precertification for medical/surgical procedures and services and mental health and substance use disorder services, see the Precertification Lists on the Aetna member website.

The Primary Care Physician

As a participant in the Plan, you will become a partner with participating PCP in preventive medicine.  The following physicians are considered PCPs: Internists, General Practitioners, Pediatricians and Family Practitioners. Consult your PCP whenever you have questions about your health. Your PCP will provide your primary care and, when medically necessary, your PCP may refer you to other doctors or facilities for treatment.

Primary and preventive care

A PCP can provide preventive care and treat you for illnesses and injuries. The Plan covers routine physical exams, well-baby care, immunizations and allergy shots provided by your PCP.

You may also obtain gynecological exams from in-network providers. You are responsible for the copayment stated in the Benefits summary.

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

Specialty and facility care

While your plan does not require a referral from a participating PCP to see specialty doctors, you will want to coordinate such care with your PCP.  Your PCP may refer you to a specialist or facility for treatment or for covered preventive care services, when medically necessary.  When your PCP refers you to a participating specialist or facility for covered services, you will be responsible for the copayment shown in the Benefits summary.

To avoid costly and unnecessary bills, follow these steps:

• You are encouraged to consult your PCP first when you need routine medical care.
• Certain services require  prior authorization from Aetna.
• All services provided by a non-network provider require prior authorization by Aetna.

Provider information

To find Aetna 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.

Your ID cards

Show your ID card each time you get covered services from a provider. Only members on your plan can use your ID card. We will mail you your ID card. If you haven’t received it before you need covered services, or if you lose it, you can print a temporary one using the Aetna website.

You will also receive separate Express Scripts ID card(s).

ESI will send 1 member ID card for single coverage, and 2 member ID cards for family coverage (any coverage for more than employee only). Temporary ID cards can be requested by logging into Express Scripts customer website at express-scripts.com, or call Express Scripts member services at 800 695-4116.

Always carry your ID cards with you, including your prescription drug card (Express Scripts ). Your cards identify you as a plan participant when you receive services from in-network providers or when you receive emergency services at non-participating facilities. If your cards are lost or stolen, please notify Aetna and Express Scripts immediately.

Effective January 1, 2024 Instead of receiving printed ID cards for the medical, dental and vision plans in the mail, they will be available on each plan’s website and apps so you can view them on your phone. You can download them and easily save, share, print or email them directly to providers. You can also request a physical version any time via customer service, as well as through the Aetna, Cigna, Express Scripts or UHC Vision app or member website.

Culture of Health and Health Management programs

Details on ExxonMobil's Culture of Health and health management programs

Culture of Health is a set of programs and resources to support the overall health of our workforce both at work and at home, including online tools and resources for individual goal setting, a personal health survey, and an annual biometric screening.  These tools and resources are available to all employees and family members (age 18 and older) eligible to enroll in the ExxonMobil Medical Plan.

Additional integrated Health Management programs are available to participants in the Open Access Aetna Select option to help you improve your health and to assist you in obtaining good health care when care is needed. These programs reflect a commitment by you and the company to good health and quality care.

Health Management tools and resources are available to you at no additional cost. However, health care claims (e.g., doctor's fees or facilities charges) are processed according to the Plan’s provisions.

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, prescribe medication, or give specific medical instruction; all at no cost to you. Topics discussed during your call may include services and expenses not covered under the Plan.

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 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 http://www.2nd.md/aetna to initiate services.

Omada Programs for Diabetes, Hypertension, and Weight Management

Omada programs are available to eligible members 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 (COEs), Institutes of Quality (IOQs) and Institutes of Excellence (IOE) 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/IOQa/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 COE/IOQ/IOE program is voluntary and designed to direct participants to nationally recognized facilities with more positive outcomes. A COE/IOQ/IOE recommended treatment plan, however, must meet the 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 COE/IOE. If access to a clinically appropriate COE/IOQ/IOE requires the patient to travel 100 or more miles, the 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 COE/IOQ/IOE, you will not incur additional out-of-pocket costs for choosing another hospital in the Plan's network. 

