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POS II A and POS II B Options

Summary plan description of the ExxonMobil Medical Plan (for Employees) – Aetna POS II A and POS II B options as of January 2022

About the Medical Plan

This summary plan description (SPD) summarizes the ExxonMobil Medical Plan (the Plan) Aetna Point of Service POS II A and B options. 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. You may obtain copies of these documents by making a written request to the Administrator-Benefits. ExxonMobil reserves the right to change benefits in any way or terminate the Plan at any time.  These options are governed by federal laws, not by state insurance laws.

Both Aetna POS II options are self-funded. There is no insurance company to collect premiums or underwrite coverage. Instead, contributions from you and ExxonMobil pay all benefits. Prior claims experience and forecasted expenses are used to determine the amount of money needed to pay future benefits. 

Applicability to represented employees is governed by collective bargaining agreements and any local bargaining requirements.

Please read it carefully and refer to it when you need information about how the Plan works, to determine what to do in an emergency situation, and to find out how to handle service issues. It is also an excellent source for learning about many of the special programs available to you as a plan participant.

If you cannot find the answer to your question(s) in the booklet, call the Member Services toll-free number on your ID card. For more information, go to the Member Services section.

Tips for new plan participants

  • Keep this guide where you can easily refer to it.
  • Keep your ID card(s) in your wallet.
  • Emergencies are covered anytime, anywhere, 24 hours a day. See In case of medical emergency for emergency care guidelines.

Information Sources

Information Sources of the Employee Medical Plan - POS II A and POS II B Options

When you need information, you may contact one or more of the following sources. Please read carefully:

For claims administration

Contact Aetna for medical/surgical and 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.

For benefits information

Contact Aetna for medical/surgical benefits information, including clinical guidelines, benefits predeterminations, and providers participating in the Aetna Choice POS II network. Aetna also provides hospital precertification review for inpatient medical services as well as for certain other medical services, tests, and equipment. Ask to speak to a health advocate nurse for ongoing consultation and referral services.

Contact Magellan for behavioral health and substance abuse benefits information, including clinical guidelines, benefits predeterminations, and providers participating in the Magellan Health Preferred Provider (MHPPO) network. Magellan also provides hospital precertification review for inpatient behavioral health and substance abuse services as well as for certain other behavioral health and substance abuse services, tests, and equipment. Ask to speak to a behavioral health advocate for ongoing consultation and referral services.

Contact Express Scripts for pharmacy benefits information, including clinical guidelines, benefits predeterminations, and providers participating in the Express Scripts pharmacy network. Express Scripts also provides precertification review for certain pharmacy services, medications, and equipment. Ask to speak to a Therapeutic Resource Center (TRC) pharmacist for ongoing consultation and referral services.

Phone numbers and addresses:

Aetna Member Services
800-255-2386
Monday – Friday 8:00 a.m. to 6:00 p.m.
(U.S. Central Time), except certain holidays
Automated Voice Response - 24 hours a day, 7 days a week 

Aetna
P. O. Box 981106
El Paso, TX 79998-1106

To visit Aetna’s website: www.aetna.com

Magellan Healthcare
800-442-4123
314-387-4700 (international, call collect)
24 hours a day, 7 days a week  

Magellan Healthcare
14100 Magellan Plaza Drive
Maryland Heights, MO 63043

To visit Magellan’s website: https://magellanascend.com/ (enter 800-442-4123)

Express Scripts
800-695-4116
800-497-4641 (international, use appropriate country access code depending on country from which you are calling)

Express Scripts Home Delivery 
P.O. Box 66577
St. Louis, MO 63166-65777

Direct Reimbursement Claim Form:
Express Scripts
ATTN: Commercial Claims
P.O. Box 14711
Lexington, KY 40512-4711

Direct Reimbursement Claim Forms may also be faxed to: 608 741-5475

ExxonMobil Benefits Service Center
Phone: 800-6822847
Hours: 8 a.m. to 6 p.m. ET, Monday through Friday, except certain holidays
Web: www.exxonmobil.com/benefits

Address:
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.

  • Employee Connect, the Human Resources Intranet Site — Can be accessed at work by employees
  • ExxonMobil Family, the Human Resources Internet Site — Can be accessed by everyone at www.exxonmobilfamily.com    

Plan at a glance

Plan at a glance the Employee Medical Plan - POS II A and POS II B Options

The Plan covers medically necessary and preventive treatment, care and services, that are not otherwise excluded. You can save money and time if you use a provider who participates in the POS II network. When you receive care through the POS II network, the provider files claims and obtains necessary precertifications and the negotiated rates generally lower your out-of-pocket costs. See the Basic Plan features section. 

The prescription drug program

The Plan offers you three cost-saving ways to buy prescription drugs – at a local participating network pharmacy for short-term prescriptions, through Express Scripts home delivery for long-term prescriptions, and through Accredo home delivery for specialty prescriptions. See the Prescription drug program section.

Mental health and substance abuse care

The Plan provides for mental health and substance abuse care through Magellan's nationwide Mental Health PPO network. All inpatient and intensive outpatient care must be precertified. If an in-patient stay is not precertified, a $500 penalty will apply and the stay may not be covered. See the Mental health and substance abuse care section.

Covered and excluded expenses

The Plan provides benefits for many, but not all medically necessary, treatment, care and services. See Covered expenses and Exclusions.

Payments

You and the Plan share costs for covered treatment and services. You pay a fixed copayment for covered items such as a POS II network doctor's office visit and most related lab work. For other types of care, you must first satisfy a deductible before the Plan begins paying. If you meet your annual out-of-pocket limit, the Plan pays 100% of most covered costs for the rest of that calendar year. See the Payments section. 

Claims

POS II network providers file claims for you. You are responsible for ensuring that claims for non-network care are filed.  The Plan treats the assignment of benefits to non-network providers as a direction to pay rather than as an assignment of benefits. See the Claims section.

Culture of Health and Health Management Programs

Culture of Health is a set of programs and resources to support the overall health of our workforce both at work and at home, including online tools and resources for individual goal setting, a personal health survey, and an annual biometric screening. These tools and resources are available to all eligible employees and family members (age 18 and older) eligible to enroll in the Plan.

Additional integrated Health Management programs are available to participants in the POS II options, to help you manage your health and to assist you in obtaining good health care when care is needed. These programs reflect a commitment by you and the company to good health and quality care. The Health Management tools and resources available to POS II participants include a 24 Hour Nurse Line, Medical and Behavioral Health Advocates, Condition Management Programs, Cancer Care Program, Online Diabetes Prevention Program, Fertility Services Counselling, Musculoskeletal Conditions Support, Expert Medical Opinion Services, and Centers of Excellence.

Health management tools and resources are available to you at no additional cost. However, health care claims (e.g., doctor's fees or facilities charges) are processed according to the Plan’s provisions. See the Health Management Programs section.

Consolidated Omnibus Budget Reconciliation Act 1985 (COBRA)

You and your family members who lose eligibility may continue medical coverage for a limited time under certain circumstances. See Continuation coverage section.

Administrative and ERISA information

This 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 section.

Key terms 

This is an alphabetized list of words and phrases, with their definitions, used in this SPD. These words are underlined and linked throughout the SPD for easy identification. See Key terms section.

Benefit summaries 

Brief summaries of benefits for the POS II A and B options. See Benefit summary.

Eligibility and enrollment

Eligibility and enrollment details for the ExxonMobil Employee Medical Plan - POS II A and POS II B Options

Most U.S. dollar payroll regular employees of Exxon Mobil Corporation and participating affiliates are eligible for this Plan.  Generally, you are eligible if:

You are not eligible if:

  • You fail to make any required contribution toward the cost of the Plan.
  • You fail to comply with general administrative requirements including but not limited to enrollment requirements.
  • You lost eligibility as described under the Loss of eligibility section.
  •  Effective July 1st, 2021, US expatriate employees are no longer eligible to participate in this Plan and are required to participate in the ExxonMobil International Medical and Dental Plan while on assignment. For additional details review the ExxonMobil International Medical and Dental plan SPD.

Eligible family members

You may also elect coverage for your eligible family members including:

  • Your spouse. When you enroll your spouse for coverage, you may be required to provide proof that you are legally married. 
  • Your child(ren) under age 26. Coverage ends at the end of the month in which they reach age 26. If your situation involves a family member other than your biological or legally adopted child, call the ExxonMobil Benefits Service Center. 
  • Your totally and continuously disabled child(ren) who is incapable of self-sustaining employment by reason of mental or physical disability, that occurred prior to otherwise losing eligibility at age 26 and meets the Internal Revenue Service's definition of a dependent. 

Refer to Key Terms for definitions of eligible family memberchildspouse, and Qualified Medical Child Support Order.

Special eligibility rules

A person who otherwise is not a spouse but who, as a dependent of a former Mobil employee who participated in or received benefits under a Mobil-sponsored plan or program prior to March 1, 2000, is considered an eligible dependent as long as that person's eligibility for coverage as a dependent under a Mobil-sponsored plan would have continued.

Classes of coverage

You can choose coverage as an:

  • Employee only,
  • Employee and spouse,
  • Employee and child(ren), or
  • Employee and family.

There are also classes of coverage for extended part-time employees and employees on certain types of leaves of absence.

For employees on an approved leave of absence, their contribution rate will change from the employee contribution rate to the Leave of Absence contribution rate as shown in the table below.

Leave of Absence Contribution Rate Begins

Immediately

No later than
after 6 months

No later than after 12 months

Type of Leave

Military (voluntary)

O

 

 

Civic Affairs

O

 

 

Health / Dependent Care

 

O

 

Education

 

O

 

Personal

 

 

O

Each class of coverage described in this section has its own contribution rate. Employees contribute to the Plan through monthly deductions from their pay on a pre-tax or after-tax basis.

Double coverage

No one can be covered more than once in the Plan. You and a family member cannot both enroll as employees and elect coverage for each other as eligible family members. If you and your spouse or adult child work for the company you may both be eligible for coverage. Each of you can be covered as an individual employee, or one of you can be covered as the employee and the other can be an eligible family member. Also, if you and your spouse have children, each child can only be covered by one of you.

In addition, a marriage between two ExxonMobil employees does not allow enrollment or cancellation in any of the ExxonMobil health plans. In order to change your coverage, you need to wait until you experience a change in status that allows coverage changes or annual enrollment.

How to enroll

As a newly hired employee, if you enroll in the Plan within 30 days of your start date, coverage begins the first day of employment. If you enroll between 31 and 60 days from your date of hire, coverage will be effective the first day of the month following completion of enrollment in ExxonMobil Benefits or through the ExxonMobil Benefits Service Center. You must enroll everyone in the same option.

If you are eligible for the ExxonMobil Pre-Tax Spending Plan, you will be enrolled to pay your monthly contributions on a pre-tax basis unless you annually decline this feature. Your monthly pre-tax contributions and class of coverage must remain in effect for the entire plan year, unless you experience a change in status. (See Annual enrollment and Changing your coverage sections.)

As a current employee, if you are not covered by a medical plan to which ExxonMobil contributes you may enroll at the next annual enrollment. You may also enroll if you experience a corresponding Change in Status. Coverage is effective the first of the month following completion of enrollment in ExxonMobil Benefits or through the ExxonMobil Benefits Service Center.

You may be requested to provide documents at some future date to prove that the family members you enrolled were eligible (e.g., marriage certificate, birth certificate). If you fail to provide such requested documents within the requested time period, coverage for the family members will be cancelled the first of the following month and you may be subject to discipline up to and including termination of employment for falsifying company records.

If you have originally enrolled in other group health plan coverage and you/your family members lose eligibility (or the employer stops contributing toward you and/or your family member(s) coverage), you may enroll yourself or your family members in any available EMMP option. In addition, you may enroll yourself or your family members in any available EMMP option within 60 days after marriage (with coverage effective the first of the following month) or after birth, adoption or placement for adoption (with coverage retroactive to the birth, adoption or placement for adoption).

You must enroll each new child for the child to be covered, even if you already have family coverage.

Under the Children's Health Insurance Program (CHIP) Reauthorization Act of 2009 you may change your EMMP election for yourself and any eligible family members within 60 days of either (1) termination of Medicaid or CHIP coverage due to loss of eligibility, or (2) becoming eligible for a state premium assistance program under Medicaid or CHIP coverage. In either case, coverage is effective the first of the month following receipt of the forms by the ExxonMobil Benefits Service Center.

Annual enrollment

Each year, during the fall, ExxonMobil offers an annual enrollment period. During this time, you can switch from your current option to another available option. This is also the time to make changes to coverage by adding or deleting family members. Family members may be added or removed for any reason but they must be removed as soon as they are no longer eligible. Changes elected during annual enrollment take effect the first of the following year.

Note: Do not wait until annual enrollment to remove a family member who loses eligibility; they should be removed at the time eligibility is lost. For consequences for covering an ineligible family member, see Loss of eligibility.

Employees are automatically enrolled in the Pre-Tax Spending Plan to pay monthly contributions on a pre-tax basis unless this feature is declined. This choice is only available during the annual enrollment period or with a change in status.

If you do not want to make any changes, you don’t have to do anything during annual enrollment to continue with your current plan selection for the following year. However, if you want to participate in a Flexible Spending Account (FSA), you must enroll each year, even if you are currently enrolled in an FSA.

If you pay your monthly contributions on an after-tax basis and would like to continue making contributions on an after-tax basis for the following year, you must elect to do so each year during annual enrollment and after each change in status. Otherwise, your contributions will be switched to a pre-tax basis beginning the first day of the following year.

During annual enrollment, changes to your EMMP coverage (option or contributions) do not automatically adjust your coverage or contributions to other plans such as the ExxonMobil Dental Plan, ExxonMobil Vision Plan or the flexible spending accounts under the ExxonMobil Pre-Tax Spending Plan. Changes to those plans must be made separately during annual enrollment.

Changing your coverage 

To make a change to your coverage after your initial enrollment, you must wait until the next annual enrollment period or until you experience one of the following Changes in Status.

Note: Changes in coverage associated with a change in status are effective the first day of a month after enrollment is completed, except in the case of a birth or adoption of a child when changes will be effective on the date of the birth or adoption. If the change is made during annual enrollment, changes are effective the first day of the following year.

Changes in Status

This section explains which events are considered changes in status and what changes you may make as a result. If you have a change in status, you are required to complete your change within 60 days. If you do not complete your change within 60 days, changes to your coverage may be limited. If you fail to remove an ineligible family member within 60 days of the event that causes the person to be no longer eligible, (e.g., divorce), you are required to continue paying the same pre-tax contribution for coverage even though you have removed the ineligible person(s).  Your pre-tax contribution for coverage will remain the same until you have another change in status or until the first day of the plan year following the next annual enrollment period. In addition, you will be required to reimburse the Plans for any claims paid after the loss of eligibility for any ineligible person(s). The only exception is death of an eligible family member.

Important Note: Your election due to a change in status cannot be changed after the transaction is completed in ExxonMobil Benefits or through the ExxonMobil Benefits Service Center.  If you make a mistake in ExxonMobil Benefits, contact ExxonMobil Benefits Service Center immediately or no later than the first work day following the day on which the mistake was made.

The following is a quick reference guide to the Changes in Status that are discussed in more detail after the table.

If this event occurs...

You may...

Marriage

Enroll yourself and spouse and any new eligible family members or change your Medical Plan option.

Divorce – Employee and spouse enrolled in ExxonMobil Health Plans

Change your level of coverage. You are required to remove coverage for your former spouse and stepchild(ren) but you may not remove coverage for yourself or other covered eligible family members.

Divorce - Employee loses coverage under spouse's health plans

Enroll yourself and other eligible family members who might have lost eligibility for spouse's medical plan.

Gain a family member through birth, adoption or placement for adoption sole court appointed legal guardian or sole managing conservator

Enroll yourself and any eligible family members and change Medical Plan option.

Death of a spouse or other eligible family member

Change your level of coverage. You may not cancel coverage for yourself or other covered eligible family members.

You or a family member loses eligibility under another employer's group health plan or other employer contributions cease which creates a HIPAA special enrollment right

Enroll yourself and other family members who might have lost eligibility. This only pertains to the Medical Plan. Change your level of coverage and change Medical Plan option.

Other loss of family member's eligibility (e.g., sole managing conservatorship of grandchild ends)

Change your level of coverage. You may not cancel coverage for yourself or other eligible family members.

You lose eligibility because of a change in your employment status, e.g., regular to non-regular or strike/ lockout

Your Medical Plan participation will automatically be termed at the end of the month.

You gain eligibility because of a change in your employment status, e.g. non-regular to regular

Enroll yourself and add any eligible family members.

Termination of Employment by spouse or other family member or other change in their employment status (e.g., change from full-time to part-time) triggering loss of eligibility under spouse's or family member's plan in which you or they were enrolled

Enroll yourself and other family members who may have lost eligibility under the spouse's or family member's plan in Medical Plan and change your Medical Plan option.

Your former spouse is ordered to provide coverage to your children through a QMCSO

End the family member's coverage, change level of coverage and terminate their participation in the Medical Plan.

Commencement of Employment by spouse or other family member or other change in their employment status (e.g., change from part-time to full-time) triggering eligibility under another employer's plan

End other family member's coverage and terminate their participation in Medical Plan if the employee represents that they have or will obtain coverage under the other employer plan. You may also cancel coverage for yourself, if health care coverage is obtained through your spouse’s employer plan.

Change in worksite or residence affecting eligibility to participate in the elected Medical Plan option

Change your Medical Plan option and change level of coverage, or cancel coverage for yourself or other eligible family members. This only pertains to the Medical Plan.

You, your spouse, or family member becomes entitled to Medicare or Medicaid

You may choose to cancel coverage for you or change level of coverage related to the Medicare/Medicaid eligible family member.

Judgment, decree or other court order requiring you to cover a family member. (e.g., begin a QMCSO)

Change your Medical Plan option and change level of coverage.

Termination of employment and rehire within 30 days or retroactive reinstatement ordered by court

Enroll in the same Medical Plan option you had prior to termination.

