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2024 Benefit summary

Benefits summary of the ExxonMobil Retiree Medical Plan – Aetna POS II A and B options

Please note: These charts provide only a brief summary of benefits under the RMP Aetna POS II A and B options. They are not intended to include all provisions. Non-network and out-of-network area benefits are subject to reasonable and customary limits.

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

Service Area: Worldwide
POS II Group Number: 476599
Member Services: 800-255-2386
Provider Website: www.aetna.com
Choice® POS II

 

Services

POS II Network

Non-Network

Out-of-Network Area

Annual Deductible
(Individual/Family)

$600 / $1200

$800 / $1600

$600 / $1200

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, Behavioral Health and Substance Use Disorder treatment

$300 deductible
75% coverage

$600 deductible
55% coverage

$300 deductible
75% coverage

Precertification
Reference the Aetna National Precertification List
for a list of procedures requiring precertification

Provider initiates

You initiate;
$500 penalty for failure to precertify inpatient care

You initiate;
$500 penalty for failure to precertify 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 Behavioral 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

$150 copay4
75% coverage

$150 copay4
75% coverage

$150 copay4
75% coverage

Urgent care

$60 copay

55% coverage

Reasonable and Customary charges apply

75% coverage

Reasonable and Customary charges apply

MinuteClinic
(includes virtual visits)

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 $1,000 or up to 20 visits, whatever is reached first

55% coverage

up to $1,000 or up to 20 visits, whatever is reached first

75% coverage

up to $1,000 or up to 20 visits, whatever is reached first

  1. Precertification is required for all inpatient care, including behavioral health and substance use disorder.
  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.

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

(up to 90-day supply)

Maximum Per Prescription

Generic Drugs

30%

$60

25%

$120

Preferred****
Brand Drugs

30%

$130

25%

$260

Non-Preferred
Brand Drugs

50%

$200

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 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, a 30% coinsurance with no maximum will apply, and any amount you pay will not count towards your Deductible or Out-of-Pocket Maximums.

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

Service Area: Worldwide
POS II Group Number: 476599
Member Services: 800-255-2386
Provider Website: www.aetna.com
Choice® POS II

 

Services

POS II Network

Non-Network

Out-of-Network Area

Annual Deductible
(Individual/Family)

$400 / $800

$700/ $1400

$400 / $800

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, Behavioral Health and Substance Use Disorder treatment

$200 deductible
80% coverage

$400 deductible
60% coverage

$200 deductible
80% coverage

Precertification
Reference the Aetna National Precertification List for a list of
procedures requiring precertification

Provider initiates

You initiate;
$500 penalty for failure to precertify inpatient care

You initiate;
$500 penalty for failure to precertify 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:
$45 copay³

60% coverage

80% coverage

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

100% coverage

100% coverage

100% coverage

 

Services

POS II Network

Non-Network

Out-of-Network Area

Emergency Care

$150 copay4
80% coverage

$150 copay4
80% coverage

$150 copay4
80% coverage

Urgent care

$45 copay

60% coverage

Reasonable and Customary charges apply

80% coverage

Reasonable and Customary charges apply

MinuteClinic
(includes virtual visits)

100% coverage

N/A

100% Coverage

Maternity

80% coverage

60% coverage

80% coverage

Chiropractic Care

  • Calendar Year Limit5

$45 copay3

up to $1,000 or up to 20 visits, whatever is reached first

60% coverage

up to $1,000 or up to 20 visits, whatever is reached first

80% coverage

up to $1,000 or up to 20 visits, whatever is reached first

  1. Precertification is required for all inpatient care, including behavioral health and substance use disorder.
  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.

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

(up to 90-day supply)

Maximum Per Prescription

Generic Drugs

30%

$50

25%

$100


Preferred****
Brand Drugs

30%

$125

25%

$250

Non-Preferred
Brand Drugs

50%

$200

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 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, a 30% coinsurance with no maximum will apply, and any amount you pay will not count towards your Deductible or Out-of-Pocket Maximums.

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