2023 Benefits summary

2023 Benefits summary on the ExxonMobil Employee Medical Plan – Open Access Aetna Select option

Type of Service or Supply	Benefit Level
Lifetime Maximum	No lifetime maximum
Individual Annual Out-of-Pocket Limit Includes Pharmacy	$3,000
Family Annual Out-of-Pocket Limit Including Pharmacy	$6,000
If an employee and one or more eligible family members are covered under this option, after one covered family member meets the individual out-of-pocket maximum, benefits for that individual are payable at 100% by the Plan. Once the family meets the family out-of-pocket maximum, benefits for all covered family members are payable at 100%.
Preventive Care as recommended by the USPSTF
Preventive Care Office Visits	No charge
Routine Physicals & Immunizations	No charge
Routine gynecological examinations and PAP smears performed by a participating PCP or a participating gynecologist	No charge
Routine mammograms for female Plan participants age 35, or over	No charge
Well-child care from birth (including Immunizations and booster doses)	No charge
Prostate Cancer Screening (PSA) and digital exam for males age 40 and over, and for males considered to be at high risk who are under age 40, as directed by physician	No charge
Colorectal cancer screening after age 45 or for high risk patients	No charge
Bone mass measurements to determine an individual's risk of osteoporosis	No charge
Routine immunizations (except those required for travel or work)	No charge
Primary Care
Non-routinePCP Office Visits Including Telemedicine	$25 copay per visit
Non-routinehome visits by your PCP	90 % coverages
Allergy Treatment- Routine injections at PCP’s office, with or without physician encounter	$25 copay per visit
Hearing Aids	Not covered (See Exclusions section for information about the Amplifon Hearing Health Care (formerly HearPo) Discount Program and the Hearing Care Solutions Discount Program)
Specialty And Outpatient Care
Specialist Office Visits Including Telemedicine	$40 copay per visit
Walk in Clinic (Retail Clinic)	$40 copay per visit
Prenatal Care (applies to standard global maternity services and initial visit)	$4025 copay per visit
Maternity (childbirth/delivery services)	90% coverage
Fertility Servicesauthorized by Progynyfor in-network benefits	90% coverage
Allergy Testing	$40 copay per visit
Imaging (CT/PET scans, MRIs)	90% coverage some tests may require prior approval by Aetna
Diagnostic X-rays and Outpatient Labs associated with an office visit.	No additional charge
Therapy (speech, occupational, physical)	$40 copay per visit
Chiropractic Care	$40 copay per visit - 20 visits per calendar year
Outpatient Rehabilitation	$40 copay per visit
Home Health Care	90% coverage
Prosthetic Devices	90% coverage some prostheses must be approved in advance by Aetna
To see a list of procedures that require precertification, please reference the National Precertification List* on the Aetna member website.
Inpatient Services (Precertification required)
Hospital Room and Board and Other Inpatient Services	90% coverage
Skilled Nursing Facilities	90% coverage
Hospice Facility	90% coverage
Surgery and Anesthesia
Inpatient Surgery	90% coverage
Outpatient Surgery	90% coverage
Mental Health and Substance Use Disorder Treatment*
Office Visit	$25 copay per visit
Habilitative and rehabilitative therapy for a diagnosis of autism, developmental disorder, or attention deficit disorder	$40 copay per visit
Outpatient Services	90% coverage
Inpatient Treatment (including residential treatment centers)	90% coverage
Urgent and Emergency Care
Urgent Care	$60 copay per visit
MinuteClinic®walk-in visit	100% coverage Participating CVS/Target MinuteClinics
Emergency Room	$150 copay (waived if admitted)
Ambulance	90% coverage
Prescription Drugs through Express Scripts (No annual maximum benefit)
Annual out-of-pocket maximum	Combined with medical out-of-pocket maximum
Short-term (30-day supply)* **	$15 copay – generic formulary drugs 30% coinsurance – brand-name formulary drugs ($125 maximum per prescription) 50% coinsurance – non-formulary drugs ($200 maximum per prescription)
Long-term (90-day supply)*	$30 copay – generic formulary drugs 25% coinsurance – brand-name formulary drugs ($200 maximum per prescription) 50% coinsurance – non-formulary drugs ($400 maximum per prescription)

* National Precertification List on the Aetna member website

* 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.

** A long-term or maintenance medication is a drug you take for an extended period of time, such as for the ongoing treatment of diabetes, arthritis, a heart condition, or blood pressure. After the third short-term fill of a maintenance medication, subsequent refills must be purchased as a 90-day supply at a Smart90 retail pharmacy (Walgreens, CVS) or Express Scripts home delivery pharmacy. If you continue to purchase short-term fills of a long-term or maintenance medication after the third fill, you will be responsible for 100% of the cost.

*** Formulary 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 the plan

Eligible health services under your plan for the ExxonMobil Medical Plan – Open Access Aetna Select option

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%.  

Routine physical exams

Eligible health services include office visits to your PCP and/or Obstetrician/Gynecologist for routine physical exams.

A routine exam is a medical exam given by a physician for a reason other than to diagnose or treat a suspected or identified illness or injury, and also includes:

• Evidence-based items that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force (USPSTF).
• Services as recommended in the American Academy of Pediatrics/Bright Futures/Health Resources and Services Administration guidelines for children and adolescents.
• Screenings and counseling services as provided for in the comprehensive guidelines recommended by the Health Resources and Services Administration. These services may include but are not limited to:

Screening and counseling services on topics such as:

• Interpersonal and domestic violence
• Sexually transmitted diseases
• Human immune deficiency virus (HIV) infections

Screening for gestational diabetes for women

High risk human papillomavirus (HPV) DNA testing for women age 30 and older

• Radiological services, lab and other tests given in connection with the exam.
• For covered newborns, an initial hospital checkup. 

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 participating 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 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 only when using in-network providers.