Termination of employment and rehire after 30 days

Enroll in the Medical Plan as a new hire.

You are covered under your spouse's medical plan and plan changes coverage to a lesser coverage level with a higher deductible mid-year

Enroll yourself and eligible family members in the Medical Plan.

You begin a leave of absence

Contact ExxonMobil Benefits Service Center

You return from a leave of absence of more than 30 days (paid or unpaid)

Contact ExxonMobil Benefits Service Center

You return from expatriate assignment outside of the U.S.

You will be defaulted to Aetna POS II A Medical Plan. If you wish to enroll in a different Medical Plan Option, you have 60 days since your repatriation date to update your election.  Any changes done within this period will be effective upon your repatriation date and there would be no gap in coverage.

If no action is taken, the next opportunity to change you Medical Plan Option will be during Annual Enrollment.

 

Marriage

If you are enrolled in the Plan, you can enroll your new spouse and his or her eligible family members (your stepchildren) for coverage. You also may change your plan option. If you are not already enrolled for coverage, you can sign up for medical coverage for yourself, your new spouse, and your stepchildren. If you gain coverage under your spouse's health plan, you can cancel your coverage. You must make these changes within 60 days following the date of your marriage or wait until annual enrollment or another change in status.

Divorce

In the case of divorce:

  • Your former spouse and any stepchildren are only eligible for coverage through the end of the month in which the divorce is final.
  • You are required to remove coverage for your former spouse and stepchild(ren) within 60 days of your divorce
  • You must notify and provide any requested documents to the ExxonMobil Benefits Service Center as soon as your divorce is final.
  • If you do not to notify and provide requested forms to the ExxonMobil Benefits Service Center within 60 days will result in your former spouse and stepchild(ren) not being entitled to elect COBRA.
  • If you fail to remove your spouse and any stepchild(ren) within 60 days of the event you will continue to have pay the same pre-tax contribution for coverage even though you have removed your former spouse and stepchild(ren).
  • Your pre-tax contribution for coverage will remain the same until you have experienced another change in status or the first of the plan year following the next Annual Enrollment period.
  • You will be required to reimburse the Plans for any claims paid after the loss of eligibility for any ineligible person.

There may also be consequences for falsifying company records. Please see the Continuation coverage section of this SPD.

You may not make a change to your coverage if you and your spouse become legally separated because there is no impact on eligibility.
If you lose coverage under your spouse's health plan because of divorce, you can sign up for medical coverage for yourself and your eligible family members. You must enroll within 60 days following the date you lose coverage under your spouse's plan or wait until annual enrollment or another change in status.

Birth, adoption, or placement for adoption

If you gain a family member through birth, adoption, or placement for adoption you may add the new eligible family member to your current coverage. You may also enroll yourself, your spouse, and all eligible children. You also may change your plan option. Coverage is effective on the date of birth, adoption or placement for adoption. You must add the new family member within 60 days even if you already have family coverage. See the Changing your coverage section for additional circumstances in which changes can be made.

If you enroll your new family member between 31 and 60 days from the birth or adoption and your coverage level changes, you will pay the cost difference on an after-tax basis until the end of the month in which the enrollment is completed in the ExxonMobil Benefits or though ExxonMobil Benefits Service Center.  Beginning the first day of the following month your deduction will be on a pre-tax basis. 

CAUTION: SHOULD YOU DECIDE TO RETROACTIVELY CHANGE TO A DIFFERENT EMMP OPTION, SUCH AS FROM AN AETNA SELECT OR CIGNA OPTION TO A POS II OPTION, YOUR BENEFITS FOR ANY MEDICAL SERVICES WHICH WERE RECEIVED ON OR AFTER THE EFFECTIVE DATE OF COVERAGE FOLLOWING THE BIRTH, ADOPTION OR PLACEMENT FOR ADOPTION MAY NOT BE COVERED OR MAY BE REIMBURSED RETROACTIVELY AT A LOWER BENEFIT LEVEL. MAKE SURE YOU FULLY UNDERSTAND THE IMPACT OF CHANGING OPTIONS BEFORE MAKING YOUR ELECTION.

Death of a spouse

If you lose coverage under your spouse's health plan, you can sign up for Medical Plan coverage for yourself and your eligible family members. You must make these changes within 60 days following the date you lose coverage or wait until annual enrollment or another change in status. If you and your family members are enrolled in the ExxonMobil Medical Plan, any stepchildren will cease to be eligible upon your spouse's death unless you are their court appointed guardian or sole managing conservator.

Change in coverage costs or significant curtailment

If the cost for coverage charged to you significantly increases or decreases during a plan year, you may be able to make a corresponding prospective change in your election, including the cancellation of your election. If you choose to cancel your elected coverage option, you may be able to elect coverage under another Medical Plan option. This provision also applies to a significant increase in health care deductible or copayment.

If the cost for coverage under your spouse's health plan significantly increases or there is a significant curtailment of coverage that permits revocation of coverage during a plan year and you drop that coverage, you will be able to sign up for medical coverage for yourself and your eligible family members. You must enroll within 60 days following the date you lose coverage under your spouse's plan.

Sole legal guardianship or sole managing conservatorship

If you (or your spouse, separately or together) become the sole court appointed legal guardian or sole managing conservator of a child and the child meets all other requirements of the definition of an eligible child, you have 60 days from the date the judgment is signed to enroll the child for coverage. You must provide a copy of the court document signed by a judge appointing you (or your spouse separately or together) guardian or sole managing conservator. 

When a child is no longer eligible

If an enrolled family member is no longer an eligible family member, coverage continues through the end of the month in which they cease to be eligible. In some cases, continuation coverage under COBRA may be available. (See Continuation coverage for more details about COBRA.) You must notify and provide the appropriate forms to ExxonMobil Benefits Service Center as soon as a family member is no longer eligible. If you fail to notify and provide the appropriate forms to ExxonMobil Benefits Service Center within 60 days, the family member will not be entitled to elect COBRA. While we have an administrative process to remove dependent children reaching the maximum eligibility age, you remain responsible for ensuring that the dependent child is removed from coverage.  If you fail to ensure that an ineligible family member is removed in a timely manner, there may be consequences for falsifying company records. 

Transfer or change residence

If you move from one location to another, and the move makes you no longer eligible for your selected Medical Plan option (e.g., move out of the Aetna Select/Cigna OPAIN service area), you may change from your current Medical Plan option to one that is available in your new location. However, if you move into a location where Aetna POS II options are available and you are enrolled in one of those options, you are not eligible to enroll until annual enrollment. For more information, contact the ExxonMobil Benefits Service Center.

Leave of absence

If you are on an approved leave of absence, you can continue coverage by making required contributions directly to the Plan by check or, if applicable, pre-pay your benefits. If you chose not to continue your coverage while on leave, your coverage ends on the last day of the month in which the cancelation form is received by ExxonMobil Benefits Service Center and you will be required to pay for the entire month's contributions. If you fail to make required contributions while on leave, coverage will end.

If the company should make any payment on your behalf to continue your coverage while you are on leave and you decide not to return to work, you will be required to reimburse the company for required contributions.

If you are on an approved leave of absence and the Leave of Absence Contribution Rate begins, you may continue your coverage by making your required contribution.

If you were on a leave that meets the requirements of the Family and Medical Leave Act of 1993 (FMLA) or the Uniformed Services Employment and Reemployment Rights Act (USERRA) and your coverage ended, re-enrollment is subject to FMLA or USERRA requirements.

For more information, contact ExxonMobil Benefits Service Center. 

Addition or improvement of medical plan options

If a new Medical Plan option is added or if benefits under an existing option are significantly improved during a plan year, you may be able to cancel your current election in order to make an election for coverage under the new or improved option.

Loss of option

If a service area under the Plan is discontinued, you will be able to elect either to receive coverage under another Medical Plan option providing similar coverage or to cancel medical coverage altogether if no similar option is available. For example, if an option is discontinued, you may elect another option that has service in your area or you may elect to participate in the POS II option.  You may also cancel medical coverage altogether.

Remember, if you experience any of the events mentioned previously, or if you are newly eligible as a result of a change or loss of coverage under your spouse's health plan, it is your responsibility to complete your change within 60 days of experiencing the event. If you miss the 60-day notification period, you will not be able to make changes until annual enrollment or until you experience another change in status.

Other situations that may affect your coverage

If you retire

If you retire as a regular employee on or after age 55 with 15 or more benefit years of service, you are eligible for the ExxonMobil Retiree Medical Plan (EMRMP) or you may elect COBRA to stay in the ExxonMobil Medical Plan for the duration of COBRA Coverage. If you retire as a regular employee and are Medicare-eligible, you are eligible to enroll in the Medicare Primary Option (MPO) option of the EMRMP.

Effective January 1, 2019: If you decline enrollment in the ExxonMobil Retiree Medical Plan at retirement, you will have limited opportunities to enroll at a later date. See the Summary Plan Description for the EMRMP option of your choice for more information.

If a covered family member lives away from home

Coverage depends on whether the plan option you are enrolled in as an employee offers service in the area where you live. If your covered family member does not live with you (for instance, you have a child away at school), please contact Aetna Member Services to confirm whether service is available where your family member lives. (See service area in Key Terms.)

If you work beyond when you become eligible for Medicare

If you continue to work for ExxonMobil after you become eligible for Medicare, although you are eligible for Medicare, your ExxonMobil employee coverage remains in effect for you and eligible family members and the Medical Plan is your primary plan. Medicare benefits, if you sign up for them, will be your secondary benefits. Refer to www.medicare.gov to learn more about Medicare while you are still employed.

If your covered family members become Medicare eligible for any reason

Employees or family members of an employee who becomes Medicare eligible, either due to age or Social Security disability status, are eligible to participate in any Medical Plan option as long as they employee remains as a regular employee. 

If the employee retires or dies, and coverage is available under the EMRMP:

  • Medicare eligible covered spouses must enroll in Medicare Primary Option including enrolling in Medicare Parts A and B. 
  • All eligible dependent children under the age of 26 (including those that are Medicare eligible) and those over the age of 26 who are totally and continuously disabled and not Medicare eligible, may enroll in the Retiree Medical Plan options of the EMRMP 
  • Medicare eligible dependent children over the age of 26 are not eligible for coverage under any ExxonMobil health plan available to retirees. You may be eligible to elect continuation coverage for your Medicare eligible dependent child under COBRA provisions. See Continuation coverage for details. 

If you are an extended part-time employee

If you terminate employment as an extended part-time employee, you are not eligible to continue participating in the Plan. You may be eligible to elect continuation coverage for yourself and your eligible family members under COBRA provisions. See Continuation coverage for details.

If you die

If you die while enrolled, your covered eligible family members may be eligible for the ExxonMobil Retiree Medical Plan. They are not eligible to continue to participate in the ExxonMobil Medical Plan except through COBRA. Their eligibility continues with the EMRMP for a specified amount of time:

  • If you have 15 or more years of benefit service at the time of your death, eligibility continues until your spouse remarries, becomes eligible for Medicare or dies.  Upon eligibility for Medicare, your spouse can continue coverage through the Medicare Primary Option.
  •  If you have less than 15 years of benefit service, eligibility continues for twice your length of benefit service or until your spouse remarries, becomes eligible for Medicare, or dies, whichever occurs first.  Upon eligibility for Medicare, your spouse can continue coverage through the Medicare Primary Option.

Children of deceased employees or retirees may continue participation as long as they are an eligible family member. If your surviving spouse remarries, eligibility for your stepchildren also ends.

Eligible family members of deceased extended part-time employees are only eligible to elect continuation coverage under COBRA provisions. See Continuation coverage for details.

When coverage ends

When coverage ends of the Employee Medical Plan - POS II A and POS II B Options

Coverage for you and/or your family members ends on the earliest of the following dates:

  • The last day of the month in which:

You terminate employment, retire, or die.
You elect not to participate.
A family member ceases to be eligible (for example, a child reaches age 26).
You are no longer eligible for benefits under this Plan (e.g., from non-represented to represented where you are no longer eligible for this Plan, from regular to expatriate).
You terminate employment after being rehired by ExxonMobil as an employee following retirement.
A Qualified Medical Child Support Order is no longer in effect for a covered family member.
Your employer discontinues participation in the Plan.

OR

  • The date:

The Plan ends.
You do not make any required contribution.
You enrolled an ineligible family member and in the opinion of the Administrator-Benefits, the enrollment was a result of fraud or a misrepresentation of a material fact.

You are responsible for ending coverage with the ExxonMobil Benefits Service Center when your enrolled spouse or family member is no longer eligible for coverage. If you do not complete your change within 60 days, any contributions you make for ineligible family members will not be refunded.

Loss of eligibility

Fraud against the Plan 

Everyone in your family may lose eligibility for Medical Plan coverage, and you may be subject to disciplinary action up to and including termination of employment if you commit fraud against the Medical Plan, for instance, by filing claims for benefits to which you are not entitled. Coverage may also be terminated if you refuse to repay amounts erroneously paid by the Medical Plan on your behalf or that you recover from a third party. Additionally, coverage may be terminated if you fail to reimburse the Plan for any amount owed to the Plan, or if you receive and fail to report to the Claims Processor any discounts, write-offs or other arrangements with providers that result in misrepresentation of your out-of-pocket costs. Your participation may be terminated if you fail to comply with the terms of the Medical Plan and its administrative requirements. You may also lose eligibility if you enroll persons who are not eligible, for instance, by covering children who do not meet the eligibility requirements. This includes failing to provide timely notification of when a covered family member loses eligibility, e.g., spouse loses eligibility due to divorce.

Extended benefits at termination

You are entitled to extended coverage for as much as a year if you are terminated due to disability with fewer than 15 years of service. This coverage is provided at no cost to you. This is considered a portion of the COBRA continuation period. In order to assure coverage beyond this extension period, you must elect COBRA upon termination of employment.

Several conditions must be met:

  • The disability must exist when your employment terminates.
  • The extension lasts only as long as the disability continues, but no longer than 12 months.

This extension applies only to the employee who is terminated because of a disability. Continuation coverage for eligible family members may be available through COBRA.

During annual enrollment, changes to your EMMP coverage (option or contributions) do not automatically adjust your coverage or contributions to other plans such as the ExxonMobil Dental Plan, ExxonMobil Vision Plan or the flexible spending accounts under the ExxonMobil Pre-Tax Spending Plan. Changes to those plans must be made separately during annual enrollment.

Basic Plan features

Basic features of the Employee Medical Plan - POS II A and POS II B Options

Basic features of the ExxonMobil Employee Medical Plan - POS II A and POS II B options

  • The Plan generally covers only medically necessary care and services.
  • Inpatient hospital stays must be precertified for maximum benefit allowed by the Plan.
  • The Medical POS II network of participating providers offers you savings in both time and money.
  • Preventive care provisions help you stay healthy.
  • The Plan offers you the opportunity to have your benefits determined before a procedure is performed.

Both EMMP POS II options include the features listed below.

Medically necessary

Expenses are covered under these options only if they are medically necessary. Care is medically necessary if it is a therapeutic procedure, service or supply used in the medical treatment of an injury, disease, or pregnancy, which is generally recognized by the United States medical community as appropriate. Claims are reviewed as submitted, and some or all of any claim or series of services could be denied as not being medically necessary. It also means that experimental or investigational procedures, drugs, devices or biological products not proven by long-term clinical studies are generally not covered. See Exclusions for limited exceptions.

When determining medical necessity, Clinical Policy Bulletins (CPBs) published by Aetna, the claims administrator, may be used.

CPBs are based on objective, credible sources, such as the scientific literature, guidelines, consensus statements and expert opinions. These CPBs may be found on the Aetna website at

https://www.aetna.com/health-care-professionals/clinical-policy-bulletins.html

Medical / surgical POS II network (also see mental health and substance abuse section)

The Aetna Choice® POS II network includes a group of physicians, hospitals, and other providers who have met standards for licensing, academic background and service. If you use network providers, the Plan pays a larger portion of the covered expenses. Network providers have agreed to negotiated charges which may save you and the Plan money. Other advantages to using Medical POS II network providers for medical care are:

  • You pay a copay for most office visits, including diagnostic laboratory and X-rays associated with that office visit. Preventive care office visits are reimbursed at 100%.
  • Emergency room physician expenses, in-patient hospital expenses, and outpatient surgery expenses are subject to deductible and coinsurance.
  • Other expenses such as home health care, durable medical equipment or complex imaging are reimbursed at the network reimbursement level (either 80% for the POS II B or 75% for the POS II A) of a negotiated rate after you meet the annual deductible.
  • Your annual out-of-pocket maximum is significantly lower.
  • Medical POS II network providers file claims and handle the hospital pre-admission review process for you.
  • All negotiated charges are within reasonable and customary limits.

Anyone in the EMMP POS II A or B option may receive network benefits by using Aetna Choice®POS II network providers for medical/surgical services and Magellan MHPPO network providers for mental health or substance abuse care. This includes employees who live in an out-of-network area.

Network locations

POS II networks are located throughout the United States. As explained in the Introduction, the Medical POS II is part of the Aetna Choice® POS II network. You are a network participant if you live in a POS II area.

Benefits Based on the Network Status of the Provider

Generally, you will receive network benefits only if the provider is in the Medical POS II network.  This applies whether or not the care is received in a network area or in an out-of-network area.

To find Aetna Choice® POS II network providers in your area, choose “Find a Doctor” on the Aetna website or mobile app. If you need further assistance, you can call Aetna Member Services.

Copayment for office visits/lab work when provided by a primary care physician; higher copayment when provided by a specialist.

When you use Medical POS II network providers for office visits, you are not subject to the annual deductible. You pay a copayment for each office visit, including most related lab work and radiology performed by a POS II network provider.

A copayment does not apply to more extensive tests, including complex imaging (i.e., CT scans, MRI, MRA, PET/SPECT), radiopharmaceutical stress tests, angiography myelography, MUGA scans and sleep studies, which are subject to the deductible and coinsurance.

