2023 Benefit summary
Benefits summary of the ExxonMobil Medical Plan – Aetna POS II A and POS II B options
These charts provide only a brief summary of benefits under the EMMP POS II A and EMMP POS II B. They are not intended to include all provisions. Non-network and out-of-network area benefits are subject to reasonable and customary limits.
This information is applicable to all non-represented employees participating in the Plan. Applicability to represented employees is governed by local bargaining requirements.
ExxonMobil Medical Plan / Aetna POS II A option |
Service Area: Worldwide |
Services |
POS II Network |
Non-Network |
Out-of-Network Area |
Annual Deductible |
$600 / $1200 |
$800 / $1,600 |
$600 / $1,200 |
Out-of-Pocket Maximum |
$4,500 / $9,000 |
$18,000 / $36,000 |
$4,500 / $9,000 |
Individual Lifetime Maximum |
Unlimited |
Unlimited |
Unlimited |
Separate Lifetime Maximum for Bariatric Surgery |
$25,000 |
$25,000 |
$25,000 |
Inpatient Hospital Services for Medical, Mental Health and Substance use disorder care. |
$300 deductible |
$600 deductible |
$300 deductible |
Pre-certification |
In-network Provider initiates |
You initiate; |
In-network Provider initiates |
Outpatient Surgery and Associated Diagnostic Lab and X-ray Services |
75% coverage |
55% coverage |
75% coverage |
Physician Services* |
POS II Network |
Non-Network |
Out-of-Network Area |
Surgeon/Hospital Doctor Visits |
75% coverage |
55% coverage |
75% coverage |
Office Visit |
Primary care: |
55% coverage |
75% coverage |
Preventive Care *Physician services include Behavioral health providers. PCP selection is not required |
100% coverage |
100% coverage
Reasonable and Customary charges apply |
100% coverage
Reasonable and Customary charges apply |
Services |
POS II Network |
Non-Network |
Out-of-Network Area |
ER Ambulance |
$150 copay4 |
$150 copay4 |
$150 copay4 |
Urgent care |
$60 copay |
55% coverage Reasonable and Customary charges apply |
75% coverage Reasonable and Customary charges apply |
MinuteClinic |
100% coverage |
N/A |
100% Coverage |
Prenatal Care (applies to standard global maternity services and initial visit) |
100% coverage |
100% coverage Reasonable and Customary charges apply |
100% coverage Reasonable and Customary charges apply |
Maternity |
75% coverage |
55% coverage |
75% coverage |
Chiropractic Care Calendar Year Limit5 |
$60 copay Up to 20 visits or $1,000 max |
55% coverage Up to 20 visits or $1,000 max |
75% coverage Up to 20 visits or $1,000 max |
|
Note: effective January 1, 2024 the Plan will adopt standard concurrency rules: if you go to network providers, you will not be impacted. However, you may pay more for a second service during the same visit if you go to a non-network provider as the plan will cover 50% of the allowed amount for that second (non-preventive) service.
Prescription Drugs |
|
Annual out-of-pocket maximum for prescription drugs: |
$2,500 per individual / $5,000 per family |
Short-Term Retail Copay* ** *** |
Express Scripts, Accredo, or Smart90 Pharmacy** |
||||
(up to 34-day supply) |
Maximum Per Prescription |
3rd+ Retail Refill**** |
(up to 90-day supply) |
Maximum Per Prescription |
|
Generic Drugs |
30% |
$60 |
55% |
25% |
$120 |
Preferred |
30% |
$130 |
55% |
25% |
$260 |
Non-Preferred |
50% |
$200 |
75% |
50% |
$400 |
* If using a non-network pharmacy, you pay 100% of the difference between the actual cost and the discounted network cost plus retail copays.
** 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 for prescription drugs.
*** You must present Express Scripts Prescription Card or Social Security number of participant or benefits will be paid at the non-network level.
**** Preferred 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 if you would like to enroll in the program. If you choose not to enroll in the program, 30% coinsurance with no maximum will apply, and any amount you pay will not count towards your Deductible or Out-of-Pocket Maximums.
ExxonMobil Medical Plan / Aetna POS II B option |
Service Area: Worldwide |
Services |
POS II Network |
Non-Network |
Out-of-Network Area |
Annual Deductible |
$400 / $800 |
$500 / $1,000 |
$400 / $800 |
Out-of-Pocket Maximum |
$3,000 / $6,000 |
$15,000 / $30,000 |
$3,000 / $6,000 |
Individual Lifetime Maximum |
Unlimited |
Unlimited |
Unlimited |
Separate Lifetime Maximum for Bariatric Surgery |
$25,000 |
$25,000 |
$25,000 |
Inpatient Hospital Services for Medical, Mental Health and Substance Use Disorder care¹ |
$200 deductible |
$400 deductible |
$200 deductible |
Pre-certification |
Provider initiates |
You initiate; |
You initiate; |
Outpatient Surgery and Associated Diagnostic Lab and X-ray Services |
80% coverage |
60% coverage |
80% coverage |
Physician Services* |
POS II Network |
Non-Network |
Out-of-Network Area |
Surgeon/Hospital Doctor Visits |
80% coverage |
60% coverage |
80% coverage |
Office Visit |
Primary care: |
60% coverage |
80% coverage |
Preventive Care *PCP selection is not required |
100% coverage |
100% coverage
Reasonable and Customary charges apply |
100% coverage
Reasonable and Customary charges apply |
Services |
POS II Network |
Non-Network |
Out-of-Network Area |
Emergency services/Ambulance |
$150 copay4 |
$150 copay4 |
$150 copay4 |
Urgent Care |
$45 copay |
60% coverage Reasonable and Customary charges apply |
80% coverage Reasonable and Customary charges apply |
MinuteClinic |
100% coverage |
N/A |
100% Coverage |
Maternity |
80% coverage |
60% coverage |
80% coverage |
Chiropractic Care Calendar Year Limit5 |
$45 copay3 |
60% coverage Up to 20 visits or $1,000 max |
80% coverage Up to 20 visits or $1,000 max |
|
Note: effective January 1, 2024 the Plan will adopt standard concurrency rules: if you go to network providers, you will not be impacted. However, you may pay more for a second service during the same visit if you go to a non-network provider as the plan will cover 50% of the allowed amount for that second (non-preventive) service.
Prescription Drugs |
|
Annual out-of-pocket maximum for prescription drugs: |
$2,500 per individual / $5,000 per family |
Short-Term Retail Copay* ** *** |
Express Scripts, Accredo, or Smart90 Pharmacy** |
||||
(up to 34-day supply) |
Maximum Per Prescription |
3rd+ Retail Refill**** |
(up to 90-day supply) |
Maximum Per Prescription |
|
Generic Drugs |
30% |
$50 |
55% |
25% |
$100 |
Preferred |
30% |
$125 |
55% |
25% |
$250 |
Non-Preferred |
50% |
$200 |
75% |
50% |
$400 |
* If using a non-network pharmacy, you pay 100% of the difference between the actual cost and the discounted network cost plus retail copays.
** 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 for prescription drugs.
*** You must present Express Scripts Prescription Card or Social Security number of participant or benefits will be paid at the non-network level.
**** Preferred 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 if you would like to enroll in the program. If you choose not to enroll in the program, 30% coinsurance with no maximum will apply, and any amount you pay will not count towards your Deductible or Out-of-Pocket Maximums.