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Aetna Select Network Only Option

Summary plan description of the ExxonMobil Employee Medical Plan - Aetna Select Network Only option as of January 2021

This is your guide to the benefits available through the ExxonMobil Medical Aetna Select Network Only Option (Aetna Select, or the Plan). Please read it carefully and refer to it when you need information about how the Plan works, to determine what to do in an emergency situation, and to find out how to handle service issues. It is also an excellent source for learning about many of the special programs available to you as a plan participant.

If you cannot find the answer to your question(s) in the booklet, call the Member Services toll-free number on your ID card. For more information, go to the Member Services section.

Tips for New Plan Participants

  • Keep this guide where you can easily refer to it.

  • Keep your ID card(s) in your wallet.

  • Enter your Primary Care Physician’s name and number in your telephone.

  • Emergencies are covered anywhere, 24 hours a day. See In case of medical emergency for emergency care guidelines.

  • All non-emergency specialty and hospital services require a prior referral from your Primary Care Physician.

Important information

THIS IS NOT AN INSURED BENEFIT PLAN. THE BENEFITS DESCRIBED IN THIS BOOKLET OR ANY RIDER ATTACHED HERETO ARE SELF-FUNDED BY EXXONMOBIL WHICH IS RESPONSIBLE FOR THEIR PAYMENT. AETNA LIFE INSURANCE COMPANY (AETNA) PROVIDES CLAIM ADMINISTRATION SERVICES TO THE PLAN, BUT AETNA DOES NOT INSURE THE BENEFITS DESCRIBED. 

In determining your specific benefits, the full provisions of the formal plan documents, as they exist now or as they may exist in the future, govern. Part 4 of the EMMP formal plan document is intended as the sole document that sets out the benefits provided through the Aetna Select option. You may obtain copies of these documents by making a written request to the Administrator-Benefits. ExxonMobil reserves the right at any time to change in any way or terminate any benefit.

This guide covers the major features of the Aetna Select administered by Aetna Life Insurance Company, effective January 1, 2021. The plan description has been designed to provide a clear and understandable summary of the Plan, and with the Provider directory serves as the Summary Plan Description (SPD) required for plans subject to ERISA.

The Aetna Select option administered by Aetna Life Insurance Company 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. This option is governed by federal laws, not state insurance laws.

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

Information sources

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

For claims administration:

Contact Aetna for medical/surgical and behavioral health and substance abuse claims forms, claims payment and other claims inquiries.

Contact Express Scripts for pharmacy claims forms, claims payment and other claims inquiries.

For benefits information:

Contact Aetna for medical/surgical benefits information, including clinical guidelines, benefits pre-determinations, and providers participating in the Aetna Select network. Aetna also provides hospital precertification review for inpatient medical 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 Magellan for behavioral health and substance abuse benefits information, including clinical guidelines, benefits pre-determinations, and providers participating in the Magellan Health Preferred Provider (MHPPO) network. Magellan also provides hospital precertification review for inpatient behavioral health and substance abuse services as well as for certain other behavioral health and substance abuse services, tests and equipment. Ask to speak to a behavioral health advocate for ongoing consultation and referral services.

Contact Express Scripts for pharmacy benefits information, including clinical guidelines, benefits pre-determinations, and providers participating 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.

For benefits administration:

References to Benefits Administration throughout this SPD pertain to the ExxonMobil Benefits Administration Health and Welfare Services team. Contact the Benefits Administration for benefits administration information, including enrollment and eligibility inquiries.

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

Phone Numbers and Addresses:
Aetna Member Services
800-255-2386
210-366-2416 (if international, call collect)

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

Aetna
P. O. Box 981106
El Paso, TX 79998-1106

To visit Aetna’s website: www.aetna.com

Magellan Healthcare
800-442-4123
314-387-4700 (international, call collect)
24 hours a day, 7 days a week

Magellan Healthcare
14100 Magellan Plaza Drive
Maryland Heights, MO 63043

To visit Magellan’s website: https://magellanascend.com/ ( (enter 800-442-4123)

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

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

Direct Reimbursement Claim Form
Express Scripts
ATTN: Commercial Claims
P.O. Box 14711
Lexington, KY 40512-4711

Direct Reimbursement Claim Forms may also be faxed to: 608-741-5475.

ExxonMobil Benefits Administration / Health and Welfare Services 
hr.health.welfare@exxonmobil.com (E-mail) 
Fax: 713-231-1743.

ExxonMobil Benefits Administration

BA BSC
P. O. Box 64111
Spring, TX 77387-4111

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

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