If an injection (other than an injection into a vein or artery) is received in a network doctor's office without an office visit, the copayment will be the actual cost of the injection or the office visit copayment, whichever is less. For infusion therapy and chemotherapy, a fixed copayment only applies to the office visit. All other related services are subject to the plan’s deductible and/or coinsurance. Allergy serum dispensed by a network doctor is reimbursed at coinsurance after the deductible.

These copayments do not apply to your annual deductible but do apply to your annual out-of-pocket limit. See the explanation beginning in the Payment section for more information about deductibles and copayments.

Is your doctor a network provider?

Call your doctor's office to confirm his or her participation in the Aetna Choice® POS II network. If your doctor is not participating, ask him or her to consider applying to participate. Your doctor can obtain information about becoming a network participant from Aetna's website (www.aetna.com/healthcare-professionals/index.html) or by calling Aetna Credentialing Customer Service at 1-800-353-1232. 

Your ID cards

When you visit a physician or other health care provider, present your Medical Plan identification card. This helps the provider confirm your eligibility and understand your benefits coverage.

If you show your ID card to a network provider, they should only ask you for your copayment and any deductible amounts and/or coinsurance amounts, not for full payment. 

If you live in a medical POS II network area and do not use medical POS II network providers:

When you use non-network providers:

  • Your out-of-pocket costs will generally be higher. The Plan's reimbursement level is 60% for the POS II B and 55% for the POS II A of reasonable and customary charges, after you satisfy the non-network deductible, and your out-of-pocket expenses will accumulate towards a higher non-network out-of-pocket maximum.    
  • You must call Aetna to initiate the medical pre-admission review process for inpatient treatment and ensure any precertification or preauthorization requirements are completed.    
  • If your provider or facility charges are above reasonable and customary limits, you are responsible for paying any amounts above reasonable and customary limits in addition to your deductible and/or coinsurance. You may be balance billed by the provider or facility for any amount not reimbursed by Aetna.
  • You are responsible for submitting claims.

If you cannot find a Network Provider (network deficiency)

Sometimes you may have difficulty finding a network provider in your area that is available when you need care. If an Aetna Choice® POS II network provider is not available for medical/surgical services, call Aetna Member Services for information on the Plan's alternate network deficiency benefit. If Aetna confirms a network provider is not available for the medical/surgical services you need, they will authorize use of a designated non-network provider for your care.

If you cannot find an available Mental Health PPO network provider in your area for behavioral health services or substance abuse treatment you need, call Magellan to request a single case agreement. If Magellan confirms a network provider is not available for the behavioral health services or substance abuse treatment you need, they will arrange for a single case agreement with a designated non-network provider for your care.

Benefits for covered services at a designated non-network provider under the alternate network deficiency benefit will be paid at the In-Network level (either 80% for POS II B or 75% for POS II A of reasonable and customary charges) after the plan year deductible has been satisfied, and out-of- pocket expenses for those services will accumulate towards your In-Network out-of-pocket maximum. Copayments will not apply.

If you live outside a POS II network area (out-of-network area benefits)

If you live outside a designated POS II network area, benefits for covered services are paid at the out-of-network area benefit level.

You still have access to Aetna Choice® POS II network providers and facilities in your area, within a short driving distance, and while travelling. When you receive care from a network provider or in a network facility, you will be reimbursed at 80% for POS II B or 75% for POS II A of the negotiated network rate for inpatient and outpatient services, your network provider will initiate the pre-admission review process, and network copayments for primary care and specialist office visits will apply.

If you live outside a POS II network area and receive care from a non-network provider or in a non-network facility, you will be reimbursed at 80% for POS II B and 75% for POS II A of reasonable and customary charges for similar services in the same area. Network discounts and network copayments do not apply, and you must satisfy the deductible for all covered services other than preventive care. You are also responsible for initiating the medical pre-admission review process for inpatient treatment unless you use a network provider.

Most non-network charges fall within reasonable and customary limits. However, you may receive a balance bill for the difference between a non-network provider’s billed charges and what is considered reasonable and customary for covered services in your area. If this happens, call Aetna Member Services. The full or partial balance bill may qualify as an allowable expense eligible for payment by the Plan. This includes balance bills for ambulance services, emergency physicians, radiologists, anesthesiologists, pathologists, hospitalists, neonatologists, and intensivists. It may also include balance bills for scheduled procedures performed by a non-network physician when a network physician is not available. However, if a network physician is available and you schedule an inpatient or outpatient procedure with a non-network physician, you will be responsible for any billed charges above reasonable and customary limits, which for professional services is set at 200% of Medicare Fee Schedule of charges for similar services in the same geographic area.

If you live outside a POS II network area, the out-of-pocket maximum for non-network services is the same as the maximum for network services. Once your annual out-of-pocket limit is reached, covered services are reimbursed at 100% of reasonable and customary charges.

Note: You are responsible for payment for services that are not covered by the Plan, including non-medical ancillary services and any balance bill that remains after adjustments for allowable expenses have been made. Payments for services not covered by the Plan do not accumulate towards your annual out-of-pocket limit.

If you live in an out-of-network area and incur claims outside of the U.S., reimbursement is paid at either 80% for POS B or 75% for POS A of billed charges after deductible. There is no reasonable and customary profiling for foreign providers.

If you receive an unexpected bill from a Non-Network Provider

Sometimes covered services are performed by a non-network provider without your knowledge or ability to choose a participating provider, for example in an emergency situation or when you receive care in a network facility but a network physician is unavailable. When this happens, charges are limited to what is considered reasonable and customary for similar services in the same geographic area, and you will be reimbursed at the network benefit level (either 80% for POS II B or 75% for POS II A), after the plan year deductible has been satisfied.

Most non-network charges will fall within reasonable and customary limits. However, if you receive a balance bill for the difference between a non-network provider’s billed charges and what is considered reasonable and customary for covered services under the POS II option, and you did not voluntarily elect to receive services from the non-network provider, call Aetna Member Services. The full or partial balance bill may qualify as an allowable expense eligible for payment by the Plan. This includes balance bills for ambulance services, emergency physicians, radiologists, anesthesiologists, pathologists, hospitalists, neonatologists, and intensivists. It may also include balance bills for scheduled procedures performed by a non-network physician when a network physician is not available.

Culture of Health and Health Management programs

Details on ExxonMobil's Culture of Health and health management programs

Culture of Health is a set of programs and resources to support the overall health of our workforce both at work and at home, including online tools and resources for individual goal setting, a personal health survey, and an annual biometric screening.  These tools and resources are available to all employees and family members (age 18 and older) eligible to enroll in the ExxonMobil Medical Plan.

Additional integrated Health Management programs are available to participants in the Aetna Select option to help you improve your health and to assist you in obtaining good health care when care is needed. These programs reflect a commitment by you and the company to good health and quality care. The Health Management tools and resources available to Aetna Select participants include a 24-Hour Nurse Line, Medical and Behavioral Health Advocates, Condition Management Programs, Cancer Care Program, Pharmacy Diabetes Management, Fertility services Counselling, Expert Medical Opinion Services, and Centers of Excellence.

Health Management tools and resources are available to you at no additional cost. However, health care claims (e.g., doctor's fees or facilities charges) are processed according to the Plan’s provisions.

24-Hour nurse line

Trained, licensed nurses are available by telephone at 1-800-556-1555, 24 hours a day, 7 days a week to answer routine questions about your health, or questions about a specific medical situation, condition, or concern. However, these nurses cannot diagnose medical conditions/ailments, prescribe medication or give specific medical instruction; all at no cost to you. Topics discussed during your call may include services and expenses not covered under the Plan. See Exclusions for more information. The nurse may refer you to a Health Advocate for a more detailed conversation if you face a health risk or serious medical condition.

Health Advocacy Program

The Health Advocate Program provides direct support to you, your family, and your treating physician(s) in the management of specific health care needs, at no cost to you. The Health Advocate staff consists of registered nurses, supported by a medical director. Once you begin working with a Health Advocate, the nurse will work personally with you as long as you need support.

Health Advocates will assist you to coordinate a wide array of health care-related support and educational services. As situations require, your Health Advocate will assist you with admission, counseling, inpatient advocacy, discharge planning and home counseling. The nurse will also act as your proactive partner, working directly with you to help you navigate the health care delivery system by assisting with the coordination and management of your health care needs and collaborating with others involved in your treatment.

Some of the condition management programs available include but not limited to Coronary artery disease (CAD), Heart failure, diabetes –adult and pediatric, Asthma –adult and pediatric, Chronic obstructive pulmonary disease (COPD), Chronic lower back pain, Osteoporosis / Osteoarthritis and Peripheral Artery Disease.  Contact AETNA to check if your chronic condition can be managed through the Health Advocate program.

Aetna Maternity Program

The Aetna Maternity Program provides free support and resources to help you have a healthy pregnancy. The program provides useful information about early labor symptoms, genetic counselling and screening, preeclampsia prevention and education and resources on caring for a newborn.

If your pregnancy is considered at-risk, nurse managers will be available to help you manage the risk, identify symptoms and understand treatment options.

Contact aetna.com for additional information.

Cancer Management Program

As a part of your coverage under this plan, Health Advocacy nurses are available to assist with newly diagnosed cancer, undergoing active treatment for cancer, or a recurrence, at no cost to you. The Health Advocacy team will support you in your cancer journey with case management and provide you with information on the many resources available to you including a personal navigator with experience in cancer diagnosis and treatments, who will provide you with personalized support whenever you need it, genetic counseling to help guide your treatment and assess your risk of developing other forms of cancer, and an extensive online cancer support center.

If you would like to receive support from a Health Advocate, call 800-255-2386.

Musculoskeletal Conditions Support

As a part of your coverage under this plan, Hinge Health offers musculoskeletal conditions support at no cost to you, with programs relating to care for different joint and muscle pain needs, for example:

  • Prevention (at risk): specific exercises and education
  • Acute (recent injury): physical therapy video visits for every body part
  • Chronic (high risk): exercise, education and behavioral change
  • Surgery (pre & post rehab): pre and post rehabilitation continuity of care

Learn more about this program at www.hingehealth.com/exxonmobil or call 855-902-2777

Expert Medical Opinion Services

If you or a family member receive a diagnosis or treatment plan requiring complex medical care, you have access to expert medical opinion services through 2ndMD. Specialists who are recognized experts in their field will review medical records related to the diagnosis and provide an opinion on the recommended treatment, including a detailed report you can share with your physician or Health Advocate nurse. Expert opinion consults are available at no additional cost to you and can be accessed through a mobile application, web portal, or phone. Call 866-410-8649 or www.2nd.md/aetna to initiate services.

Pharmacy Diabetes Management

Insulin and diabetic supplies are covered under the prescription drug plan through Express Scripts.  They can be obtained through a retail pharmacy or through home delivery by paying your required coinsurance.  In those rare instance where insulin or diabetic supplies are received in a doctor’s office, outpatient facility or hospital setting, they are covered as a medical expense.

Centers of Excellence and Institutes of Excellence

Centers of Excellence (COE) and Institutes of Excellence (IOEs) are nationally recognized facilities for the treatment of certain conditions or the delivery of certain procedures where high-level knowledge and expertise provide better care and more likely positive outcomes.

COEs/IOEs are not available for all diseases and all conditions or procedures relevant to a disease state. For instance, at this time there are COEs/IOEs for pancreatic cancer, but there is insufficient information available to select COEs/IOEs for lung cancer. Changes to identified COEs/IOEs may occur in the future.

Participation in a COE/IOE program is voluntary, and designed to direct participants to nationally recognized facilities with more positive outcomes. A COE/IOE-recommended treatment plan, however, must meet the Plan provisions for medically necessary care in order for claims to be eligible for reimbursement.

Whenever clinically appropriate, you will be referred to a local COE/IOE. If access to a clinically appropriate COE/IOE requires the patient to travel 100 or more miles, the Plan will reimburse reasonable transportation costs for you and a caregiver. The Plan will also provide a per diem for you and a caregiver to cover lodging and other expenses. If you become hospitalized, only your caregiver will receive the per diem, because food and lodging are already provided as part of the hospital charge. The per diem amounts are established by the Administrator-Benefits.

If you decide not to use a COE/IOE, you will not incur additional out-of-pocket costs for choosing another hospital in the Plan's network.

Eligible health services under your plan

Your benefits on the ExxonMobil Employee Medical Plan- POSII A and B options.

Although a specific service may be listed as a covered benefit, it may not be covered unless it is medically necessary for the prevention, diagnosis or treatment of your illness or condition. Refer to the Key Terms section for the definition of medically necessary.

Certain services must be pre-certified by Aetna. Your participating provider is responsible for obtaining this approval.

Preventive care

Preventive care services will be covered at 100%. If you use a non-network provider or live in a location where there is not a Medical POS II network, reasonable and customary charges for covered preventive care services will continue to apply. Preventive care services covered at 100% (for either network or non-network providers) include the following: 

Routine physical exams

Eligible health services include office visits to your physician or other health professional for routine physical exams. A routine exam is a medical exam given by a physician for a reason other than to diagnose or treat a suspected or identified illness or injury. , and also includes:

  • Evidence-based items that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force.
  • Services as recommended in the American Academy of Pediatrics/Bright Futures/Health Resources and Services Administration guidelines for children and adolescents.
  • Screenings and counseling services as provided for in the comprehensive guidelines recommended by the Health Resources and Services Administration. These services may include but are not limited to:
    • Screening and counseling services on topics such as:
      • Interpersonal and domestic violence
      • Sexually transmitted diseases
      • Human immune deficiency virus (HIV) infections
    • Screening for gestational diabetes for women
    • High risk human papillomavirus (HPV) DNA testing for women age 30 and older
  • Radiological services, lab and other tests given in connection with the exam.
  • For covered newborns, an initial hospital checkup.

Preventive care immunizations

Eligible health services include immunizations for infectious diseases recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

Immunizations/vaccinations obtained outside of a physician's office or hospital:

Some immunizations can also be obtained or administered at participating retail pharmacies, using the Aetna ID card at an Aetna network pharmacy, or the Express Scripts ID card at an Express Scripts network pharmacy.

Well woman preventive visits

Eligible health services include your routine:

  • Well woman preventive exam office visit to your physician, obstetrician (OB), gynecologist (GYN) or OB/GYN. This includes pap smears. Your plan covers the exams recommended by the Health Resources and Services Administration. A routine well woman preventive exam is a medical exam given for a reason other than to diagnose or treat a suspected or identified illness or injury.
  • Preventive care breast cancer (BRCA) gene blood testing by a physician and lab.
  • Preventive breast cancer genetic counseling provided by a genetic counselor to interpret the test results and evaluate treatment.
  • Screening for diabetes after pregnancy for women with a history of diabetes during pregnancy.
  • Screening for urinary incontinence.

Preventive screening and counseling services

Eligible health services include screening and counseling by your health professional for some conditions. These are obesity, misuse of alcohol and/or drugs, use of tobacco products, sexually transmitted infection counseling and genetic risk counseling for breast and ovarian cancer.

Routine cancer screenings

Eligible health services include the following routine cancer screenings:

  • Mammograms
  • Prostate specific antigen (PSA) tests
  • Digital rectal exams
  • Fecal occult blood tests
  • Sigmoidoscopies
  • Double contrast barium enemas (DCBE)
  • Colonoscopies which includes removal of polyps performed during a screening procedure, and a pathology exam on any removed polyps
  • Lung cancer screenings (only paid 100% for network providers)

These benefits will be subject to any age, family history and frequency guidelines that are:

  • Evidence-based items or services that have in effect a rating of A or B in the recommendations of the United States Preventive Services Task Force
  • Evidence-informed items or services provided in the comprehensive guidelines supported by the Health Resources and Services Administration

If you need a routine gynecological exam performed as part of a cancer screening, you may go directly to a network provider who is an OB, GYN or OB/GYN.

Prenatal care

Eligible health services include your routine prenatal physical exams as Preventive Care, which is the initial and subsequent history and physical exam such as:

  • Maternal weight
  • Blood pressure
  • Fetal heart rate check
  • Fundal height

You can get this care at your physician's, OB's, GYN's, or OB/GYN’s office. Prenatal care is only paid 100% for network providers.

Comprehensive lactation support and counseling services

Eligible health services include comprehensive lactation support (assistance and training in breast feeding) and counseling services during pregnancy or at any time following delivery for breast feeding. The plan will cover this counseling only from a certified lactation support provider.

Breast feeding durable medical equipment

Eligible health services include renting or buying durable medical equipment you need to pump and store breast milk. Contact Aetna for additional details.

Family planning services – female contraceptives

Eligible health services include family planning services such as:

  • Counseling services: provided by a physician, OB, GYN, or OB/GYN on contraceptive methods.
  • Devices: contraceptive devices (including any related services or supplies) when they are provided by, administered or removed by a physician during an office visit.
  • Voluntary sterilization: charges billed separately by the provider for female voluntary sterilization procedures and related services and supplies. This also could include tubal ligation and sterilization implants.

Important note:

Lactation support, Breastfeeding durable medical equipment and contraceptive services are covered at 100% only through in-network providers.

To receive preventive care benefits, the doctor's bill must indicate that the service is preventive in nature. If you are found to have a condition requiring additional treatment, the additional covered services will be paid after you meet any remaining annual deductible.

Please note that the list above is not all inclusive, so for more information on the most updated preventive services, please refer to the following sites:

https://www.hhs.gov/healthcare/about-the-aca/preventive-care/index.html

https://www.healthcare.gov/coverage/preventive-care-benefits/

Physicians and other health professionals

Physician services

Physician services include: non-routine office visits with your physician, such as your primary care physician, during both office and non-office hours - including Telemedicine, non-routine home visits, treatment for illness and injury and injections, including routine allergy desensitization injections in your physician´s office, with or without physician encounter. All, subject to copay.

