Forms and useful links

Medical

Key Health Insurance Words (video)

Medical Claim Form (Including instructions)

Medicare Supplement Plan Claim Form

Ordering medications from Express Scripts by mail (mail order pharmacy)

Prescriptions Claim Form (Express Scripts)

Pre-Tax Spending Plan (Flexible Spending Account)

Employee Dependent Care Affidavit - Flexible Spending Account Dependent Care Reimbursement Account

Employee Health Care Affidavit - Flexible Spending Account Health Care Reimbursement Account

Pre-Tax Direct Deposit Form

Health and Dependent Care Flexible Spending Account Claim Form
Please note that Aetna supports the Flexible Spending Account reimbursement process for all options under the ExxonMobil Medical Plan and ExxonMobil International Medical and Dental Plan. Participants in Cigna OAPIN, Cigna International Medical and Dental Plan, and Aetna POS and Aetna Select options should all utilize this form.

Click here to find the following IRS Publications located on the irs.gov website.

IRS Publication 502 - Medical and Dental Expenses

IRS Publication 503 - Child and Dependent Care Expenses

IRS Publication 2441 - Instructions for Child and Dependent Care Expenses

IRS Form 2441 - Child and Dependent Care Expenses

Vision

ExxonMobil Vision Plan

U.S. Expats & Rotators mail order anti-malarials

Anti-Malarial Mail Order Program Notice

ExxonMobil Expat Skill Center Letter to Employees Explaining the Program

ExxonMobil Malaria Chemoprophylaxis Prescription Fax Order Form

Word document (you can edit, save and attach to an e-mail)
PDF document (you can print, write on changes, bring or mail to prescriber - changes cannot be saved)