Medicare Supplement Plan Option
Summary plan description of the Medicare Supplement Plan option as of January 2021
About the Medicare Supplement Plan option
This summary plan description (SPD) is a summary of the Medicare Supplement Plan (MSP, the Plan), which effective July 1, 2022 is no longer an option under the ExxonMobil Retiree Medical Plan (EMRMP). The provisions described are those in effect immediately prior to the discontinuation of this option. It does not contain all Plan details. 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, always govern. Copies of these documents are available for your review.
The Medicare numbers used in this SPD are current for 2020 but are subject to change. The dollar amounts in the examples are for explanation purposes only and may not reflect what a specific service might cost or how much Medicare and the Plan would pay toward that service.
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, 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.
Prescription drug program -Express Scripts is the claims processor for outpatient prescription drugs provided through home delivery and Smart90 retail pharmacies (Express Scripts, Walgreens, CVS) for long-term prescriptions or a local retail pharmacy for short-term prescriptions.
In addition, Express Scripts can provide pharmacy benefits information, including clinical guidelines, benefits pre-determinations, and providers participating in the Express Scripts pharmacy network. Express Scripts also provides prior-authorization review for certain pharmacy services, medications, and equipment. Ask to speak to a Therapeutic Resource Center (TRC) pharmacist for specialized support services.
|Express Scripts Pharmacy:|
Express Scripts Home Delivery Pharmacy
Home Delivery Pharmacy:
|For questions regarding Retail Prescriptions:|
800-497-4641 (international, use appropriate country access code depending on the country from which you are calling)*
|Direct Reimbursement Claim Form:
ATTN: Commercial Claims
P.O. Box 14711
Lexington, KY 40512-4711
Direct Reimbursement Claim Forms may also be faxed to: 608-741-5475
*To be able to reach this international access line for Express Scripts, please use the appropriate access number (e.g., AT&T Direct Service) for the country you are calling from.
Another way to locate retail network pharmacies and order refills is via the Express Scripts website at www.express-scripts.com.
All other medical - Aetna, the claims administrator, provides claim forms, claims payment information and advanced approval for in-home skilled-nursing care. Aetna is also the claims processor for all medical expenses except outpatient prescriptions.Phone Numbers:
Aetna Member Services
210-366-2416 (international, call collect)
Monday - Friday 8:00 a.m. to 6:00 p.m. (U.S. Central Time),
except certain holidays
Automated Voice Response Hours: 24 hours a day, 7 days a week
P.O. Box 981106
El Paso, TX 79998-1106
Benefits Administration - Retirees and survivors can enroll/change coverage on the ExxonMobil Benefits Service Center website at www.exxonmobil.com/benefits. If you are unable to access the Internet or need additional information, you may contact:Phone Numbers:
Retirees and Survivors call:
ExxonMobil Benefits Service Center
Monday – Friday 8:00 a.m. to 6:00 p.m.
(U.S. Eastern Time), except certain holidays
or 800-TDD-TDD4 (833-8334) for hearing impaired
ExxonMobil Benefits Service Center
P.O. Box 18025
Norfolk, VA 23501-1867
ExxonMobil sponsored sites - Access to plan-related information including claim forms for employees, retirees, survivors, and their family members.
- ExxonMobil Family, the Human Resources Internet Site — Can be accessed by everyone at www.exxonmobilfamily.com.
- Retiree Online Community Internet Site — Can be accessed by retirees and survivors only at www.emretiree.com.
- ExxonMobil Benefits Service Center at Xerox Internet Site — Can be accessed by everyone at www.exxonmobil.com/benefits.
The Medicare Supplement Plan option, referred to as the Plan in this SPD, is a medical plan for retirees, survivors and their eligible family members who are also eligible for Medicare. It is designed to work with Medicare Parts A and B to give you medical coverage similar to that available to employees and retirees not eligible for Medicare.