Telemedicine

Telemedicine services are available via phone, web, or mobile app, 24 hours/day, 7 days/week through the Plan’s designated service provider (Teladoc). Teladoc’s health care professionals can evaluate, diagnose, and treat non-emergency medical and behavioral health conditions, such as cold/flu symptoms, stomach aches, common childhood illnesses, dermatology support, depression, stress, and anxiety. To register for services, call 855-835-2362 or visit www.Teladoc.com/Aetna.

Hospital and other facility care

Hospital care

The types of hospital care services that are eligible for coverage include:

  • Room and board charges up to the hospital’s semi-private room rate.
  • Services of physicians employed by the hospital.
  • Operating and recovery rooms.
  • Intensive or special care units of a hospital.
  • Administration of blood and blood derivatives, but not the expense of the blood or blood product.
  • Radiation therapy.
  • Cognitive rehabilitation.
  • Speech therapy, physical therapy and occupational therapy.
  • Oxygen and oxygen therapy.
  • Radiological services, laboratory testing and diagnostic services.
  • Medications.
  • Intravenous (IV) preparations.
  • Discharge planning.
  • Services and supplies provided by the outpatient department of a hospital.

Alternatives to hospital stays

Outpatient surgery and physician surgical services

Eligible health services include services provided and supplies used in connection with outpatient surgery performed in a surgery center or a hospital’s outpatient department.

Home health care

Eligible health services include home health care provided by a home health care agency in the home, but only when all of the following criteria are met:

  • You are homebound.
  • Your physician orders them.
  • The services take the place of your needing to stay in a hospital or a skilled nursing facility, or needing to receive the same services outside your home.
  • The services are a part of a home health care plan.
  • The services are skilled nursing services, home health aide services or medical social services, or are short-term speech, physical or occupational therapy.
  • If you are discharged from a hospital or skilled nursing facility after a stay, the intermittent requirement may be waived to allow coverage for continuous skilled nursing services. See the schedule of benefits for more information on the intermittent requirement.
  • Home health aide services are provided under the supervision of a registered nurse.
  • Medical social services are provided by or supervised by a physician or social worker.

Home health care services do not include custodial care.

Hospice care

Eligible health services include inpatient and outpatient hospice care when given as part of a hospice care program.

Outpatient private duty nursing

Eligible health services include private duty nursing care provided by an R.N. or L.P.N. for non-hospitalized acute illness or injury if your condition requires skilled nursing care and visiting nursing care is not adequate.

Skilled-nursing care

Skilled-nursing care is covered if medically necessary. Nursing care that helps a person meet personal needs and daily living activities, such as bathing, dressing, eating or administering oral medication, even if ordered by a physician and performed by a licensed medical professional, is considered custodial and is not a covered expense eligible for benefits. Also, charges for a private-duty nurse in a hospital or an extended-care facility are not covered.

Skilled nursing facility

The types of skilled nursing facility care services that are eligible for coverage include:

  • Room and board, up to the semi-private room rate
  • Services and supplies that are provided during your stay in a skilled nursing facility

Skilled care

Skilled care involves nursing or rehabilitation services that can be provided only by licensed medical professionals. For example, intravenous feeding is a skilled service.

Emergency services and urgent care

In case of a medical emergency

Go to the nearest hospital for treatment. Benefits for emergency care (as a result of emergency outpatient treatment or an emergency admission to a hospital following emergency outpatient treatment received at the same hospital) are paid at the network reimbursement level for both network and non-network providers. However, the network reimbursement level for emergency care by non-network providers is only payable until the patient is determined able to be safely transferred to a network facility.

If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. Aetna has adopted the following definition of an emergency medical condition:

 

An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson (including the parent of a minor child or the guardian of a disabled individual), who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

  • Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
  • Serious impairment to bodily function, or
  • Serious dysfunction of any bodily organ or part.
  • Some examples of emergencies are:
  • Heart attack or suspected heart attack.
  • Uncontrolled or severe bleeding.
  • Suspected overdose of medication.
  • Severe burns.
  • High fever (especially in infants).
  • Loss of consciousness.
  • Some common examples of non-emergencies are:
  • Routine exams and immunizations.
  • Ear Infections.
  • Colds and Flu.

Reimbursement for emergency services

Reimbursement for emergency services from non-network providers are limited to reasonable and customary amounts, including professional fees for radiologists, anesthesiologists, pathologists, hospitalists, neonatologists, intensivists, ambulance, or emergency room physician services. In most instances, the provider will accept this reimbursement; however in the event you are billed for any balance, you may submit the balance to Aetna for additional processing. If you do so and you are enrolled in the automatic rollover process to the Health Care Flexible Spending Account (HCFSA), an overpayment from the HCFSA may result, and you should contact Aetna to discuss options to return the overpaid HCFSA funds back into the account.

When you go to the emergency room, you are subject to a deductible. If you are admitted as an inpatient to the hospital following emergency outpatient hospital treatment, the deductible amount will apply to your separate inpatient hospital deductible. See the Benefit summary.

Reimbursement for non-emergency services

If you go to a non-network emergency room and your condition is determined to be non-emergency, then the expense may be subject to the non-network level of reimbursement (either 60% for the POS II B or 55% for the POS II A), after the plan year deductible has been satisfied

In case of an urgent condition

Your physician may direct you to an Urgent Care Center as an alternative to a hospital emergency room when he or she feels it is appropriate to do so. If you or a family member receive care at a network urgent care center, you will pay the applicable copay, equal to the specialist physician copay under your plan option, and the Plan pays the remaining charges.  If you live in a network area, and you use a non-network urgent care center, you will be reimbursed at the non-network level (either 60% for the POS II B or 55% for the POS II A), after the plan year deductible has been satisfied.  If you live in an out of network area, you will be reimbursed at the out of network area level (either 80% for the POS II B or 75% for the POS II A) after you have met your deductible.

Care while traveling

For non-emergency care, call Aetna Member Services to identify a nearby Medical POS II network provider, choose Find a Doctor on Aetna 's website (www.aetna.com) or launch the Aetna mobile app.

If a covered family member lives away from home

If you live in a Medical POS II network area and you have a covered family member who lives away from home (for instance, you have a child away at school), your family member's ZIP code determines the level of benefits the Plan pays.

Call Aetna Member Services with your family member's ZIP code to find out if Aetna has a Choice® POS II network in the area. If a network is there, you can contact Aetna Member Services, choose Find a Doctor on Aetna’s member website (www.aetna.com), or launch the Aetna mobile app to identify providers in the area. Here is how benefits are determined:

  • If your family member receives care from a network provider, benefits will be paid at the network level.
  • If your family member lives in a Medical POS II network area but uses non-network providers, benefits are paid at the non-network level.

Specific conditions

Autism spectrum disorder

Eligible health services include the services and supplies provided by a physician or behavioral health provider for the diagnosis and treatment of autism spectrum disorder.

Applied Behavior Analysis (ABA) will be covered when authorized by Magellan.

Fertility Services

Fertility services will be covered, when services are authorized by Progyny, the Plan’s designated Fertility Services Network Organization.

Your coverage includes:

Highlights of Your Progyny Benefit

2*

Smart Cycles per family (employee and dependents)

2

Initial consultations per year

Fertility preservation and Tissue storage

Egg and sperm freezing coverage

Tissue storage is included in applicable treatment cycles for the first year. The Plan covers an additional 1 year of storage

*You have access to an additional Smart Cycle if your first two are not successful

To learn more and activate your benefit, contact Progyny at 1-833-851-2229 to initiate services.

Note: Claims related to diagnosis and treatment of the underlying conditions during your treatment will Progyny will continue to be filed through Aetna.

Family planning services – other

Eligible health services include certain family planning services provided by your physician such as voluntary sterilization for males.

Gender affirming surgery

Gender affirming surgery is considered medically necessary when certain criteria are met. Please refer to Aetna's Clinical Policy Bulletins for more information about the criteria relating to gender affirming surgery.

Insulin and diabetic supplies

Insulin and diabetic supplies are covered under the prescription drug plan through Express Scripts.  They can be obtained through a retail pharmacy or through home delivery by paying your required coinsurance.  In those rare instance where insulin or diabetic supplies are received in a doctor’s office, outpatient facility or hospital setting, they are covered as a medical expense.

Maternity and related newborn care

Eligible health services include prenatal and postpartum care and obstetrical services related to the pregnancy of a covered child, but not those related to the child born to the family member.

After your child is born, eligible health services include:

  • 48 hours of inpatient care in a hospital after a vaginal delivery
  • 96 hours of inpatient care in a hospital after a cesarean delivery
  • A shorter stay, if the attending physician, with the consent of the mother, discharges the mother or newborn earlier

The mother could be discharged earlier. If so, the plan will pay for 1 post-delivery visit by a health care provider.

Obesity surgery

Eligible health services include obesity surgery, which is also known as “weight loss surgery.” Obesity surgery is a type of procedure performed on people who are morbidly obese, for the purpose of losing weight. Obesity is typically diagnosed based on your body mass index (BMI). To determine whether you qualify for obesity surgery, your doctor will consider your BMI and any other condition or conditions you may have. In general, obesity surgery will not be approved for any member with a BMI less than 35.

Your doctor will request approval in advance of your obesity surgery. The plan will cover charges made by a network provider for the following outpatient weight management services:

  • An initial medical history and physical exam
  • Diagnostic tests given or ordered during the first exam
  • Outpatient prescription drug benefits included under the Outpatient prescription drugs  section

Health care services include one obesity surgical procedure. However, eligible health services also include a multi-stage procedure when planned and approved by the plan. Your health care services include adjustments after an approved lap band procedure. This includes approved adjustments in an office or outpatient setting.

You may go to any in-network facilities that perform obesity surgeries.

Oral and maxillofacial treatment (mouth, jaws and teeth)

Covered services include the following when provided by a physician, dentist and hospital:

  • Dental work required by an accidental injury to sound, natural teeth or the mouth
  • Cutting out:
    • Cysts, tumors, or other diseased tissues
  • Cutting into gums and tissues of the mouth.
    • Only when not associated with the removal, replacement or repair of teeth
  • Oral surgery and related procedures covered under the POS II plan are reimbursed at 75% for the POS II A and 80% for the POS II B, regardless of the provider’s network participation.
  • Treatment of temporomandibular disorders, sometimes referred to as TMJ/TMD, including splints and orthotics, when preauthorized by Aetna. This includes diagnosis and surgical treatment of the jaw and cranio-mandibular joint resulting from an accident, trauma, congenital or developmental defect, or pathology.

Reconstructive surgery and supplies

Eligible health services include all stages of reconstructive surgery by your provider and related supplies provided in an inpatient or outpatient setting only in the following circumstances:

  • Your surgery reconstructs the breast where a necessary mastectomy was performed, such as an implant and areolar reconstruction. It also includes surgery on a healthy breast to make it symmetrical with the reconstructed breast, treatment of physical complications of all stages of the mastectomy, including lymphedema and prostheses.
  • Your surgery is to implant or attach a covered prosthetic device.
  • Your surgery corrects a gross anatomical defect present at birth. The surgery will be covered if:

    -     The defect results in severe facial disfigurement or major functional impairment of a body part.

    -     The purpose of the surgery is to improve function.

  • Your surgery is needed because treatment of your illness resulted in severe facial disfigurement or major functional impairment of a body part, and your surgery will improve function.

Transplant services

Eligible health services include transplant services provided by a physician and hospital.

This includes the following transplant types:

  • Solid organ
  • Hematopoietic stem cell
  • Bone marrow
  • CAR-T and T-Cell receptor therapy for FDA approved treatments

Network of transplant facilities

The amount you will pay for covered transplant services is determined by where you get transplant services. You can get transplant services from:

  • An Institutes of Excellence™ (IOE) facility we designate to perform the transplant you need
  • A Non-IOE facility

Your cost share will be lower when you get transplant services from the IOE facility we designate to perform the transplant you need. You may also get transplant services at a non-IOE facility, but your cost share will be higher.

The National Medical Excellence Program® will coordinate all solid organ, bone marrow and CAR-T and T-Cell therapy services and other specialized care you need.

Important note:

If there is no IOE facility for your transplant type in your network, the National Medical Excellence Program® (NME) will arrange for and coordinate your care at an IOE facility in another one of our networks.

If you don’t get your transplant services at the IOE facility we designate, your cost share will be higher.

Many pre and post-transplant medical services, even routine ones, are related to and may affect the success of your transplant. While your transplant care is being coordinated by the NME Program, all medical services must be managed through NME so that you receive the highest level of benefits at the appropriate facility. This is true even if the covered service is not directly related to your transplant.

Specific therapies and tests

Outpatient diagnostic testing

Diagnostic complex imaging services

Eligible health services include complex imaging services by a provider, including:

  • Computed tomography (CT) scans
  • Magnetic resonance imaging (MRI) including Magnetic resonance spectroscopy (MRS), Magnetic resonance venography (MRV) and Magnetic resonance angiogram (MRA)
  • Nuclear medicine imaging including Positron emission tomography (PET) scans
  • Other outpatient diagnostic imaging service where the billed charge exceeds $500

Complex imaging for preoperative testing is covered under this benefit.

Diagnostic lab work and radiological services

Eligible health services include diagnostic radiological services (other than diagnostic complex imaging), lab services, and pathology and other tests, but only when you get them from a licensed radiological facility or lab.

Chemotherapy

Eligible health services for chemotherapy depends on where treatment is received. In most cases, chemotherapy is covered as outpatient care. However, your hospital benefit covers the initial dose of chemotherapy after a cancer diagnosis during a hospital stay.

Oral-motor therapy

Oral-motor therapy ordered by a physician for treatment of dysphagia, hypotonia and/or other diagnoses listed in Aetna Coverage Policy Bulletins.

Outpatient infusion therapy

Eligible health services include infusion therapy you receive in an outpatient setting including but not limited to a free-standing outpatient facility, the outpatient department of a hospital, a physician in the office or a home care provider in your home.

Outpatient radiation therapy

Eligible health services include the following radiology services provided by a health professional:

  • Radiological services
  • Gamma ray
  • Accelerated particles
  • Mesons
  • Neutrons
  • Radium
  • Radioactive isotopes

Specialty prescription drugs

Eligible health services include specialty prescription drugs when they are:

  • Purchased by your provider, and
    • Injected or infused by your provider in an outpatient setting such as:
  • A free-standing outpatient facility
  • The outpatient department of a hospital
  • A physician in the office
  • A home care provider in your home
  • And, listed on our specialty prescription drug list as covered under this booklet.

You can access the list of specialty prescription drugs by contacting Member Services by logging onto your Aetna secure member website at www.aetna.com or calling the number on your ID card to determine if coverage is under the outpatient prescription drug benefit or this booklet.

When injectable or infused services and supplies are provided in your home, they will not count toward any applicable home health care maximums.

Short-term cardiac and pulmonary rehabilitation services

  • Cardiac rehabilitation: includes cardiac rehabilitation services you receive at a hospital, skilled nursing facility or physician’s office, but only if those services are part of a treatment plan determined by your risk level and ordered by your physician.
  • Pulmonary rehabilitation: includes pulmonary rehabilitation services as part of your inpatient hospital stay if it is part of a treatment plan ordered by your physician.

Short-term rehabilitation services

Short-term rehabilitation services help you restore or develop skills and functioning for daily living.

Eligible health services include short-term rehabilitation services your physician prescribes. The services have to be performed by:

  • A licensed or certified physical, occupational or speech therapist
  • A hospital, skilled nursing facility, or hospice facility
  • A home health care agency
  • A physician

Short-term rehabilitation services have to follow a specific treatment plan.

Outpatient cognitive rehabilitation, physical, occupational, and speech therapy

Eligible health services include:

  • Physical therapy, but only if it is expected to significantly improve or restore physical functions lost as a result of an acute illness, injury or surgical procedure.
  • Occupational therapy (except for vocational rehabilitation or employment counseling), but only if it is expected to:
    • Significantly improve, develop or restore physical functions you lost as a result of an acute illness, injury or surgical procedure, or
    • Relearn skills so you can significantly improve your ability to perform the activities of daily living.
  • Speech therapy, but only if it is expected to:
    • Significantly improve or restore the speech function or correct a speech impairment as a result of an acute illness, injury or surgical procedure, or
    • Improve delays in speech function development caused by a gross anatomical defect present at birth.
  • Cognitive rehabilitation associated with physical rehabilitation, but only when:
    • Your cognitive deficits are caused by neurologic impairment due to trauma, stroke, or encephalopathy and
    • The therapy is coordinated with us as part of a treatment plan intended to restore previous cognitive function.

If you or your provider anticipates that your current course of therapy may exceed 25 visits, have your physician or therapist submit medical records with each physical therapy claim. Claims for therapy service beyond the 25th visit are subject to medical review. Additional information will be required. Claims will not be paid if the service is found not to be medically necessary or rendered in connection with an IEP (Individualized Education Program) in a school setting.

Habilitation therapy services

Habilitation therapy services are services that help you keep, learn, or improve skills and functioning for daily living (e.g. therapy for a child who isn’t walking or talking at the expected age). The plan standardly covers rehabilitation and habilitation services, as long as the services aren’t considered experimental and investigational.

Habilitation therapy services have to follow a specific treatment plan, ordered by your physician.

Outpatient physical, occupational, and speech therapy

Eligible health services include:

  • Physical therapy (except for services provided in an educational or training setting), if it is expected to develop any impaired function.
  • Occupational therapy (except for vocational rehabilitation or employment counseling), if it is expected to develop any impaired function.
  • Speech therapy (except for services provided in an educational or training setting or to teach sign language) is covered provided the therapy is to:
  • Restore speech after a demonstrated previous ability to speak is lost or impaired,
  • Improve or develop speech after surgery to correct a birth defect which impaired or would have impaired the ability to speak, or
  • Improve, develop, or maintain speech impaired as a result of delayed development, including autism spectrum disorder, down syndrome, cerebral palsy, fetal alcohol syndrome, and muscular dystrophy. (See Speech Therapy under Exclusions. Submission of a proposed treatment plan for a benefit predetermination is strongly recommended.)

Other services

Acupuncture

Eligible health services include the treatment by the use of acupuncture (manual or electroacupuncture) provided by your physician, if the service is performed as a form of anesthesia in connection with a covered surgical procedure.