Well woman preventive visits

Eligible health services include your routine:

• Well woman preventive exam office visit to a network PCP, obstetrician (OB), gynecologist (GYN) or OB/GYN. This includes pap smears. Your plan covers the exams recommended by the Health Resources and Services Administration. 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  a network PCP 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

These benefits will be subject to any age, family history and frequency guidelines that are:

• Evidence-based items or services that have in effect a rating of A or B in the recommendations of the United States Preventive Services Task Force
• Evidence-informed items or services provided in the comprehensive guidelines supported by the Health Resources and Services Administration

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 a  PCP’s, OB's, GYN's, or OB/GYN’s office.

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, PCP, 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.

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 subject to the appropriate coinsurance.

Please note that the list above is not all inclusive, so for more information on the most updated preventive services, please refer to the following sites:

https://www.hhs.gov/healthcare/about-the-aca/preventive-care/index.html

https://www.healthcare.gov/coverage/preventive-care-benefits/

Physicians and other health professionals

Physician services

Physician services include: non-routine office visits with  aa network PCP during both office and non-office hours - including Telemedicine, non-routine home visits by a network  a PCP, treatment for illness and injury and injections, including routine allergy desensitization injections at PCP's office, with or without physician encounter. All, subject to copay.

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 charge 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 mental health or substance abuse 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

Emergency care while traveling for business or a personal vacation:

If you require emergency medical care while traveling for business or a personal vacation, the Plan will cover your emergency treatment 24 hours a day, 7 days a week, anywhere in the world. 

Covered expenses are subject to the Plan’s applicable coinsurance, and copays.

If you are traveling outside the United States, unless you have made other arrangements with the emergency medical providers, you will be required to pay the medical bills and then submit the claims to Aetna for reimbursement. The ExxonMobil Plans do not directly reimburse medical providers located outside the United States.

For reimbursement, submit the itemized bills along with a claim form. If the original bills are in a foreign language, you should obtain an English translation if possible. Bills must be submitted in the appropriate foreign currency. The claims administrator will convert the bill to U.S. dollars as of the date of service.

Follow-up care after emergencies

You must have approval from Aetna to receive follow-up care from a non network provider. Suture removal, cast removal, X-rays, and clinic and emergency room revisits are some examples of follow-up care.

Urgent care

Treatment that you obtain outside of your service area for an urgent medical condition is covered if:

• The service is a covered benefit,
• You could not reasonably have anticipated the need for the care prior to leaving the network service area, and
• A delay in receiving care until you could return and obtain care from a participating network provider would have caused serious deterioration in your health.

Aetna has adopted the following definition of urgent medical condition:

Urgent medical condition – means a medical condition for which care is medically necessary and immediately required because of unforeseen illness, injury, or condition, and it is not reasonable, given the circumstances, to delay care in order to obtain the services through your home service area or from  a network PCP.

Some examples of urgent medical conditions are:

• Severe vomiting,
• Earaches,
• Sore throat, or
• Fever.

Follow-up care provided by aa network PCP is covered, subject to the office visit copayment. Other follow-up care by participating specialists is subject to the specialist copay shown in the Benefits schedule.  If you are in your service area, you must use an in-network urgent care center.

Telemedicine services

Telemedicine services are available through the designated service provider (Teladoc) for non-emergency medical and behavioral health conditions such as cold/flu symptoms, stomach aches, common childhood illnesses, dermatology support, depression, stress, and anxiety. Services are available 24/7 via phone or video chat. You pay a primary care visit copayment each time you use the service. Call 1-855-Teladoc (835-2362) or visit Teladoc.com/Aetna.

What to do outside your Aetna service area

Emergency care

If a participant goes to a hospital emergency room for an Emergency Medical Condition, any medical provider can be utilized and the emergency room copay will apply.

Urgent care

For urgent care, if you are out of your service area, participants can use a non-network urgent care provider or go to an emergency room.  Non-emergency or non-urgent use of an urgent care provider is not covered.  Urgent care may be obtained from a walk-in clinic, or an urgent care center.  An urgent medical condition that occurs outside your Aetna service area can be treated in any of the above settings.

• If, after reviewing information submitted to Aetna by the provider(s) who supplied your care, the nature of the urgent or emergency problem does not clearly qualify for coverage, it may be necessary to provide additional information.

Although the Aetna Select is a network only plan option, if you receive emergency services out-of-network, the out-of-network provider exceptions below will apply.

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.

Specifically, Covered Expenses rendered by a non-Participating Provider are generally paid at the “Surprise Billing Reimbursement Rate” (i.e., a rate calculated in accordance with ERISA § 716) when:

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.
1. 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.

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.

For more information on your rights, please refer to the Surprise Medical Bills notice located in exxonmobilfamily.com

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.

Applied Behavior Analysis (ABA) will be covered consistent with Aetna´s clinical policy bulletins..

Coverage does not include services for custodial care, educational services, or services performed in an academic, vocational or recreational setting.

Fertility Services

Fertility services will be covered, when services are authorized by Progyny, the Plan’s designated Fertility Services Network Organization.

Covered services include comprehensive fertility treatment, Advanced Reproductive Technology (ART), ovulation induction, donor tissue purchase and cryopreservation services, as well as member support services and digital tools, for up to three “smart cycles” or episodes of care (four cycles if required for the first pregnancy) as defined by Progyny and when obtained at a Progyny network provider. Contact Progyny at 1-833-851-2229 to initiate services.