The Medicare Supplement Plan option also covers care and supplies such as outpatient prescription drugs, in-home skilled-nursing care and medical care received outside the United States, which are not covered by Medicare Parts A and B; however, if you enroll in a Medicare Advantage (Part C) plan, which provides a Medicare prescription drug benefit or Medicare Part D (coverage for prescription drugs), the Plan will not cover any outpatient prescription drugs even if they are not covered under Medicare Part C or D.
While the Plan is designed to work with Medicare Parts A and B, it is not intended to pay all amounts that Medicare does not cover. Benefits payable under the Plan are considered together with the benefits received from Medicare.
The Plan does not involve an insurance policy. All claims are funded by contributions from ExxonMobil, other participating employers and participants. Aetna Life Insurance Company (Aetna) and Express Scripts are paid fees to provide services such as processing claims, answering questions, and managing the pharmacy network and home delivery pharmacy service. Neither Aetna nor Express Scripts has any responsibility for funding benefits under the Plan.
Aetna does not render medical services or treatments. Neither the Plan nor Aetna is responsible for the health care that is delivered by providers participating in the Medicare Supplement Plan option, and those providers are solely responsible for the health care they deliver. Providers are not the agents or employees of the Plan or Aetna.
The Plan is described in detail in this SPD. These tools help you find specific information quickly and easily:
- Plan at a glance, a quick user's guide highlighting Plan basics.
- Charts and tables to provide information, examples, highlights of Plan provisions, including a Benefit summary chart.
- References to places where you can find more information.
- A list of Key terms containing definitions of some words and terms used in this SPD.
A careful reading of this SPD will help you understand how the Plan works so you can make the best use of the Plan provisions. You may obtain additional information from the sources listed in the Information Sources section of this SPD.
Plan at a glance
Retirees and their eligible family members who are also eligible for Medicare as their primary plan may participate. Survivors of retirees or deceased employees may also be eligible once they become eligible for Medicare as their primary plan. See Eligibility and enrollment.
The prescription drug program
The Plan offers cost-saving ways to buy outpatient prescription drugs if you are not participating in a Medicare Advantage (Part C) plan which provides a Medicare prescription drug benefit or Medicare Part D — at local participating network pharmacies, Smart90 pharmacies (Walgreens, CVS), and through home delivery. See Prescription drug program.
Other plan provisions
If you meet your annual out-of-pocket limit of $3,000, the Plan's reimbursement level — when combined with Medicare Parts A and B — is 100% of the Medicare approved amount for most covered expenses for the rest of that calendar year. You must satisfy an annual deductible of $300 before the Plan starts paying. The Plan covers some items Medicare may not, such as transition benefits from pre-65 medical plans sponsored by ExxonMobil, in-home skilled-nursing care and medical care received outside the United States. See Other Plan Provisions.
If your doctor or other health care providers accept assignment, they accept the amount Medicare approves as payment in full for each service or supply. You must still pay any coinsurance amount. See Accepting assignment.
Covered and excluded expenses
The Plan provides benefits for many, but not all, types of treatment, care and services. See Covered expenses and Exclusions for more information.
Coordination of benefits
The Plan treats Medicare coverage as another group plan for purposes of coordinating benefits. See Coordination of benefits.
All claims should be submitted to Medicare first. If you participate in Medicare Direct, your Medicare Part B claims are automatically forwarded from Medicare to Aetna. If you do not participate in Medicare Direct, you submit the claim along with the Explanation of Medicare Benefits forms to Aetna. See Claims.
Your family members who lose eligibility may continue medical coverage for a limited time in certain circumstances. See Continuation coverage.
Administrative and ERISA information
The Plan is subject to rules of the federal government, including the Employee Retirement Income Security Act of 1974, as amended (ERISA), not state insurance laws. See Administrative and ERISA information.
This is an alphabetized list of words and phrases, with their definitions, used in this SPD. See Key terms.
Key features of the Plan and Medicare are highlighted. See Benefit summary.