Chiropractic services

Chiropractic services will be covered only when performed by a licensed doctor or chiropractic who is acting within the scope of his or her license, up to $1,000 per person per year (benefits paid for acupuncture and supplies billed by a doctor of chiropractic are not included in the $1,000 annual maximum).

Ambulance service

Eligible health services include transport by professional ground ambulance services:

  • To the first hospital to provide emergency services.
  • From one hospital to another hospital if the first hospital cannot provide the emergency services you need.
  • From a hospital to your home or to another facility if an ambulance is the only safe way to transport you.
  • From your home to a hospital if an ambulance is the only safe way to transport you. Transport is limited to 100 miles.

Your plan also covers transportation to a hospital by professional air or water ambulance when:

  • Professional ground ambulance transportation is not available.
  • Your condition is unstable, and requires medical supervision and rapid transport.
  • You are travelling from one hospital to another and
    • The first hospital cannot provide the emergency services you need, and
    • The two conditions above are met.

Clinical trial therapies (experimental or investigational)

Eligible health services include experimental or investigational drugs, devices, treatments or procedures from a provider under an “approved clinical trial” only when you have cancer or terminal illnesses and all of the following conditions are met:

  • Standard therapies have not been effective or are not appropriate.
  • Aetna determines based on published, peer-reviewed scientific evidence that you may benefit from the treatment.

An "approved clinical trial" is a clinical trial that meets all of these criteria:

  • The FDA has approved the drug, device, treatment, or procedure to be investigated or has granted it investigational new drug (IND) or group c/treatment IND status. This requirement does not apply to procedures and treatments that do not require FDA approval.
  • The clinical trial has been approved by an Institutional Review Board that will oversee the investigation.
  • The clinical trial is sponsored by the National Cancer Institute (NCI) or similar federal organization.
  • The trial conforms to standards of the NCI or other, applicable federal organization.
  • The clinical trial takes place at an NCI-designated cancer center or takes place at more than one institution.
  • You are treated in accordance with the protocols of that study.
  • The clinical trial has been pre-approved by Aetna / Magellan.

Clinical trials (routine patient costs)

Eligible health services include "routine patient costs" incurred by you from a provider in connection with participation in an "approved clinical trial" as a “qualified individual” for cancer or other life-threatening disease or condition, as those terms are defined in the federal Public Health Service Act, Section 2709.

As it applies to in-network coverage, coverage is limited to benefits for routine patient services provided within the network.

Durable medical equipment (DME)

Durable medical equipment (DME) when medically necessary, prescribed by a physician for the treatment of an illness or injury. Some DME may require preauthorization from Aetna. For more information on precertification, see the National Precertification List on the Aetna member website. Replacement, repair and maintenance are only covered for purchased DME if:   

- It cannot be repaired

- Repairs would be more expensive than purchasing or renting replacement equipment   

- The attending physician recommends replacement because of a change in the patient’s physical condition   

Coverage includes:

  • One item of DME for the same or similar purpose.
  • Repairing DME due to normal wear and tear. It does not cover repairs needed because of misuse or abuse.
  • A new DME item you need because your physical condition has changed. It also covers buying a new DME item to replace one that was damaged due to normal wear and tear, if it would be cheaper than repairing it or renting a similar item.

Your plan only covers the same type of DME that Medicare covers. But there are some DME items Medicare covers that your plan does not. We list examples of those in the exclusions section.

Extended-care facilities

An extended-care facility provides skilled-nursing services and rehabilitation care. Extended-care facility charges are covered expenses if these conditions are met:

  • The inpatient stay must be medically necessary, and
  • The inpatient stay has been pre-certified.

Reimbursement is based on the facility charge or daily room and board rate of the hospital from which the patient transferred, whichever is less.

Hearing aids and exams

Benefits are provided up to a maximum of $2,500 after the deductible and coinsurance are paid for one or more hearing aids every rolling five year period, which also includes the repair of a hearing aid. However, shipping and handling charges and routine maintenance such as battery replacement are not covered. The amount allowed is subject to reasonable and customary limits but not negotiated rates. There are no Medical POS II preferred providers for hearing aids and related materials. The member will be responsible for the difference between the billed and allowable amount regardless of provider participation.

You may be able to maximize your benefit through the Amplifon Hearing Health Care (formerly HearPo) or the Hearing Care Solutions Discount Program. These programs are available to Aetna participants and offer discounts on hearing exams, services and hearing aids. If you go to a participating hearing discount center, your out-of-pocket expenses could be lower. To find a participating hearing discount center location, visit www.aetna.com and select "Hearing Discount Locations". To compare costs, please call Amplifon Hearing Health Care at 1-877-301-0840 or Hearing Care Solutions at 1-866-344-7756 and identify yourself as an Aetna member.

Non-routine/non-preventive care hearing exams

Eligible health services for adults and children include charges for an audiometric hearing exam for evaluation and treatment of illness, injury or hearing loss, if the exam is performed by:

  • A physician certified as an otolaryngologist or otologist
  • An audiologist who is legally qualified in audiology; or holds a certificate of Clinical Competence in Audiology from the American Speech and Hearing Association (in the absence of any applicable licensing requirements); and who performs the exam at the written direction of a legally qualified otolaryngologist or otologist.

Prosthetic devices

Braces, crutches and prostheses required because of an injury or disease. Coverage is generally limited to the purchase price.

Coverage includes:

  • Repairing or replacing the original device you outgrow or that is no longer appropriate because your physical condition changed
  • Replacements required by ordinary wear and tear or damage
  • Instruction and other services (such as attachment or insertion) so you can properly use the device

Mental health and substance abuse care

Mental health and substance abuse care for the ExxonMobil Employee Medical Plan - POS II A and POS II B options

The Plan provides for mental health and substance abuse care through a nationwide mental health PPO (MHPPO) administered by Magellan Healthcare. The Aetna network is not used for mental health or substance abuse care. Magellan provides precertification for inpatient treatment and intensive outpatient treatment, provider referral, ongoing consultation and review, and case management for mental health and substance abuse treatment.

The EMMP POS II options include a number of provisions specific to mental health and substance abuse treatment. When determining whether a service or supply is medically necessary, Magellan's utilizes written medical necessity criteria.  Those criteria are available upon request, consistent with applicable law. You and your providers may contact Magellan at 800-442-4123 to request the medical necessity criteria applicable to a treatment or visit their website at Magellan Ascend.

Precertification

All inpatient and intensive outpatient mental health and substance abuse care must be pre-certified by Magellan. The health care provider is responsible for obtaining pre-certification for network care. The participant is responsible for obtaining required pre-certifications for services at non-network facilities; if pre-certification for inpatient care is not obtained, a $500 penalty will be assessed for failure to pre-certify inpatient care at a non-network facility.

Intensive outpatient programs provide planned, structured mental health services, for at least 2 hours per day and 3 days per week, consistent with Magellan’s published Medical Necessity criteria.

Precertification is required even if the Plan is secondary to other medical coverage. Whenever treatment for mental health or substance abuse is needed, call Magellan. The telephone numbers are shown in the Information sources section at the front of this SPD.

Emergency Treatment

If emergency mental health or substance abuse care is needed:

  • The patient (or a responsible adult, if the patient is incapable) should contact Magellan and indicate that there is an emergency. Magellan will direct the patient to the nearest MHPPO facility for treatment.
  • If it is not feasible to contact Magellan in an emergency, the patient should seek treatment at the nearest emergency facility. However, seek to notify Magellan:
  • Within 48 hours of treatment or admission, or
  • Within 72 hours of a weekend or holiday treatment or admission.

Expenses for emergency care at a MHPPO facility will be reimbursed at the 80% benefit level for the EMMP POS II B or 75% for the EMMP POS II A. 

If the patient is admitted and the emergency facility does not participate in the MHPPO, Magellan will work with the emergency care treatment team to arrange a transfer to a MHPPO facility as soon as possible after the patient is stabilized. Expenses for emergency care at a non-network MHPPO facility will be reimbursed at the 80% benefit level for the EMMP POS II 'B' or 75% for the EMMP POS II 'A'. 

If you require mental health or substance abuse care in conjunction with a medical emergency, please notify Magellan within the time periods described above.

Mental Health PPO

The Mental Health PPO (MHPPO) is a nationwide network of providers who offer quality, cost-effective care. MHPPO providers work with Magellan to develop suitable treatment plans and provide needed services.

If you use mental health network providers

You pay the EMMP POS II A and B primary care copay for most outpatient office visits provided by a specialist, which does not apply to the annual deductible. If you need intensive outpatient or inpatient treatment, your covered expenses are reimbursed at 80% for the EMMP POS II B or 75% for the EMMP POS II A after the annual deductible is satisfied. There are no limits on the number of inpatient days or outpatient visits per year. The portion of expenses you pay for both inpatient and outpatient care is applied to the annual out-of-pocket limit with the exception of the $500 penalty for failure to pre-certify for inpatient non-network and out-of-network care.

For inpatient mental health and substance abuse treatment to be reimbursed at the network level, both the provider and the facility must participate in the MHPPO network. If either the provider or the facility is non-network, all expenses associated with the inpatient stay will be reimbursed at the non-network level.

If you do not use mental health network providers

You should contact Magellan for precertification of non-network care. Remember: 

  • If you are referred, even in an emergency, by a Medical POS II network provider to a mental health provider, you still must pre-certify with Magellan.

Example - Payment of network and non-network expenses for inpatient mental health and substance abuse cases: 

Assume you participate in the EMMP POS II B option and submit a claim for covered inpatient expenses to the Plan. Magellan determines that network charges for your treatment would be $15,000. Also assume that a non-network provider charged $19,000 for the same service. Assume that no deductibles have been met.  Here is how payment of both network and non-network certified and non-certified expenses would compare:

 

Certified Network Care

Certified Non-Network Care

Non-Certified Non-Network Care

Total Charges:

$15,000.00

$19,000.00

$19,000.00

Total Covered Charges:

$15,000.00

$15,000.00

$15,000.00

You Pay:

$200.00 (inpatient deductible)
$300.00
(annual deductible)

$400.00 (annual deductible)

$400.00 (annual deductible)

Certified Network Care– 20% of covered charges after the deductible, up to the remaining out-of-pocket limit of $3,000 ($15,000 - $500) = $14,500 X 20%) = $2,890

$2,890.00

 

 

Certified Non-network Care– 40% of covered charges after the deductible ($15,000-$400 = $14,600 x 40%) = $5,840

 

$5,840.00

 

Non-certified, Non-network Care– 40% of covered charges after the deductible ($15,000-$400 = $14,600 x 40% + $500 penalty for no precertification = $6,340)

 

 

$6,340.00

  • Expenses exceeding covered charges:

 

$4,000.00

$4,000.00

Your Total Payment:

$3,390.00

$9,840.00

$10,340.00

Your Plan Pays:

$11,610.00

$9,160.00

$8,660.00

Mental health care outside the United States

If you live or travel outside the United States and need treatment for a mental health or substance abuse condition, you should contact Magellan.

Currently, there are no network providers outside the United States. However, Magellan will recommend providers with whom it has experience. Treatment received is reimbursed at 80% for the EMMP POS II B and 75% for the EMMP POS II A after you satisfy the annual deductible. The same emergency care procedures apply inside and outside the United States.

Prescription drug program

Prescription drug program information for the Employee Medical Plan POS II A and POS II B Options

The Plan contains a prescription drug program that offers you three cost-saving ways to buy outpatient prescription drugs. You may buy your prescriptions through:

  • A network of local participating retail pharmacies for short-term prescriptions.
  • Express Scripts Pharmacy, the home delivery pharmacy, and participating Smart90 retail pharmacies (Walgreens, CVS) for long-term or maintenance prescriptions.
  • Express Scripts Specialty Pharmacy, Accredo, for prescriptions requiring special handling.

Short-term prescriptions

A short-term prescription is written for a drug taken for a limited period of time, such as an antibiotic for a specific illness. The Plan generally provides benefits for up to a 34-day supply. See Special provisions for more information.

You have the choice of filling your prescriptions at:

  • A local participating retail pharmacy (part of Express Scripts' extensive network of pharmacies), where you will pay your share of the discounted cost, and there are no claims to file.
  • A non-participating retail pharmacy of your choice, where you will pay the full price and file a claim for partial reimbursement of the cost.

The participating retail network pharmacy

You may call Express Scripts or check the Express Scripts website (www.express-scripts.com), or use the Express Scripts mobile app to locate a participating retail pharmacy near you.

When you fill a prescription, you must identify yourself as a member of Express Scripts’ retail pharmacy program to maximize your savings.

Cost per prescription

For short-term (<34 day supply) prescription drugs purchased at a participating retail pharmacy, you pay a percentage of the discounted cost of the drugs:

Type of Short-Term Drug

Percentage Copayment

POS A maximum per prescription

POS B maximum per prescription

Generic drugs

30%

$ 60

$ 50

Preferred brand name drugs

30%

$ 130

$ 125

Non-preferred brand name drugs

50%

$ 200

$ 200

Examples:

Generic short-term drug purchased at a retail network pharmacy
Discounted cost of medication is $20.
You pay a 30% copayment ($20 x .30) = $6

Preferred brand name short-term drug purchased at a retail network pharmacy (if no generic is available)
Cost of medication is $40
You pay a 30% copayment ($40 x .30) = $12

Non-preferred brand name short-term drug purchased at a retail network pharmacy
Cost of medication is $60
You pay a 50% copayment ($60 x .50) = $30

Short-term retail refill limitation for maintenance medications

A long-term or maintenance medication is a drug you take for an extended period of time, such as for the ongoing treatment of diabetes, arthritis, a heart condition, or blood pressure. After the third short-term fill of a maintenance medication at a participating, or non-participating retail pharmacy, subsequent refills must be purchased as a 90-day supply at a Smart90 retail pharmacy (Walgreens, CVS) or Express Scripts home delivery pharmacy. If you continue to purchase short-term fills of a long-term, or maintenance medication after the third fill, you will be responsible for 100% of the cost.

How to obtain your prescription or a refill

  • Refills can be obtained if prescribed and needed. You must have generally used 75% of the previous prescription, based on the dosage prescribed, before you can refill and receive Plan benefits.
  • To receive the discounted price, present your prescription and either your prescription drug identification card or the primary participant's identification number at a participating network retail pharmacy. See the definition for primary participant.
  • The pharmacist enters the prescription and the primary participant's Social Security number or ID number into the pharmacy's computer system to confirm:
  • That the participant or family member is covered,
  • That it is a covered prescription, and
  • The prescription's cost share.
  • No claim filing is necessary.

The term Primary Participant refers to the participant whose identification number is used. The primary participant is the employee or individual who elected COBRA coverage. Covered family members use the primary participant's identification number to access all medical benefits. Be sure to give identification cards or the primary participant's identification number to your spouse and any covered family members who may live away from home.

Note: Family members who elect COBRA coverage must use their identification number after the date they enroll as a COBRA participant.

Using a non-participating pharmacy or not showing your Express Scripts or Medco ID card

You are not eligible for a discounted price if you have your prescription filled at a non-participating retail pharmacy or fail to show your prescription drug ID card at a participating network retail pharmacy. You may print out a temporary ID card if you have registered for access to your personal account on the Express Scripts website at www.express-scripts.com.

  • You pay the full price of the prescription at the time of purchase.
  • You must submit a completed Direct Reimbursement Claim Form to Express Scripts within two years following purchase. You may obtain a claim form by accessing the ExxonMobil Family Internet site or by contacting Express Scripts at the number shown in the front of this SPD.
  • You will be responsible for:
  • 100% of the difference between the non-discounted and the discounted cost of the prescription (the ineligible cost) PLUS
  • Your percentage copayment portion of the discounted cost 

Long-term prescriptions

A long-term or maintenance drug is one you take for an extended period of time, such as for ongoing treatment of diabetes, arthritis, a heart condition or blood pressure. The Plan generally provides benefits for up to a 90-day supply. See Special provisions for more information.

How to get started with Express Scripts Pharmacy

If you need maintenance medication immediately, ask your doctor for two prescriptions — one for an immediate supply to be filled at a local retail pharmacy and a second for an extended supply to be ordered through the home delivery pharmacy. You can also fill maintenance medications at a Smart90 retail pharmacy (Walgreens, CVS).

Home delivery pharmacy prescriptions

With Express Scripts Pharmacy, you save money and have the convenience of home delivery. Ask the doctor to write a prescription for up to a 90-day supply with appropriate refills. Prescriptions can be submitted electronically from most doctor’s offices. You can also enclose your original prescription(s) and payment of your percentage copayment in an envelope. If you are paying by check or money order, you may obtain a calculation of your percentage copayment from the Express Scripts website or by calling Express Scripts directly. If you are paying by credit card, Express Scripts will deduct the appropriate percentage copayment and you will receive notification of the deduction with your medication.

Your prescription will be delivered to the address on your order form within 14 working days. By law, prescriptions may not be sent outside the U.S.

You may order refills by calling Express Scripts or sending in the refill label provided with your previous order. You may also order refills through Express Scripts’ website. You should order a refill about three weeks before your current supply will be exhausted, but remember that you must have generally used 75% of the previous prescription based on the prescribed dosage. 

Cost per Prescription

For each long-term (90-day) prescription filled at a Smart90 retail pharmacy or Express Scripts home delivery pharmacy, you pay:

Type of Long-Term Drug

Percentage Copayment

POS A maximum per prescription

POS B maximum per prescription

Generic drugs

25%

$ 120

$ 100

Preferred brand name drugs

25%

$ 260

$ 250

Non-preferred brand name drugs

45%

$ 400

$ 400

 

Whether you fill prescriptions through Express Scripts Pharmacy or at a local retail pharmacy:

  • Your payments and copayments under the outpatient prescription drug benefits do not apply toward your deductible for other benefits under the Plan.
  • Your prescription drug payments and copayments do not apply toward your annual medical out-of-pocket limit.
  • Your prescription drugs annual out-of-pocket maximum is $2,500 for each individual in your family, or $5,000 for your entire family. 
  • The additional cost for purchasing brand-name prescription drugs when a generic is available, as well as the full cost for purchasing subsequent refills of maintenance medication after the third fill obtained at retail pharmacies that are not part of the Smart90 network (Walgreens, CVS), will not count toward your annual out-of-pocket maximum.