Examples of how a Smart Cycle can be used:

• Egg Freezing = ½ Smart Cycle
• Frozen Embryo Transfer (FET) = ¼ Smart Cycle
• Frozen Oocyte Transfer (FOT) = ½ Smart Cycle
• Intrauterine Insemination (IUI) or Timed Intercourse (TIC) = ¼ Smart Cycle
• In Vitro Fertilization (IVF) Fresh Cycle or IVF Freeze-All Cycle = ¾ Smart Cycle
• Sperm Freezing = ¼ Smart Cycle
• Surrogacy Embryology Services (pre-transfer) = ½ Smart Cycle

Notes: Claims related to diagnosis and treatment of the underlying conditions during your treatment with Progyny will continue to be filed through Aetna.

Dependent children are not eligible for fertility services.

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 instances 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:

• 48 hours of inpatient care in a hospital after a vaginal delivery
• 96 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

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

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.

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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 we designate 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 we designate 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.

Specific therapies and tests

Outpatient diagnostic testing

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 procedures.
• 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 25^th 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.

Habilitation therapy services

Habilitation therapy services are services that help you keep, learn, or improve skills and functioning for daily living (e.g. therapy for a child who isn’t walking or talking at the expected age). The plan standardly covers rehabilitation and habilitation services, as long as the services aren’t considered experimental and investigational.

Habilitation therapy services have to follow a specific treatment plan, ordered by your physician.

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. 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 maximum per year.

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.

Chiropractic services

Chiropractic services will be covered only when performed by a licensed doctor or chiropractic who is acting within the scope of his or her license, limited to a 20-visit annual maximum.

Clinical Trials

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 in  Key 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.

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®️, 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.

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, if the exam is performed by:

• A physician certified as an otolaryngologist or otologist
• An audiologist who is legally qualified in audiology; or holds a certificate of Clinical Competence in Audiology from the American Speech and Hearing Association (in the absence of any applicable licensing requirements); and who performs the exam at the written direction of a legally qualified otolaryngologist or otologist.

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 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.

Behavioral health and substance use disorder care

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.

Prescription drug program

Prescription drug program for the ExxonMobil Medical Plan – Open Access Aetna Select option

The Plan pays, subject to any limitations specified under Your Benefits, the cost incurred for outpatient prescription drugs that are obtained from a participating pharmacy. Express Scripts is the pharmacy benefit manager for your prescription drugs.  You must present your Express Scripts  ID card and make the copayment shown in the Benefits summary for each prescription at the time the prescription is dispensed.

The Plan covers the costs of prescription drugs, in excess of the copayment, that are:

• Medically necessary for the care and treatment of an illness or injury, as determined by Express Scripts;
• Prescribed in writing by a physician who is licensed to prescribe federal legend prescription drugs or medicines, and
• Not listed under Prescription Drug Exclusions and Limitations, below.

Non-emergency prescriptions must be filled at a participating pharmacy. Generic drugs may be substituted for brand-name products where permitted by law.

Coverage is based upon Express Scripts’ formulary. 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. The formulary includes both brand-name and generic drugs and is designed to provide access to quality, affordable outpatient prescription drug benefits. You can reduce your copayment by using a covered generic or brand-name drug that appears on the formulary. Your copayment will be highest if your physician prescribes a covered drug that does not appear on the formulary. 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.

Long-term or maintenance medications

A long-term or maintenance medication is a drug you take for an extended period of time, such as for the ongoing treatment of diabetes, arthritis, a heart condition, or blood pressure. After the third short-term fill of a maintenance medication, subsequent refills must be purchased as a 90-day supply at a Smart90 retail pharmacy (Walgreens, CVS) or Express Scripts home delivery pharmacy. If you continue to purchase short-term fills of a long-term or maintenance medication after the third fill, you will be responsible for 100% of the cost.

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’ website. 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. 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.

Emergency prescriptions

You may not have access to a participating pharmacy in an emergency or urgent care situation, or if you are traveling outside of the Plan’s service area. If you must have a prescription filled in such situations, the Plan will reimburse you as follows:

• Non-Participating Pharmacy – You must pay the pharmacy directly for the full cost of the prescription and you will be responsible for submitting a request for reimbursement in writing to the pharmacy benefit manager with a receipt for the cost of the prescription. The pharmacy benefit manager will directly reimburse the Member 100% of the prescription, less the applicable copay.  Coverage for items obtained from non-participating pharmacies is limited to items obtained in connection with covered Emergency and Out-of-Area Urgent Care services.  Contact Express Scripts Member Services for more information.
• Participating Pharmacy – When you obtain an emergency or urgent care prescription at a participating pharmacy (including an out-of-area participating pharmacy), you must pay the applicable copay. The pharmacy benefit manager will not reimburse claims submitted as a direct reimbursement request from a Member for a prescription purchased at a participating retail pharmacy except upon professional review and approval by the pharmacy benefit manager.

