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2023 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 2023 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)	$500 / $1000	$700 / $1400	$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, Behavioral Health and Substance Use Disorder treatment	$300 deductible 75% coverage	$600 deductible 55% coverage	$300 deductible 75% coverage
Precertification Reference the AetnaNational 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	$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
Precertification is required for all inpatient care, including behavioral health and substance use disorder. Excludes MRI, CAT scan, PET/Spect, Muga Scan, Thallium stress test, Angiography and Myelography. Not subject to deductible. Charge applied to hospital deductible if admitted. 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 ExxonMobil Retiree Medical POS II A option provisions.

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	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 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 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 2023 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)	$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, 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: $40 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	$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
Precertification is required for all inpatient care, including behavioral health and substance use disorder. Excludes MRI, CAT scan, PET/Spect, Muga Scan, Thallium stress test, Angiography and Myelography. Not subject to deductible. Charge applied to hospital deductible if admitted. 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 Retiree Medical POS II 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	(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	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 or Medco Prescription Card or Social Security number of participant or benefits will be paid at the non-network level.

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