Comparing retail pharmacy with Express Scripts Pharmacy

This example shows how you can save money by purchasing long-term medications through either the Express Scripts home delivery or a Smart90 retail pharmacy.

At a Participating Retail Pharmacy

 

Through Express Scripts or Smart90 Pharmacy

$108.00

Cost of formulary preferred brand name drug (30-day supply)

 

$324.00

Cost of formulary preferred brand name drug (90-day supply)

x 30%

Percentage copayment

x 25%

Percentage copayment

$32.40

Your copayment

$81.00

Your copayment

You pay$32.40, or$97.20 for 3 purchases.

You pay$81.00

By purchasing a 90-day supply of this prescription through Express Scripts home delivery or at a Smart90 retail pharmacy, you would save $16.20. That is $64.80 a year for one prescription

Covered prescriptions

The prescription drug program covers drugs, medicines, and supplies that are:

  • Obtainable only with a physician's prescription or are specifically covered expenses (see Covered expenses),
  • Approved by the U.S. Food and Drug Administration for the specific diagnosis,
  • Medically necessary, and
  • Not experimental or investigational.

If you participate in the pre-tax spending plan health care flexible spending account

Do not file a claim for pre-tax benefits for your prescription drug out-of-pocket expenses. Express Scripts will notify Aetna of your prescription purchase, and Aetna will process the claims for any pre-tax reimbursement due you.

Generic drugs

The program encourages consideration of generic alternatives, which are less expensive to you and the Plan. About half of all brand name medications have a generic equivalent available. By law, the brand name and generic medications must meet the same standards for safety, purity, strength and effectiveness. The pharmacist will dispense only generics that receive FDA approval and only if authorized by your doctor.

Note: If both generic and brand name drugs are available to treat your condition, your percentage copayment amount will depend on which medication you select.

If you purchase the brand name drug, you are responsible for paying the generic drug percentage copayment PLUS the full difference in cost between the generic drug and the brand name. This difference in cost will not count toward your annual prescription drug out-of-pocket maximum.

Here is an example from the POS II B option of how you can save by choosing a generic drug at a retail pharmacy when a brand-name drug is available on the Plan's formulary list of medications.

 

Generic

Brand

Prescription cost

$50.00

$200.00

Copayment (30% of the cost of generic drug)

$15.00

$15.00

Difference in cost with available generic

$0

$150.00

Total cost

$15.00

$165.00

If you purchase the brand name drug:

  • Your copayment will be $15 + $150 (difference in cost) = $165
  • The additional $150 does not count toward your annual prescription drug out-of-pocket maximum.

Available alternatives

Sometimes, a generic drug or a less expensive brand name drug which provides the same therapeutic effect at a lower cost to you may be available. If so, the network system will inform the pharmacist that a less expensive alternative medication is available to fill your prescription. A pharmacist from the network or Express Scripts Pharmacy may contact your doctor to discuss the generic or less expensive brand name alternative. If the doctor authorizes a substitution, the pharmacist will dispense it based solely on your doctor's agreement. If Express Scripts Pharmacy fills a prescription with a generic or an alternative brand name drug, your order will include an explanation of the doctor's change and a credit for any excess percentage copayment.

The network formulary program

A formulary is a list of commonly prescribed medications within particular therapeutic categories. The drugs on the list have been selected based on their effectiveness and cost.

To be included in the formulary list, a drug must meet rigorous standards of approval by the Express Scripts Pharmacy and Therapeutic Committee — a group of nationally recognized medical professionals.

It is always up to your doctor to decide which medications to prescribe. If you have questions about the Express Scripts formulary, you should contact Express Scripts directly.

Drug monitoring service

All prescriptions, both home delivery and retail, are screened by the network's computerized drug monitoring service. This service analyzes all of your prescriptions in the system for potential problems such as adverse drug interactions, drug duplications, and unusually high or low dosages. This monitoring service may also detect if a refill is requested too soon. If a potential problem is detected, the drug monitoring service transmits a message to the pharmacist.

The pharmacist will contact your doctor about the potential problem or otherwise resolve the issue before dispensing the prescription. Your doctor makes the final decision about any change in your prescription or course of treatment.

Special provisions

In most cases, the pharmacist will fill the prescription according to the doctor's written orders. However, there are some limitations:

  • If the prescription is written for an amount that is greater than the Plan covers, the pharmacist will fill the prescription up to the Plan limit. You have the option of buying the additional amount at that time if purchasing at a retail pharmacy, but there is no Plan benefit.
  • If the medicine is a controlled substance or if there is a manufacturer's or prescription benefit manager's directive, a smaller amount may be provided.
  • For most prescriptions, you must have used at least 75% of the previous prescription, based on the dosage prescribed, before you can obtain a refill and receive Plan benefits.
  • During natural disasters, you may be able to replace lost or damaged medications without having used 75% of the previous prescription.

Specialty medications

Specialty medications, including injectables and infusions for rheumatoid arthritis and other inflammatory conditions, require special handling and may be administered in a hospital, clinic, doctor’s office, or in your home. Some specialty medications, like most oncology drugs administered in a hospital setting, are covered under the medical benefit administered by Aetna. Other specialty medications are covered under the prescription drug program administered by Express Scripts. If you have questions about starting a specialty medication, call Aetna Member Services and ask to speak to a Health Advocate nurse.

Specialty medications administered by Express Scripts are filled through their specialty pharmacy, Accredo, and can be delivered to hospitals, clinics, doctor’s offices, or to a home health care provider. 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.

Advanced Utilization Management (AUM)

In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the Plan will cover another (usually more expensive) drug.  Prior authorization and preferred drug step therapy rules are designed to encourage the use of effective, lower-cost drugs.

As part of Express Scripts’ Advanced Utilization Management (AUM) program, certain targeted drugs will not be covered unless pre-certified by Express Scripts, based on medical evidence submitted by your physician. In addition, some therapies will be monitored for appropriate pharmacogenomic parameters, and oral oncology medications will be limited to ensure appropriate use. Please visit www.express-scripts.com to more information about your medications and if they require a coverage review.  If you have a question regarding a drug on the AUM program list, contact Express Scripts at the number listed in the Information Sources section of this SPD.

Preferred drug step therapy rules

Preferred drug step therapy rules are used for certain therapeutic classes of drugs, to encourage the use of effective, lower-cost drugs initially by excluding some targeted medications from coverage unless prior authorization is provided by Express Scripts. Therapeutic classes include: proton pump inhibitors, sleep agents, depression, osteoporosis, respiratory, cardiovascular, triptans, glaucoma, diabetes, respiratory allergy/asthma, anti-inflammatory and rheumatoid arthritis, growth hormone, stimulants for Attention Deficit Hyperactivity Disorder (ADHD), prostate therapy drugs, topical steroids, and stroke prevention. Non-targeted drugs will be covered without such authorization and will continue to be dispensed with no further action by either you or the prescribing physician. If you have a question regarding a drug in any of these therapeutic classes, contact Express Scripts to determine whether your drug is covered. You will be notified directly by Express Scripts if you are affected by these rules.

Prior authorization rules

Prior authorization rules apply to certain therapeutic classes of drugs; some therapies in this section will be monitored for appropriate use, including pharmacogenomics parameters in some cases.  These classes include miscellaneous immunological agents, central nervous system/miscellaneous neurological therapy, biotechnology/adjunctive cancer therapy, central nervous system/headache therapy, central nervous system/analgesics, neurology/miscellaneous psychotherapeutic agents, and miscellaneous pulmonary agents. In addition, anabolic steroids, high cost antibiotics, anti-emetics, antivirals, narcotics, acne dermatologicals and topical pain medications may trigger a prior authorization.  Oral oncology medications will also be limited to ensure appropriate use. Certain drugs within each classes as determined by Express Scripts will only be covered to the extent they are authorized by Express Scripts. If you have a question regarding coverage for a drug in any of these therapeutic classes, contact Express Scripts. You will be notified directly by Express Scripts if you are affected by these rules.

Therapeutic Resource Centers

Plan participants and their physicians may receive outreach calls from Express Scripts Therapeutic Resource Center (TRC) pharmacists or healthcare specialists to offer personal over-the-phone guidance as well as other health management tools. You can also ask to speak to a TRC pharmacy specialist when you call Express Scripts.

Split-fill program

Express Scripts' split fill program applies to certain select specialty conditions where participants often stop or change therapy early in treatment due to side effects or their ability to tolerate treatment. This program will provide smaller initial fills (15-day supply) and clinical support to participants as they begin their therapy. Coinsurance and the per prescription maximum will be applied on a prorated basis so that the participant will not be disadvantaged financially. This program is designed to help manage side-effects, eliminate wasted medications and manage specialty drug costs.

When a prescription drug becomes available over the counter

When a prescription medication becomes available over the counter so that it can be purchased without a prescription (at the same strength and for the same use), it will no longer be covered under the Prescription Drug Program. In addition, other drugs in the same therapeutic class may be excluded from the program, but this determination will be made on a case-by-case basis, based on clinical data available at that time.

Coordinating benefits for prescriptions

The Plan coordinates benefits with any other group medical plan under which you or your family members are covered, which is described in more detail in Coordination of benefits in the Payments section of this SPD. This information is provided to the prescription drug network.

When a pharmacist reviews your or your family member's eligibility information in the network system, a code will indicate if your or your family member has other coverage that should pay benefits first. In these cases, you must first pay according to the primary plan provisions (i.e. you cannot purchase prescriptions using the Express Scripts or Medco card or through the Express Scripts Pharmacy). After the primary plan has paid, you may file a claim for reimbursement of any remaining amount; the procedure is the same as when a non-participating pharmacy is used. The Plan will pay the lesser of what would have been paid under this Plan or the amount not paid by the primary plan.

Exclusions: What your plan doesn’t cover

Exclusions for the ExxonMobil Medical Plan - POS II A and POS II B options

Although the Plan covers many types of treatments and services, it does not cover all of them.  Exclusions shall be interpreted and applied consistently with Clinical Policy Bulletins published by Aetna. These bulletins can be accessed on the Aetna website at www.aetna.com. See Basic Plan features for more information.

No benefits are payable under the Plan (EMMP POS II A and B) for any charge incurred for:

General exclusions

  • Any claim submitted past the claim-filing deadline.
  • Any expense incurred before you or your family members became covered under this option (except children less than 31 days old).
  • Any expenses that exceed reasonable and customary limits.
  • Any procedure, treatment or other type of coverage prohibited under federal, state, local or other applicable law.
  • Charges for missed appointments, and/or completion of claim forms are excluded by the Plan

Physicians and other health professionals

  • Any expense not recommended and approved by a physician acting within the scope of his or her license.
  • Any program or service performed in a nonconventional setting, even if the services are performed by a licensed provider, including: spas/resorts, outdoor learning or leadership programs; wilderness, camp, or ranch programs; academic, vocational, or recreational settings.
  • Experimental or investigational drugs or treatments for a particular diagnosis.
  • Periodic physical examinations paid for by the company.
  • Treatment not specifically covered or meeting the Plan's requirements for medically necessary for the care or treatment of a particular disease, injury, or pregnancy, even when medical provider has recommended/prescribed the services

Hospital and other facility care

  • Cosmetic surgical procedures, treatments or hospital stays, except for those that are primarily for the purpose of restoring a bodily function or surgery, which is medically necessary. 
  • Custodial care or maintenance care, even if ordered by a physician.
  • In-hospital expenses for non-medical items, such as a telephone or television set.
  • Private-duty nursing, except as defined in the Covered expenses section.
  • Private room rate above the hospital's most common semiprivate room rate, except when medically necessary.
  • Stay in a facility that is primarily a school, place of rest, or nursing home.

Specific conditions

  • Bariatric surgery expenses for the treatment of morbid obesity in excess of the $25,000 lifetime maximum.
  • Chelation therapy.
  • Chiropractic services for therapeutic purposes in excess of $1,000 per person per year and any maintenance chiropractic care.
  • Concierge or annual fees.  Any portion not related to medical care (such as a private waiting room, same-day appointments, extended time with physician) is excluded.
  • Dental charges except as specifically provided in the Covered Expenses section.
  • Drugs or vitamins that are available over the counter, even if prescribed by a physician (referred to as legend vitamins, except prenatal vitamins, Rocaltrol).
  • Services primarily of an educational nature or in an educational setting, including but not limited to services for developmental reading disorders, developmental arithmetic disorders, developmental language disorders or developmental articulation disorders.
  • Non-therapeutic or elective abortions.
  • Foot orthotics and other supportive devices for feet with the exception of some types of foot braces, even if prescribed by a physician.
  • Laser-assisted in situ keratomileusis (LASIK), photorefractive keratectomy (PRK), and other similar or related procedures to improve visual acuity. Revision or repeated treatment of surgery is not covered.
  • Nutritional programs, weight programs, and related food supplements, except for physician expenses and lab costs for treatment of morbid obesity, and for nutritional counseling performed by a licensed nutritionist or dietician, consistent with Aetna's Clinical Policy Bulletins.
  • Nutritional supplements, even if prescribed by a physician, except for treatment of phenylketonuria (PKU). 
  • Outpatient prescription drugs in excess of the allowed supply (34 days for retail and 90 days for home delivery) per fill or refill.
  • Routine eye examinations, eyeglasses, contact lenses, and orthoptics.
  • Self-treatment.
  • Some prescription medications including injections, billed by and provided in an outpatient hospital or Doctor's office, are not covered under Aetna, but may be covered under the prescription drug program administered through Express Scripts.
  • Wigs or hairpieces for androgenic alopecia (male pattern baldness).
  • Treatment of injuries received or illnesses contracted while on military assignment and covered by a government medical plan.
  • Treatment of occupational illnesses or injuries sustained in situations covered by workers' compensation or a similar law.
  • Transportation or travel expenses other than emergency transportation service by professional ambulance, transportation costs to travel to a COE/IOE, if the distance is over 100 miles, and for Organ, Tissue, and Bone Marrow Transplants.
  • Voluntary sterilization reversal procedures (including any services for infertility related to voluntary sterilization and its reversal).

Continuation of coverage

Continuation of coverage for the ExxonMobil Employee Medical Plan – POSII A and B options

Introduction

You are required to be given the information in this section because you are covered under a group health plan (the Medical Plan). This section contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan under certain circumstances when coverage would otherwise end. This section generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. 

The right to COBRA coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to your spouse and children, if they are covered under the Plan when they would otherwise lose their group health coverage or other rights under the Plan. This section does not fully describe COBRA coverage or other rights under the Plan. For additional information about your rights and obligations under the Plan and under federal law, you should review this SPD or contact the ExxonMobil Benefits Service Center at the telephone numbers or address listed under Benefits Administration in the Contacts for COBRA rights Under the ExxonMobil Medical Plan section.

You, your spouse and your family members may have other options available when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace.  By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs.  Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

Determination of Benefits Administration Entity to Contact:

  • Current ExxonMobil and XTO Employees or their covered family members should use ExxonMobil Benefits or contact the ExxonMobil Benefits Service Center;
  • Former Exxon, ExxonMobil or XTO Employees and their covered family members, who have elected and are participating through COBRA, contact the ExxonMobil COBRA Administration.

The contact information for each of these entities is as shown in the Contacts for COBRA Rights Under the ExxonMobil Medical Plan section.

What is COBRA coverage?

COBRA coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a qualifying event. Specific qualifying events are listed later in this section.  If a specific qualifying event occurs and any required notice of that event is properly provided to the ExxonMobil Benefits Service Center, COBRA coverage must be offered to each person losing coverage who is a qualified beneficiary.  You, your spouse, and your children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Certain newborns, newly adopted children, and alternate recipients under QMCSOs may also be qualified beneficiaries. This is discussed in more detail in separate paragraphs below. Under the Plan, qualified beneficiaries who elect COBRA coverage must pay the entire cost of COBRA coverage (employee plus employer portions) plus a 2% administrative fee.

Who is entitled to elect COBRA?

If you are an employee, you will be entitled to elect COBRA, if you lose your coverage under the Plan because either one of the following qualifying events happens:

  • Your hours of employment are reduced, or
  • Your employment ends for any reason other than your gross misconduct.

If you are the spouse of an employee, you will be entitled to elect COBRA if you lose coverage under the Plan because any of the following qualifying events happens:

  • Your spouse dies,
  • Your spouse's hours of employment are reduced,
  • Your spouse’s employment ends for any reason other than his or her gross misconduct,
  • You become divorced from your spouse.  Also, if your spouse (the employee) reduces or eliminates your group health coverage in anticipation of a divorce, and a divorce later occurs, then the divorce may be considered a qualifying event for you even though your coverage was reduced or eliminated before the divorce.

A person enrolled as the employee’s child will be entitled to elect COBRA if he or she loses coverage under the Plan because any of the following qualifying events happens:

  • The parent-employee dies,
  • The parent-employee's hours of employment are reduced,
  • The parent-employee's employment ends for any reason other than his or her gross misconduct, or
  • The child stops being eligible for coverage under the Plan as a child.

When is COBRA coverage available?

When the qualifying event is the end of employment or reduction of hours of employment or death of the employee, the Plan will offer COBRA coverage to qualified beneficiaries.  You need to notify the ExxonMobil Benefits Service Center of any other qualifying events.

For the other qualifying events (divorce of the employee resulting in the spouse or a child losing eligibility for coverage), a COBRA election will be available to you only if you notify and provide the appropriate forms to the ExxonMobil Benefits Service Center or ExxonMobil COBRA Administration within 60 days after the later of (1) the date of the qualifying event or (2) the date on which the qualified beneficiary loses (or would lose) coverage under the terms of the Plan as a result of the qualifying event. Current employees may give notice of qualifying events by logging onto ExxonMobil Benefits located on the Employee Connect intranet site. (Effective February 1, 2022, the internal EDA site has been retired, so all changes and notices of qualifying events from current or former employees should be made through the ExxonMobil Benefits Service Center, where forms are also available.)