Covered drugs

The Plan covers the following:

• Outpatient prescription drugs when prescribed by a provider who is licensed to prescribe federal legend drugs or medicines, subject to the terms, limitations and exclusions described in this booklet.
• FDA-approved prescription drugs when the off-label use of the drug has not been approved by the FDA to treat the condition in question, provided that:
• the drug is recognized for treatment of the condition in one of the standard reference compendia (the United States Pharmacopoeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information), or
• the safety and effectiveness of use for the condition has been adequately demonstrated by at least one study published in a nationally recognized peer reviewed journal.
• Diabetic supplies as follows:
• diabetic needles and syringes
• alcohol swabs
• test strips for glucose monitoring and/or visual reading
• diabetic test agents
• lancets (and lancing devices)
• insulin
• prescriptive and nonprescriptive oral agents for controlling blood sugar levels
• glucagon emergency kits
• Smoking Cessation aids and drugs prescribed by a physician.
• Oral and implantable contraceptive drugs and contraceptive devices.
• Injectable contraceptives (Depo-Provera).
• Growth hormone therapy, when pre-certified by Express Scripts

Prescription drug exclusions and limitations

Prescription drug exclusions

The following services and supplies are not covered by the Plan, and a medical exception is not available for coverage:

• Any drug that does not, by federal or state law, require a prescription order (such as an over-the- counter drug), even when a prescription is written.
• Any drug that is not medically necessary.
• Charges for the administration or injection of a prescription drug or insulin.
• Cosmetics and any drugs used for cosmetic purposes or to promote hair growth, including (but not limited to) health and beauty aids.
• Any prescription for which the actual charge to you is less than the copayment.
• Any prescription for which no charge is made to you.
• Insulin pumps or tubing for insulin pumps.
• Medication which is to be taken by you or administered to you, in whole or part, while you are a patient in a licensed hospital or similar facility.
• Take-home prescriptions dispensed from a hospital pharmacy upon discharge from the hospital, unless the hospital pharmacy is a participating retail pharmacy.
• Any medication that is consumed or administered at the place where it is dispensed.
• Immunization or immunological agents, including, but not limited to:
• biological sera.
• blood, blood plasma or other blood products administered on an outpatient basis.
• allergy sera and testing materials.
• Drugs used for the purpose of weight reduction, including the treatment of obesity.
• Any prescription refilled in excess of the number specified by the physician, or any refill dispensed after one year from the physician’s original order.
• Drugs labeled Caution - Limited by Federal Law to Investigational Use and experimental drugs.
• Drugs prescribed for uses other than the uses approved by the FDA under the Food, Drug and Cosmetic Law and regulations.
• Medical supplies, devices and equipment, and non-medical supplies and substances, regardless of their intended use.
• Prescription drugs purchased prior to the effective date, or after the termination date, of coverage under this Plan.
• Replacement of lost or stolen prescriptions.
• Performance and athletic performance lifestyle-enhancement drugs and supplies.
• Smoking-cessation aids or drugs unless prescribed by a physician.
• Test agents and devices, except diabetic test strips.
• Needles and syringes, except diabetic needles and syringes.
• Any drug or device that terminates a pregnancy.
• Prophylactic drugs for travel.
• Nutritional Supplements.
• Medication packaged in unit dose form (except those approved by payment by Express Scripts).

Prescription drug limitations

The following limitations apply to the prescription drug coverage:

• A participating retail or home delivery pharmacy may refuse to fill a prescription order or refill when, in the professional judgment of the pharmacist, the prescription should not be filled.
• Prescriptions may be filled only at a participating retail or home delivery pharmacy, except in the event of emergency or urgent care. Plan participants will not be reimbursed for out-of-pocket prescription purchases from a non-participating pharmacy in non-emergency, non-urgent care situations.
• Plan participants must present their ID cards at the time each prescription is filled to verify coverage. If you do not present your ID card, your purchase may not be covered by the Plan, except in emergency and urgent care situations, and you may be required to pay the entire cost of the prescription.
• The Plan is not responsible for the cost of any prescription drug for which the actual charge to the plan participant is less than the required copayment or for any drug for which no charge is made to the recipient.
• Plan participants will be charged the non-formulary prescription drugs copayment for prescription drugs covered on an exception basis.
• For maintenance medications (those taken on a regular basis to treat ongoing conditions like allergies, asthma, diabetes, heart conditions, etc.), the Plan will provide coverage for three short-term fills at a retail pharmacy; for subsequent short-term fills the participant will be responsible for 100% of the cost.  Any long-term refill that is submitted to a Smart90 retail pharmacy (Walgreens, CVS) or the Express Scripts home delivery pharmacy will be subject to the long-term pharmacy copayments.
• When a clinically equivalent generic is available, and a brand name drug is purchased, the copayment will be equal to the generic copayment amount plus the full difference in the cost of the brand name drug and the generic.  The difference in cost will not count toward the annual out-of-pocket maximum for 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.

