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Benefit summary

Benefits summary of the ExxonMobil Employee Medical Plan - POS II A and POS II B options

Please note: 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.

ExxonMobil Medical Plan / POS II A option
2021 Summary of Benefits / Plan Code: 1021

Service Area: Worldwide
POS II Group Number: 721000
Member Services: 800-255-2386
Provider Website: www.aetna.com
Choice® POS II
(for mental health and substance abuse, access Magellan Ascend)

Services POS II Network Non-Network Out-of-Network Area

Annual Deductible
(Individual/Family)

$500 / $1000 $700 / $1,400 $500 / $1000
Out-of-Pocket Maximum
(Individual/Family)
$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 Medical¹ (managed by Aetna), Mental Health and Substance Abuse treatment (managed by Magellan) $300 deductible
75% coverage
$600 deductible
55% coverage
$300 deductible
75% coverage

Pre-certification
Reference the Aetna National Precertification List
for a list of procedures requiring pre-certification (for mental health and substance abuse treatment, contact Magellan)

Provider initiates You initiate;
$500 penalty for failure to pre-certify inpatient care
You initiate;
$500 penalty for failure to pre-certify inpatient care
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
(including most diagnostic lab and X-ray services)²
Primary care:
$40 copay³
Specialist:
$60 copay³
55% coverage 75% coverage

Preventive Care
(including most diagnostic lab and X-ray services)²

*Physician services include Mental Health providers. PCP selection is not required

100% coverage 100% coverage 100% coverage
Services POS II Network Non-Network Out-of-Network Area

Emergency Care

$100 copay4
75% coverage
$100 copay4
75% coverage
$100 copay4
75% coverage
Maternity 75% coverage 55% coverage 75% coverage

Chiropractic Care

  • Calendar Year Limit5
$60 copay
$1,000
55% coverage $1,000 75% coverage $1,000
  1. Precertification is required for all inpatient care, including mental health and substance abuse.
  2. Excludes MRI, CAT scan, PET/Spect, Muga Scan, Thallium stress test, Angiography and Myelography.
  3. Not subject to deductible.
  4. Charge applied to hospital deductible if admitted.
  5. Applies to all chiropractic expenses regardless of network status of provider.

IMPORTANT NOTE: This chart provides only a brief summary of benefits under this option. It is not intended to include all POS II A option provisions.

This information is applicable to all non-represented employees participating in the Plan. Applicability to represented employees is governed by local bargaining requirements.

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
Brand Drugs
30% $130 55% 25% $260
Non-Preferred
Brand Drugs
50% $200 75% 45% $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 or Medco 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, 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, you will be responsible for the higher copayment.

ExxonMobil Medical Plan / POS II B option
2021 Summary of Benefits / Plan Code: 1022

Service Area: Worldwide
POS II Group Number: 721000
Member Services: 800-255-2386
Provider Website: www.aetna.com
Choice® POS II
(for mental health and substance abuse, access Magellan Ascend)

Services POS II Network Non-Network Out-of-Network Area

Annual Deductible
(Individual/Family)

$300 / $600 $600 / $1200 $300 / $600
Out-of-Pocket Maximum
(Individual/Family)
$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 Medical¹ (managed by Aetna), Mental Health and Substance Abuse treatment (managed by Magellan) $200 deductible
80% coverage
$400 deductible
60% coverage
$200 deductible
80% coverage

Pre-certification
Reference the Aetna National
Precertification List
for a list of
procedures requiring pre-certification (for mental health and substance abuse treatment, contact Magellan)

Provider initiates You initiate;
$500 penalty for failure to pre-certify inpatient care
You initiate;
$500 penalty for failure to pre-certify inpatient care
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
(including most diagnostic lab and X-ray services)²
Primary care:
$25 copay³
Specialist:
$40 copay³
60% coverage 80% coverage

Preventive Care
(including most diagnostic lab and X-ray services)²

*PCP selection is not required

100% coverage 100% coverage 100% coverage
Services POS II Network Non-Network Out-of-Network Area

Emergency Care

$100 copay4
80% coverage
$100 copay4
80% coverage
$100 copay4
80% coverage
Maternity 80% coverage 60% coverage 80% coverage

Chiropractic Care

  • Calendar Year Limit5
$40 copay3
$1,000
60% coverage $1,000 80% coverage $1,000
  1. Precertification is required for all inpatient care, including mental health and substance abuse.
  2. Excludes MRI, CAT scan, PET/Spect, Muga Scan, Thallium stress test, Angiography and Myelography.
  3. Not subject to deductible.
  4. Charge applied to hospital deductible if admitted.
  5. Applies to all chiropractic expenses regardless of network status of provider.

IMPORTANT NOTE: This chart provides only a brief summary of benefits under this option. It is not intended to include all POS Il A option provisions.

This information is applicable to all non-represented employees participating in the Medical Plan. Applicability to represented employees is governed by local bargaining requirements.


Prescription Drugs

Annual out-of-pocket 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
Brand Drugs****
30% $125 55% 25% $250
Non-Preferred
Brand Drugs
50% $200 75% 45% $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 or Medco 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, 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, you will be responsible for the higher copayment.

 

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