Please note:  Notice is not effective until either a change is made on ExxonMobil Benefits or the proper information is received by the ExxonMobil Benefits Service Center. If notice is not submitted during the 60-day notice period, then all qualified beneficiaries will lose their right to elect COBRA.

Election of COBRA

Each qualified beneficiary will have an independent right to elect COBRA. Covered employees and spouses (if the spouse is a qualified beneficiary) may elect COBRA on behalf of all qualified beneficiaries, and parents may elect COBRA on behalf of their children. Any qualified beneficiary for whom COBRA is not elected within the 60-day election period specified in the Plan’s COBRA election notice WILL LOSE HIS OR HER RIGHT TO ELECT COBRA.

How long does COBRA coverage last?

COBRA coverage is a temporary continuation of Plan coverage that lasts between 18-36 months depending on the qualifying event.

You, your spouse and covered dependents may qualify for up to 18 months of continuation coverage, if you qualify due to one of the following qualifying events:

  • Your employment ends for any reason other than termination for gross misconduct;
  • Your work hours are reduced and you are no longer eligible to participate in the Plan ; or
  • Unpaid Leave of Absence.

Your covered spouse and covered dependent may qualify for up to 36 months of continuation coverage, if they qualify due to one of the following qualifying events:

  • You die;
  • You and your spouse get a divorce; or
  • An enrolled child no longer meets the definition of “child” under the terms of the Plan

Second qualifying event extension COBRA coverage

If your family experiences another qualifying event while receiving COBRA coverage as a result of the covered employee’s termination of employment or reduction of hours (including COBRA coverage during a disability extension as described above), the covered spouse and children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given the COBRA Administrator. This extension may be available to the spouse and any children receiving COBRA coverage if the employee or former employee dies, gets divorced, or if the covered child stops being eligible under the Plan as a child. This extension is not available under the Plan when a covered employee becomes entitled to Medicare after his or her termination of employment or reduction of hours.  This extension due to a second qualifying event is available only if you notify the correct benefits administration entity within 60 days of the date of the second qualifying event.

Disability extension of 18-month COBRA continuation coverage

The 18-month continuation period may be extended for you and your covered family members if the Social Security Administration determines that you or another family members, who is a qualified beneficiary, is disabled at any time during the first 60 days of continuation coverage.  If all of the following requirements are met, coverage for all family members who are qualified beneficiaries as a result of the same qualifying event can be extended for up to an additional 11 months (for a total of 29 months):

  • This extension is available only for qualified beneficiaries who are receiving COBRA coverage because of a qualifying event that was the covered employee’s termination of employment or reduction of hours.
  • The disability must have started at some time before the 61st day after the covered employee’s termination of employment or reduction of hours and must last at least until the end of the period of COBRA coverage that would be available without the disability extension (generally 18 months, as described above).
  • A copy of the Notice of Award from the Social Security Administration is provided to the COBRA Administrator [ExxonMobil Benefits Service Center] within 60 days of receipt of the notice and before the end of the initial 18 months of continuation coverage.
  • If the disabled qualified beneficiary elects continuation coverage, you must pay an increased premium of 150 percent of the monthly cost of Plan coverage that’s continued, beginning with the 19th month of continuation coverage.

Extension Due to Medicare Eligibility

Coverage may also last up 36 months for a covered spouse or covered dependent when loss of coverage is the result of a qualifying event that is the end of the employee’s employment or the reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event.  In this case, COBRA coverage under the Plan for qualified beneficiaries (other than the employee) may last until up to 36 months after the date of the employee’s Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA coverage for his spouse and children who lost coverage as a result of his termination can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). This COBRA coverage period is available only if the covered employee becomes entitled to Medicare within 18 months BEFORE termination or reduction of hours.

When COBRA Coverage Ends

COBRA coverage can end before the end of the maximum coverage period for several reasons:

  • The premium for your continuation coverage is not paid on time.
  • If after electing continuation coverage, you become covered by another group health plan, unless the plan contains any exclusions or limitations with respect to any pre-existing condition you or your coverage dependents may have.
  • If after electing continuation coverage, you first come eligible for and enroll in Medicare Part A, Part B or both.
  • You extend coverage for up to 29 months due to a qualified beneficiary’s disability and there has been a final determination by the Social Security Administration that the qualified beneficiary is no longer disabled. In this case, continuation coverage will end on the first of the month that begins more than 30 days after the final determination o by the Social Security Administration that the qualified beneficiary is no longer disabled. This will be the case only if the qualified beneficiary has been covered by continuation coverage for at least 18 months.
  • Exxon Mobil Corporation no longer provides group health coverage to any of its eligible employees or eligible retirees.

Are there other coverage options besides COBRA continuation coverage?

Yes.  Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a special enrollment period. Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.

More information about individuals who may be qualified beneficiaries during COBRA

A child born to, adopted by, or placed for adoption with a covered employee during a period of COBRA coverage is considered to be a qualified beneficiary provided that, if the covered employee is a qualified beneficiary, the covered employee has elected COBRA coverage for himself or herself.

The child's COBRA coverage begins when the child is enrolled in the Plan, whether through special enrollment or open enrollment, and it lasts for as long as COBRA coverage lasts for other family members of the employee. To be enrolled in the Plan, the child must satisfy the otherwise-applicable Plan eligibility requirements (for example, regarding age).

Alternate recipients under QMCSOs

A child of the covered employee who is receiving benefits under the Plan pursuant to a qualified medical child support order (QMCSO) received by ExxonMobil during the covered employee's period of employment with ExxonMobil is entitled to the same rights to elect COBRA as an eligible child of the covered employee.

Cost of COBRA coverage

A person who elects continuation coverage may be required to pay 102% of the cost to the Plan to maintain the coverage, unless the person is entitled to extended coverage due to disability. If the person becomes entitled to such extended coverage due to disability, the person may be required to contribute up to 150% of contributions after the initial 18-month's coverage until coverage ends. A person who elects continuation coverage must pay the required contributions within 45 days from the date coverage is elected retroactively to the date benefits terminated under the Plan.

If you have questions

Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below.  For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa.  (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.)  For more information about the Marketplace, visit www.healthcare.gov. 

Keep your plan informed of address changes

In order to protect your family's rights, you should keep ExxonMobil Benefits Service Center informed of any changes in your address as well as the addresses of family members. You should also keep a copy, for your records, of any notices you send.

Contacts for COBRA rights under the ExxonMobil Medical Plan

The following sets out the contact numbers based on your status under the ExxonMobil Medical Plan. FAILURE TO NOTIFY THE CORRECT ENTITY COULD RESULT IN YOUR LOSS OF COBRA RIGHTS.

If your status is not listed, call the ExxonMobil Benefits Service Center for help.

Employees and their covered family members:

Contact:

Address:

ExxonMobil Benefits Service Center

Phone: 1-800-682-2847

Monday – Friday 8:00 a.m. to 6:00 p.m. (U.S. Eastern Time)

Web: ExxonMobil Benefits

 

ExxonMobil Benefits Service Center

Address: P.O. Box 18025

Norfolk, VA 23501-1867

 

Former employees and family members who have elected and are participating through COBRA:

ExxonMobil COBRA Administration
Monday - Friday except certain holidays
8:00 a.m. to 7:00 p.m. (U.S. Central Time)

800-526-2720

Wageworks National Accounts Services
ExxonMobil COBRA Administration

P.O. Box 2968
Alpharetta, GA 30023-2968
Fax: 833-514-6416

 

 

Payments

Payment information for the ExxonMobil Employee Medical Plan - POS II A and POS II B options

Payment information for the ExxonMobil Employee Medical Plan - POS II A and POS II B options

You and the Plan share costs for covered treatment and services. You pay a fixed copayment for covered items such as a POS II network doctor's office visit and emergency room visits. For other types of care, you must satisfy an annual deductible and if applicable, an inpatient hospital deductible before the Plan starts paying. If you meet your annual out-of-pocket limit, the Plan pays 100% of most covered costs for the rest of that calendar year.

Coinsurance

You share in the cost of most covered expenses. For some services, such as hospital stays, the coinsurance will be a percentage of the cost of the covered service once the deductible has been satisfied. For other services, such as office visits to an EMMP POS II network provider, the copayment will be a fixed amount. For outpatient prescription drugs, there is a percentage copayment.

  • Fixed Copayment - A set amount you pay for covered services or treatments such as POS II doctor's office visits, certain related lab work and x-rays and hospital emergency room visits.
  • Percentage Coinsurance - This is your share of the cost of certain covered services or treatments, such as retail and home delivery prescriptions. For medical expenses other than outpatient prescription drugs, once you meet your deductible, you and the Plan share covered costs until you reach your out-of-pocket limit. Your share is your percentage coinsurance and is typically 20% or 40% for the EMMP POS II B and 25% or 45% for the EMMP POS II A depending on the providers you select and whether you live in a network or an out-of-network area. If you reach your annual out-of-pocket limit, the Plan pays 100% of most covered charges for you for the remainder of that calendar year.

Deductible

The deductible is the amount of covered expenses you must pay each calendar year before the Plan begins sharing the cost. Fixed amount copayments do not apply toward this amount. Outpatient prescription drug percentage copayments are not subject to nor do they count toward the annual deductible.

An additional hospital deductible applies to inpatient hospital services. For network hospitals, it is $200, and for non-network hospitals, the deductible is $400 for the EMMP POS II B and $300 for network hospitals and $600 for non-network hospitals for the EMMP POS II A.

The network deductible for medical, mental health and substance abuse expenses is currently $300 per year for an individual or $600 per year for a family for the EMMP POS II B. The non-network deductible is currently $400 per year for an individual or $800 per family for the EMMP POS II B. For the EMMP POS II A, the network deductible is $500 per year for an individual or $1,000 per year for a family, and the non-network deductible is $700 per year for an individual or $1,400 per year for a family.

There are several ways for a family to meet the deductible, including:

  • Two covered members of your family each meet the individual deductible.
  • One person meets the individual deductible and other members of your family have combined covered charges equaling an individual deductible.
  • No one person meets the family deductible, but the combined covered charges of all members of your family equal the family deductible.

Note: A family deductible cannot be met by only one person.

Charges that do not count toward the deductible

  • Charges above reasonable and customary levels.
  • Charges not covered by the Plan.
  • Charge of $500 for failure to pre-certify non-POS II network hospital stays.
  • POS II copayments.
  • Any outpatient prescription drug percentage copayments.
  • Charges for a private hospital room above the cost of the hospital's most common rate for a semiprivate room.

The deductible is applied to your claims in the order Aetna processes them, not when the provider collects the money from you. This means if you pay your deductible to one provider, it may not be applied to your annual deductible if Aetna has received and processed other claims first. Please be sure to always get an itemized bill from your provider and retain proof of your payment.

Adjustments to billed charges

When providers submit charges for payment, the following factors affect the amount that will be considered eligible for reimbursement. References to these limitations may appear on your Explanation of benefits (EOB). Contact Aetna Member Services for more information. A predetermination of benefits is strongly recommended before you incur any major or unusual expenses.

Reasonable and customary limits

Allowable amounts for services are determined by reasonable and customary (R&C) limits. Aetna’s reimbursement is based on a percentage of the Medicare allowable rate or on reasonable & customary limits for the geographical area as determined by Aetna.

R&C limits are based on data from several surrounding regions rather than one specific zip code. R&C limits apply only to non-network providers and services.

Example: A non-network provider charges $80 for a particular medical procedure, the reasonable and customary limit is $30, and the network provider charge is $25. Only $30 of the $80 charge will be allowed for payment. At the 60% benefit level for the EMMP POS II B option, the Plan will pay $18 and you will be responsible for paying $12 plus the $50 difference between the reasonable and customary limit and the non-network charge for a total of $62. If you used a Medical POS II provider, you would be charged only the network-negotiated rate of $25 at the 80% network reimbursement level for the EMMP POS II B option. You would have paid only $5 for the same service.

Incidental charges

Aetna's current standards for incidental charges are based on the Current Procedural Terminology (CPT) codes and guidelines authored and revised by the American Medical Association since 1966. CPT coding has become the most widely accepted format, by both government and private health insurance programs, in reporting physician procedures. CPT coding furnishes health care providers with a uniform system to accurately describe medical services. CPT coding guidelines explain that services commonly carried out as an integral component of a total service or procedure should not be reported as a separate procedure.

When a claim is submitted with multiple CPT codes, Aetna uses the CPT guidelines to determine whether the charges should be considered as separate costs or if the charges are typically considered as one cost. If Aetna determines that the charges should have been submitted together under one CPT code, the separate charges would be considered incidental to the primary procedure, and the amount allowed for reimbursement would be the amount for the primary procedure.

Example: Your provider administers an immunization and submits separate charges: one for the medication administered in the immunization and another for administering the shot. In most cases, an immunization should be submitted for payment using one CPT code. If it is submitted as two separate charges, Aetna uses the CPT guidelines and pays only one CPT code for the cost of the medication. The charge for administering the shot is considered to be incidental and is not paid.

Network providers have agreed to accept incidental charges reductions; however, you are responsible for incidental expenses when you use a non-participating provider or if you have signed a statement in the provider's office saying you will be responsible for incidental charges.

Multiple surgeries (including bilateral procedures)

When multiple surgeries are performed, a health industry standard calculation method is used to reflect the cost savings that accompany services rendered during the same operative session. The amount allowed for multiple procedures performed during the same operative session are as follows:

  • 100% for the primary procedure (typically the most complex procedure),
  • 50% for the second procedure, and
  • 25% for all subsequent procedures.

Example: You have foot surgery involving three toes on the same foot. The following chart explains how the multiple surgery calculation works if you use a network provider and assumes you are enrolled in the EMMP POS II B option.

A

B

C

D

E

Multiple Surgery Charges Submitted

Multi-Surgery %

Allowed Amount
(A X B)

Plan pays at 80%
(C X 80%)

You Pay
(C - D)

$80.00

100%

$80.00

$64.00

$16.00

$60.00

50%

$30.00

$24.00

$6.00

$40.00

25%

$10.00

$8.00

$2.00

$180.00

 

$120.00

$96.00

$24.00

Note: Network providers have agreed to accept multiple surgery reductions.

Example: You have foot surgery involving three toes on the same foot. The following chart explains how the multiple surgery calculation works if you use a non-network provider and assumes you are enrolled in the EMMP POS II B option. Procedures performed by a non-network provider are first subject to R&C limits. Those allowed amounts are further reduced by multiple surgery calculations.

A

B

C

D

E

Multiple Surgery Charges Submitted

Multi-Surgery %

Allowed Amount
(A X B)

Plan pays at 60%
(C X 60%)

You Pay
(A - D)

$80.00

100%

$80.00

$48.00

$32.00

$60.00

50%

$30.00

$18.00

$42.00

$40.00

25%

$10.00

$6.00

$34.00

$180.00

 

$120.00

$72.00

$108.00

 

Multiple imaging diagnostic tests

When certain multiple imaging diagnostic tests (e.g., MRIs, CT scans, ultrasounds) are performed on the same date of service, the amount allowed for reimbursement is 100% of the fee schedule (network) or reasonable and customary charge (non-network) for the first diagnostic test and 50% for subsequent tests ordered during a single encounter. 

No volitional control

Charges incurred if you had no volitional control in determining the provider will be reimbursed at 80% after the deductible for the EMMP POS II B and 75% after the deductible for the EMMP POS II A option, as though a network provider was used.

Non-network charges incurred through the use of a network facility for radiologists, anesthesiologists, pathologists, neonatologists, intensivists, will also be reimbursed at 80% after the deductible for the EMMP POS II B and 75% after the deductible for the EMMP POS II A option, as though a network provider was used. However, charges incurred for non-network radiologists, anesthesiologists, pathologists, neonatologists, intensivists, and hospitalists through non-network providers continue to be reimbursed as non-network.

Reimbursement to non-network providers will be limited to a reasonable and customary amount, rather than billed charges. In the event you are billed for any balance at a network facility or in an emergency situation at a non-network facility, by a non-network physician, you may submit the balance to Aetna for additional processing. Only amounts that are above the reasonable and customary fee schedule will be considered for additional reimbursement. Charges for services not covered by the Plan will not be reprocessed. If you do and you are enrolled in the automatic rollover process to your Health Care Flexible Spending Account (HCFSA), an overpayment from the HCFSA may result from the additional processing. You should contact Aetna to discuss options to return the overpaid HCFSA funds back into the account.

Out-of-Pocket limits

The annual out-of-pocket limit helps protect participants from high medical costs by increasing the reimbursement level when your payments for covered charges reach certain dollar limits. This limit is separate from the limits established for outpatient prescription drugs. In Medical POS II areas, the limit is different depending on whether you use network or non-network providers.

EMMP POS II A option - Annual Out-of-Pocket Limits

 

Your coinsurance

Until you reach your annual out-of-pocket limit of:

If:

Fixed copayment:

Percentage coinsurance*:

 

You live in a Medical POS II area and:

Use network providers for medical services

$40 (PCP) or $60 (Specialist)

25%

$4,500 per person
$9,000 per family unit

Do not use network providers for medical services

N/A

45%**

$18,000 per person
$36,000 per family unit

You do not live in a Medical POS II area and:

Use network providers for medical services

$40 (PCP) or $60 (Specialist)

25%

$4,500 per person
$9,000 per family unit

Do not use network providers for medical services

N/A

25%**

$13,500 per person
$27,000 per family unit

For precertified*** mental health care, you:

Use mental health network providers

$40

25%

$4,500 per person
$9,000 per family unit

Do not use network providers. Magellan's network, not Aetna's, is used for mental health and chemical dependency care.