Advanced Utilization Management (AUM)

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 drugs will not be covered unless pre-certified 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 obtain 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 by initially 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 dermatological and topical pain medications may trigger a prior authorization.  Oral oncology medications will also be limited to ensure appropriate use. Certain drugs within each class 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. 

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.

Therapeutic Resource Center

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.

Exclusions

What your plan doesn’t cover on the ExxonMobil Employee Medical Plan– Open Access Aetna Select option

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.

The Plan does not cover the following services and supplies:

General exclusions

• Any services or supplies that are not medically necessary, as determined by Aetna.
• 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.  
• Care for conditions that, by state or local law, must be treated in a public facility.
• Court-ordered services and services required by court order as a condition of parole or probation, unless medically necessary and provided by participating providers upon referral from your PCP.
• Expenses that are the legal responsibility of Medicare or a third party payer.
• Experimental and investigational services and procedures; ineffective surgical, medical, psychiatric, or dental treatments or procedures; research studies, or other experimental or investigational health care procedures or pharmacological regimes, as determined by Aetna, unless approved by Aetna in advance. This exclusion will not apply to drugs:
• that have been granted treatment investigational new drug (IND) or Group c/treatment IND status,
• that are being studied at the Phase III level in a national clinical trial sponsored by the National Cancer Institute, or
• that Aetna has determined, based upon scientific evidence, demonstrate effectiveness or show promise of being effective for the condition.
• Refer to the Key Terms section for a definition of experimental or investigational.
• Health services, including those related to pregnancy that are provided before your coverage is effective or after your coverage has been terminated.
• Treatment in a federal, state or governmental facility, including care and treatment provided in a nonparticipating hospital owned or operated by any federal, state or other governmental entity, except to the extent required by applicable laws.
• Treatment of illnesses, injuries or disabilities related to military service for which you are entitled to receive treatment at government facilities that are reasonably available to you.
• Treatment of injuries sustained while committing a felony.
• Treatment of sickness or injury covered by a worker’s compensation act or occupational disease law, or by United States Longshoreman’s and Harbor Worker’s Compensation Act.
• Services not covered by the Plan, even when your PCP has issued a referral for those services.
• Services or supplies covered by any automobile insurance policy, up to the policy’s amount of coverage limitation.
• Services provided by your close relative (your spouse, child, brother, sister, or the parent of you or your spouse) for which, in the absence of coverage, no charge would be made.
• Services required by a third party, including (but not limited to) physical examinations, diagnostic services and immunizations in connection with:
• ·obtaining or continuing employment,
• ·obtaining or maintaining any license issued by a municipality, state or federal government,
• securing insurance coverage,
• travel, and
• school admissions or attendance, including examinations required to participate in athletics, unless the service is considered to be part of an appropriate schedule of wellness services.
• Services and supplies that are not medically necessary.
• Services you are not legally obligated to pay for in the absence of this coverage.

Physicians and other health professionals

• 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.
• Any service in connection with, or required by, a procedure or benefit not covered by the Plan.
• 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.

Hospital and other facility care

• Ambulance services, when used for non-emergency transportation.
• Cosmetic surgery or surgical procedures primarily for the purpose of changing the appearance of any part of the body to improve appearance or self-esteem. However, the Plan covers the following:
• reconstructive surgery to correct the results of an injury.
• surgery to treat congenital defects (such as cleft lip and cleft palate) to restore normal bodily function.
• surgery to reconstruct a breast after a mastectomy that was done to treat a condition, or as a continuation of a staged reconstructive procedure.
• Inpatient care for serious mental illness which is not provided in a hospital or mental health treatment facility.
• Outpatient supplies, including (but not limited to) outpatient medical consumable or disposable supplies such as syringes, incontinence pads, elastic stockings and reagent strips, (except as described under Prescription Drugs).
• Personal comfort or convenience items, including services and supplies that are not directly related to medical care, such as guest meals and accommodations, barber services, telephone charges, radio and television rentals, homemaker services, travel expenses, take-home supplies, and other similar items and services.
• Private duty nursing care, unless preauthorized.
• Radial keratotomy, including related procedures designed to surgically correct refractive errors.
• Surgical operations, procedures or treatment of obesity, except when approved in advance by Aetna. Bariatric surgery is excluded in all events and will not be pre-authorized

Specific conditions

• Acupuncture and acupuncture therapy, except when performed by a participating physician as a form of anesthesia in connection with covered surgery.
• Biofeedback, except as specifically approved by Aetna.
• Blood, blood plasma, or other blood derivatives or substitutes.
• Breast augmentation and otoplasties, including treatment of gynecomastia.
• Care furnished to provide a safe surrounding, including the charges for providing a surrounding free from exposure that can worsen the condition or injury.
• Contact Lens Fitting.
• Custodial care and rest cures.
• Dental care and treatment, including (but not limited to):
  • care, filling, removal or replacement of teeth,
  • dental services related to the gums,
  • apicoectomy (dental root resection),
  • ·orthodontics,
  • root canal treatment,
  • soft tissue impactions,
  • alveolectomy,
  • augmentation and vestibuloplasty treatment of periodontal disease,
  • prosthetic restoration of dental implants, and
  • dental implants.
• Elective abortions.
• Hair analysis.
• Hearing aids. Even though this Plan does not provide coverage for hearing aids, if you are considering the purchase of hearing aids, you may be able to lower your out-of-pocket expenses through the Amplifon Hearing Health Care (formerly HearPo) Discount Program or the Hearing Care Solutions Discount Program. 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, you can visit www.aetna.com or call Amplifon Hearing Health Care (formerly HearPo) at 1-877-301-0840 or Hearing Care Solutions at 1-866-344-7756 and identify yourself as an Aetna member.
• Home births.
• Home uterine activity monitoring.
• Household equipment, including (but not limited to) the purchase or rental of exercise cycles, air purifiers, central or unit air conditioners, water purifiers, hypo-allergenic pillows, mattresses or waterbeds, is not covered. Improvements to your home or place of work, including (but not limited to) ramps, elevators, handrails, stair glides and swimming pools, are not covered.
• Hypnotherapy, except when approved in advance by Aetna.
• Incidental charges.
• Implantable drugs.
• Maintenance, replacement, or repair for continuously rented Durable Medical Equipment (DME), frequently serviced DME, or oxygen equipment are not covered as a separate expense under the Plan.
• Orthoptics (a technique of eye exercises designed to correct the visual axes of eyes not properly coordinated for binocular vision).
• Orthotics (except for diabetes).  If for diabetes, the orthotic must be coordinated by the PCP. Contact Aetna Member services for preauthorization.
• Recreational, educational and sleep therapy, including any related diagnostic testing.
• Religious, marital and sex counseling, including related services and treatment.
• Reversal of voluntary sterilizations, including related follow-up care and treatment of complications of such procedures.
• Routine hand and foot care services, including routine reduction of nails, calluses and corns.
• Routine hearing exam.
• Special education, including lessons in sign language to instruct a plan participant whose ability to speak has been lost or impaired to function without that ability.
• Special medical reports, including those not directly related to the medical treatment of a plan participant (such as employment or insurance physicals) and reports prepared in connection with litigation.
• Specific injectable drugs, including:
  • experimental drugs or medications, or drugs or medications that have not been proven safe and effective for a specific condition or approved for a mode of treatment by the FDA and the National Institutes of Health,
  • ·needles, syringes and other injectable aids (except as described under Prescription Drugs),
  • drugs related to treatments not covered by the Plan, and
  • performance-enhancing steroids.
• Specific non-standard allergy services and supplies, including (but not limited to):
  • cytotoxicity testing (Bryan’s Test),
  • treatment of non-specific candida sensitivity, and
  • urine auto injections.
• Therapy or rehabilitation, including (but not limited to):
  • primal therapy
  • chelation therapy
  • rolfing
  • psychodrama
  • megavitamin therapy
  • purging
  • bioenergetic therapy
  • ·vision perception training
  • carbon dioxide therapy
  • Thermograms and thermography.
• Treatment, including therapy, supplies and counseling, for sexual dysfunctions or inadequacies that do not have a physiological or organic basis.
• Treatment of temporomandibular joint (TMJ) syndrome, with the exception of diagnostic and surgical treatment, including (but not limited to):
• treatment performed by placing a prosthesis directly on the teeth,
• non-surgical medical and dental services, and
• therapeutic services related to TMJ.

• Weight reduction programs and dietary supplements.

Medical claims and appeals

Filing claims for the ExxonMobil Medical Plan – Open Access Aetna Select option

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. Plan eligibility is determined by the Administrator-Benefits. The Administrator-Benefits determination of eligibility is final and no appeals are available.

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 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 a deductible or 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 a href="https://www.exxonmobilfamily.com/en/health/pos-ii-a-and-b/key-terms#Short-term%20prescriptions" target="_self">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. 

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 Member Services will provide you with a written explanation supporting the denial and describing additional information, if any, that may improve the claim’s likelihood of being approved.

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, the time frames shown may be extended. 

Type of Claim	Level One Appeal	Level Two Appeal
Urgent care claim:a claim for medical care or treatment where delay could: Seriously jeopardize your life or health, or your ability to regain maximum function, or Subject you to severe pain that cannot be adequately managed without the requested care or treatment	36 hours Review provided by Aetna personnel not involved in making the adverse benefit determination.	36 hours Review provided by Appeals Committee.
Pre-service claim:a claim for a benefit that requires Aetna’s approval of the benefit in advance of obtaining medical care.	15 calendar days Review provided by Aetna personnel not involved in making the adverse benefit determination	15 calendar days Review provided by Appeals Committee.
Concurrent care claim extension:a request to extend a previously approved course of treatment.	Treated like an urgent care claim or a pre-service claim depending on the circumstances	Treated like an urgent care claim or a pre-service claim depending on the circumstances
Post-service claim:a claim for a benefit that is not a pre-service claim.	30 calendar days Review provided by Aetna personnel not involved in making the adverse benefit determination.	30 calendar days Review provided by Appeals Committee.

External review of Aetna’s final appeal determinations

The external review process is expanded to apply with respect to any adverse determination by a plan or issuer under the CAA, including grandfathered plans, and with respect to any item or service to which the No Surprises Act applies.

 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.

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

The 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.

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 Medical Plan – Open Access Aetna Select option

Basic Plan information

Plan name

ExxonMobil Medical Plan.

This SPD describes the Open Access Aetna Select – in network option.

Plan sponsor and participating affiliates

The ExxonMobil Medical Plan is sponsored by:

ExxonMobil Corporation

5959 Las Colinas Blvd.
Irving, Texas 75039-2298

Effective July 2023 the above address is replaced with:

ExxonMobil 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 Medical Plan is identified with government agencies under two numbers:

The Employer Identification Number (EIN), 13-5409005, and the Plan Number (PN), 538.

Plan administrators

The Plan Administrator for the ExxonMobil Medical Plan is the Administrator-Benefits. The Administrator-Benefits is the Manager-Global Benefits Design, Exxon Mobil Corporation.

Claims fiduciary and administrator

The Claims fiduciary has been delegated authority by the Administrator-Benefits to determine all claims and appeals for benefits. You may contact the claims fiduciary as follows:

Medical, Behavioral Health and Substance Use disorders.

Aetna
P. O. Box 14463
Lexington KY 40512

Prescription Drugs:

Express Scripts
P.O. Box 66587
St. Louis, MO 63166-6587
Attn: Administrative Appeals Dept.

Forum and Venue

The exclusive forum and venue for any legal or equitable action relating to or arising under the plan shall be in the United States District Court for the Southern District of Texas, Houston Division, so long as the federal courts may assert subject matter jurisdiction over the action (unless the parties to the action have agreed otherwise). In the event the action is not subject to the subject matter jurisdiction of the federal courts, the exclusive forum and venue for such action shall be the district courts of Harris County, Texas (unless the parties to the action have agreed otherwise). Per the terms of the plan, you consent to the personal jurisdiction of these courts, as applicable, and waive any objections to personal jurisdiction or inconvenience of the forum and venue specified in this paragraph

For service of legal process:

Corporation Service Co.
211 East 7^th 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 Medical Plan in its application to any participant or beneficiary, and to decide any and all claim appeals.

Type of plan

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

Plan year

The plan year is the calendar year.

Collective bargaining agreements.

Eligibility for participation in the ExxonMobil Medical Plan by represented employees is governed by local bargaining requirements. A copy of the plan documents is available for examination upon written request

Funding

The Plan is funded through contributions by the Employer and/or plan participants. Benefits under the EMMP are funded through participant and company contributions. Each year, ExxonMobil determines the rates of required participant contributions to the Medical Plan. These rates are based on past and projected plan experience. This plan is self-funded by ExxonMobil. (See Self-funded in the Key terms.)

Claims administrator

The claims administrator provides information about claims payment. The claims administrator is Aetna for medical, 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 Plan

The company reserves the right at any time and for any reason to terminate, suspend, withdraw, amend or modify the ExxonMobil Medical Plan or any of its provisions. If any changes are made in the future, you will be notified in accordance with legal requirements. In the event the ExxonMobil Medical Plan is terminated, you will have the right to elect continuation coverage, as described in the COBRA section of this guide, in any other health plan maintained by ExxonMobil or its controlled group.

Your rights under ERISA

As a participant in the ExxonMobil Medical Plan, you have certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all participants 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 Medical Plan, including contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the 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 Medical Plan including collective bargaining agreements and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Descriptions. The Administrator may require a reasonable charge for the copies.

Receive a summary of the Medical 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 plan fiduciaries

In addition to creating rights for Medical Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Medical Plan, called fiduciaries, of the Medical Plan have a duty to do so prudently and in the interest of you and other Medical Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise 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 Medical Plan documents or the latest Summary Annual Report from the Medical 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 both denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the Medical Plan's decision or lack thereof concerning the qualified status of a domestic relations order, you may file suit in Federal court. Any such lawsuits must be brought within one year of the date on which an appeal was denied. If it should happen that Medical Plan fiduciaries misuse the Plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. 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.

Applicable Law

The Plan and all rights hereunder are governed by and construed, administered, and regulated in accordance with the provisions of ERISA, HIPAA and the Internal Revenue Code (“Code”) to the extent applicable, and to the extent not preempted by ERISA, the laws of the state of Texas, without giving effect to its conflicts of laws provision.  The Plan may not be interpreted to require any person to take action, or fail to take any action, if to do so would violate any applicable law.

Assistance with your questions

If you have any questions about the Medical Plan, you should contact the Plan Administrator. If you have any questions 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 related to the ExxonMobil Medical Plan – Open Access Aetna Select option

Coverage for maternity hospital stay

Under federal law, the Plan may not restrict benefits for 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 caesarean 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.  

The Women’s Health and Cancer Rights Act

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 which applies 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 copayments and limits applicable to other covered services.

If you have any questions about your benefits, please contact Aetna Member Services.

Key terms

List of key terms in the ExxonMobil Medical Plan – Open Access Aetna Select option