N/A

45%** ***

$18,000 per person
$36,000 per family unit

* After the annual deductible and, if applicable, the inpatient hospital deductible is met.
** All non-network out-of-pocket expenses are subject to R&C limits.
*** Call Magellan for pre-certification. See Pre-certification in the Mental Health and Substance Abuse Care section for details.

EMMP POS II B option - Annual Out-of-Pocket Limits

 

Fixed
copayment:

Percentage coinsurance*:

Until you reach your annual out-of-pocket limit of:

If you live in a Medical POS II area and:

Use network providers for medical services

$25 (PCP) or $40 (Specialist)

20%

$3,000 per person
$6,000 per family unit

Do not use network providers for medical services

N/A

40%**

$15,000 per person
$30,000 per family unit

If you do not live in a Medical POS II area and:

Use network providers for medical services

$25 (PCP) or $40 (Specialist)

20%

$3,000 per person
$6,000 per family unit

Do not use network providers for medical services

N/A

20%**

$3,000 per person
$6,000 per family unit

If for precertified*** mental health care, you:

Use mental health network providers

$25

20%

$3,000 per person
$6,000 per family unit

Do not use network providers. Magellan's network, not Aetna's, is used for mental health and substance abuse care.

N/A

40%** ***

$15,000 per person
$30,000 per family unit

* After the annual deductible and, if applicable, the inpatient hospital deductible is met.
** All non-network out-of-pocket expenses are subject to R&C limits.
*** Call Magellan for pre-certification. See Pre-certification in the Mental Health and Substance Abuse Care section for details.

The family out-of-pocket limits work similarly, but the increased reimbursement then applies to you and all of your covered family members — not just the person who met the individual limit.

Using both network and non-network providers

If you live in a Medical POS II network area and you choose some network and some non-network providers, the annual out-of-pocket limit works this way:

  • Network and non-network out-of-pocket maximums must be met separately, unless you are eligible for Out of network area benefits.
  • Once your annual out-of-pocket total from a network provider reaches $3,000 for an individual (or $6,000 for a family) for the POS II B and $4,500 for an individual (or $9,000 for a family) for the POS II A, the Plan pays 100% of covered expenses when you use network providers. However, at this point, the Plan would still pay only 60% of covered expenses for non-network medical providers for the POS II B and 55% of covered expenses for non-network medical providers for the POS II A.
  • Once your out-of-pocket total from a non-network provider reaches $15,000 for an individual (or $30,000 for a family) for the POS II B and $18,000 for an individual (or $36,000 for a family) for the POS II A, the Plan pays 100% of covered medical expenses when you use a non-network provider.  

Expenses that do not count toward the out-of-pocket limit for either EMMP POS II option

  • Charges above reasonable and customary limits. 
  • Charges not covered by the Plan. 
  • Charge of $500 for non-compliance with medical pre-admission review process. 
  • Charge of $500 for failure to pre-certify inpatient non-network and out-of-network mental health or substance abuse services.
  • Copayments for outpatient prescription drugs.
  • Charges for a private hospital room greater than the cost of the hospital's most common rate for a semiprivate room.

No lifetime maximum

There is no maximum lifetime limit on benefits paid by the Plan with the exceptions of the $25,000 lifetime maximum on bariatric surgery.

Coordination of benefits

Coordination of benefits information for the ExxonMobil Employee Medical Plan - POS II A and POS II B options

If you are covered by more than one group medical plan (e.g., your spouse's employer's medical plan), to the extent possible, the Plan will attempt to coordinate benefits, with the intent not to reimburse more than 100% of the amount of the charges.

However, if you or a family member is covered under an individual medical plan (e.g., auto insurance, homeowners insurance personal injury protection, etc.), the coordination of benefits provision does not apply.

One of the plans covering you is the primary plan. Claims must be filed first with the primary plan. After the primary plan pays, file the claim with the secondary plan, including a copy of the bills and an explanation of benefits indicating the amount paid by the primary plan.

For example, if you, as an employee in this option, incur covered expenses, this Plan is primary and your spouse's plan is secondary. However, if your spouse incurs the expenses, his or her plan is primary and this Plan is secondary.

The primary plan always pays benefits first, without considering the other plan. The secondary plan then pays based on its provisions — up to the total allowable expenses covered by that plan or up to the total of all covered expenses.

Refer to Special provisions for coordination of benefits for the Prescription drug program.

Coverage of a child

When a child is covered under both parents' plans, the "birthday rule" is used: the plan of the parent whose birthday occurs earlier in the year is the primary plan. The other parent's plan is secondary. If both parents have the same birthday or the spouse's plan has not adopted the birthday rule, the Plan will consider the plan that has covered the child longer as primary.

There are special rules for children of divorced or separated parents. Unless specifically ordered otherwise by a court decree, the plan of the parent with custody, if he or she has not remarried, is primary and the plan of the non-custodial parent is secondary. If the parent with custody remarries, that parent's plan is primary, the stepparent's plan is secondary, and the plan of the non-custodial parent is last.

Payments

If payment for covered medical expenses should have been made under this Plan, but has been made under any other plan, any insurance company or other organization may be reimbursed an amount the Administrator-Benefits determines will satisfy the intent of coordination of benefits provisions. That amount will be considered to be benefits paid under this Plan and shall fully discharge any obligation to make such payments.

Incorrect computation of benefits

If you believe that the amount of the benefit you receive from the Plan is incorrect, you should notify Aetna in writing or contact Aetna Member Services.

If it is found that you or a beneficiary were not paid benefits you or your beneficiary were entitled to, the Plan or ExxonMobil will pay the unpaid benefits. See Claims and Administrative and ERISA information sections.

Recovery of overpayment

If the calculation of your or your beneficiary's benefit results in an overpayment, you or your beneficiary will be required to repay the amount of the overpayment to ExxonMobil or the Plan. The Plan Administrator may make reasonable arrangements with you for repayment, see Fraud against the Plan above.

Claims

Filing claims for the ExxonMobil Employee Medical Plan - POS II A and POS II B options

The Plan has contracted with Aetna to process claims for medical and mental health care. See Information Sources at the front of this SPD for the address and telephone number.

If you use network providers, they will file claims for you.

If your providers do not file claims for you, follow the instructions on the claim forms, which are available from the Employee Connect Intranet site, the ExxonMobil Family Internet site, and Aetna Member Services

If you have paid a provider's invoice in full and are submitting the invoice to Aetna yourself, please make sure that the claim form is completed and note the following:

  • Assignment Section — Do not complete this section or else payment will be made to the provider. Clearly indicate that you, not the provider, should receive the reimbursement.
  • Provider bill should clearly state that the bill is paid in full.

Aetna Member Services reviews and responds to your claim, usually within 30 days after the claim is received. If special circumstances delay the processing of your claim, you will receive written notice telling you why the claim is delayed and when you can expect to receive a decision.

If you need to file a claim:

  • Submit a completed claim form with necessary documentation within two years from the date the expense was incurred.
  • Aetna will send you an explanation of benefits (EOB) for each claim. The EOB shows what service was performed, how much the provider charged, and what the covered charge was under the Plan. It shows if a deductible or copayment was involved, as well as the calculation used to determine your benefit.
  • Keep the explanation of benefits for your records.
  • You can review your EOB by going to Aetna's website at www.aetna.com and following the instructions.

If you participate in the Pre-Tax Spending Plan Health Care Flexible Spending Account, Aetna processes any reimbursements due to you after processing your medical claim. This means that, in most cases, you will not need to file a separate pre-tax claim form for this account.

Outpatient prescription drug purchases from a non-network pharmacy must be filed with Express Scripts. See Short-term prescriptions in the Prescription Drug Program section for details.

Claim denial and reconsideration

If all or part of a claim is denied, Aetna Member Services will provide you with a written explanation supporting the denial and describing additional information, if any, that may improve the claim's likelihood of being approved. See the Administrative and ERISA information section in this SPD.

Right of reimbursement and subrogation

If your claim results from an accident or other injury that may be the fault of another party, the Plan will be subrogated to your (or your covered family member's) right of recovery against any party. In addition, you must reimburse any amount paid by the Plan that you recover from any responsible party. The Plan does not require reimbursement from any voluntary medical payments coverage you may carry under your motor vehicle or homeowner's insurance. The Plan will seek reimbursement/subrogation from coverage you may carry for uninsured/underinsured motorists. The Plan's right to subrogation and reimbursement also constitute an equitable lien against any payments by any responsible party made or payable to you, your covered family members, or anyone acting on your behalf, now or in the future, regardless of how the payments are characterized. For example, injury, illness or disability related payments that you receive for expenses such as past medical expenses, future medical expenses, attorneys' fees and expenses, or other costs or compensation, up to the full amount of all benefits paid by the Plan, must first be used to repay the Plan before any money goes to you. This creates a priority recovery right in favor of the Plan and is not subject to any application of a "make-whole" or "common fund" rule under local or other law. By accepting benefits from the Plan you are agreeing to this arrangement. The Plan's right to do this is called its right to impose an equitable lien or constructive trust.

You are required to promptly notify the Plan of any occurrence that may give rise to the Plan's reimbursement/subrogation rights and to cooperate with the Plan (or its representative) to secure these rights.

Please refer to the Plan's master documents for additional information on the Plan's reimbursement/subrogation rights.

Claims when traveling and working outside the United States

If you receive medical care when traveling or working outside the United States, generally you must pay the medical bills first. For reimbursement, submit an itemized bill along with a claim form. If the original bills are in a foreign language, you should obtain an English translation, if possible, of the services rendered. Covered expenses are payable at 75% for Option A or 80% for Option B subject to any applicable deductibles, copays and coinsurance. 

Please note, a dose or doses of prescription medication or injections given at the time of treatment in a doctor’s office is covered under the POS II Medical Plan as a part of the medical service rendered. Self-administered or take home use prescription medication may be covered under your prescription drug benefit and you must submit claims separately to Express Scripts for reimbursement.

Bills should be submitted in the appropriate foreign currency. The claims administrator will convert the bill to U.S. dollars as of the date of service.

Benefits Claims procedures

Filing claims for the ExxonMobil Employee Medical Plan - POS II A and POS II B options

Filing a claim

A claim occurs whenever a plan participant requests:

  • An authorization or referral from a participating provider or Aetna, or
  • Payment for items or services received.

You do not need to submit a claim for most of your covered healthcare expenses. However, if you receive a bill for covered services, the bill must be submitted promptly to Aetna for payment. Send the itemized bill for payment with your identification number clearly marked to the address shown on your ID card.

You must submit a claim form within two calendar years from the date of a service.

Aetna will make a decision on your claim using coverage policies and the definitions included in this document. For concurrent care claims, Aetna will send you written notification of an affirmative benefit determination. For other types of claims, you may only receive notice if Aetna makes an adverse benefit determination.

Adverse benefit determinations are decisions Aetna makes that result in denial, reduction, or termination of a benefit or the amount paid for it. It also means a decision not to provide a benefit or service.

Adverse benefit determinations can be made for one or more of the following reasons:

  • The individual is not eligible to participate in the Plan, or
  • Aetna determines that a benefit or service is not covered by the Plan because:
    • it is not included in the list of covered benefits,
    • it is specifically excluded,
    • a Plan limitation has been reached, or
    • it is not medically necessary.

Aetna will provide you with written notices of adverse benefit determinations within the time frames shown below. These time frames may be extended under certain limited circumstances. The notice you receive from Aetna will provide important information that will assist you in making an appeal of the adverse benefit determination, if you wish to do so. Please see Complaints and Appeals for more information about appeals.

A claim must be filed in writing to the appropriate claims administrator:

  • Aetna Member Services for medical, mental health and substance abuse-related claims, or
  • Express Scripts for non-network and coordination of benefit prescription drug claims.

Type of Claim

Response time

Urgent care claim: a claim for medical care or treatment where delay could:

  • Seriously jeopardize your life or health, or your ability to regain maximum function, or
  • Subject you to severe pain that cannot be adequately managed without the requested care or treatment

As soon as possible but not later than 72 hours.

Pre-service claim: a claim for a benefit that requires Aetna’s approval of the benefit in advance of obtaining medical care.

15 calendar days

Concurrent care claim extension: a request to extend a previously approved course of treatment.

 

Urgent care claim - as soon as possible, but not later than 24 hours, provided the request was received at least 24 hours prior to the expiration of the approved treatment.

Other claims - 15 calendar days

Concurrent care claim reduction or termination: a decision to reduce or terminate a course of treatment that was previously approved.

With enough advance notice to allow the plan participant to appeal.

Post-service claim: a claim for a benefit that is not a pre-service claim.

30 calendar days

Extensions of time frames

The time periods described in the chart may be extended.

For urgent care claims: If Aetna does not have sufficient information to decide the claim, you will be notified as soon as possible (but no more than 24 hours after Aetna receives the claim) that additional information is needed. You will then have at least 48 hours to provide the information. A decision on your claim will be made within 48 hours after the additional information is provided.

For non-urgent pre-service and post service claims: The time frames may be extended for up to 15 additional days for reasons beyond the Plan’s control. In this case, Aetna will notify you of the extension before the original notification time period has ended. If you fail to provide the information, your claim will be denied.

If an extension is necessary because Aetna needs more information to process your post service claim, Aetna will notify you and give you an additional period of at least 45 days after receiving the notice to provide the information. Aetna will then inform you of the claim decision within 15 days after the additional period has ended (or within 15 days after Aetna receives the information, if earlier). If you fail to provide the information, your claim will be denied.

Grievances and appeals

There are procedures for you to follow if you are dissatisfied with a decision that Aetna has made or with the operation of the Plan. The process depends on the type of complaint you have. There are two categories of complaints:

  • Quality of care or operational issues, and
  • Adverse benefit determinations.

Complaints about quality of care or operational issues are called grievances. Complaints about adverse benefit determinations are called appeals.

Appeals of Adverse Benefit Determinations by Aetna

Aetna will send you written notice of an adverse benefit determination. The notice will give the reason for the decision and will explain what steps you must take if you wish to appeal. The notice will also tell you about your rights to receive additional information that may be relevant to the appeal. Requests should be presented within 180 days from the date of the notice.

The Plan provides for two levels of appeal plus an option to seek External Review of the adverse benefit determination. You must complete the two levels of appeal before bringing a lawsuit. The following chart summarizes some information about how appeals are handled for different types of claims. In certain situations, the time frames shown may be extended.

Type of Claim

Level One Appeal

Level Two Appeal

Urgent care claim: a claim for medical care or treatment where delay could:

  • Seriously jeopardize your life or health, or your ability to regain maximum function, or
  • Subject you to severe pain that cannot be adequately managed without the requested care or treatment

36 hours

Review provided by Aetna personnel not involved in making the adverse benefit determination.

36 hours

Review provided by Appeals Committee.

Pre-service claim: a claim for a benefit that requires Aetna’s approval of the benefit in advance of obtaining medical care.

15 calendar days

Review provided by Aetna personnel not involved in making the adverse benefit determination

15 calendar days

Review provided by Appeals Committee.

Concurrent care claim extension: a request to extend a previously approved course of treatment.

Treated like an urgent care claim or a pre-service claim depending on the circumstances

Treated like an urgent care claim or a pre-service claim depending on the circumstances

Post-service claim: a claim for a benefit that is not a pre-service claim.

30 calendar days

Review provided by Aetna personnel not involved in making the adverse benefit determination.

30 calendar days

Review provided by Appeals Committee.

Effective January 1st, 2021, you may perform your appeal in writing or verbally. You may also choose to have another person (an authorized representative) make the appeal on your behalf by providing written consent to Aetna. However, in case of an urgent care claim or a pre-service claim, a physician familiar with the case may represent you in the appeal.

Depending on the type of appeal, you and/or an authorized representative may attend the Level 2 appeal hearing and question the representative of Aetna and any other witnesses, and present your case. The hearing will be informal. You may bring your physician or other experts to testify. Aetna also has the right to present witnesses.

If the Level One and Level Two appeals uphold the original adverse benefit determination, you may have the right to pursue an external review of your claim. See External review of Aetna’s final appeal determinations for more information.

External review of Aetna’s final appeal determinations

You may file a voluntary appeal for external review of any final appeal determination that qualifies.

You must complete the two levels of appeal described above before you can appeal for external review. Subject to verification procedures that may be established, your authorized representative may act on your behalf in filing and pursuing this voluntary appeal. You must request this voluntary level of review within 60 days after you receive the final denial notice.

If you file a voluntary appeal, any applicable statute of limitations will be tolled while the appeal is pending. The filing of a claim will have no effect on your rights to any other benefits under the Plan. However, the appeal is voluntary and you are not required to undertake it before pursuing legal action.

If you choose not to file for voluntary review, the Plan will not assume that you have failed to exhaust your administrative remedies because of that choice.

An external review is a review by an independent physician, with appropriate expertise in the area at issue, of claim denials and denials based upon lack of medical necessity, or the experimental or investigational nature of a proposed service or treatment. You may request a review by an external review organization (ERO) if:

  • You have received notice of the denial of a claim by Aetna, and
  • Your claim was denied because Aetna determined that the care was not medically necessary or was experimental or investigational, and

The claim denial letter you receive from Aetna will describe the process to follow if you wish to pursue an external review, and will include a copy of the Request for External Review Form.

You must submit the Request for External Review Form to Aetna within 60 calendar days of the date you received the final claim denial letter. The form must be accompanied by a copy of the final claim denial letter and all other pertinent information that supports your request.

Aetna will contact the External Review Organization that will conduct the review of your claim. The External Review Organization will select an independent physician with appropriate expertise to perform the review. In rendering a decision, the external reviewer may consider any appropriate credible information submitted by you with the Request for External Review Form, and will follow the applicable plan’s contractual documents and plan criteria governing the benefits. You will generally be notified of the decision of the External Review Organization within 45 days of Aetna’s receipt of your request form and all necessary information. An expedited review is available if your physician certifies (by telephone or on a separate Request for External Review Form) that a delay in receiving the service would jeopardize your health. Expedited reviews are decided within 3-5 calendar days after Aetna receives the request.

You are responsible for the cost of compiling and sending the information that you wish to be reviewed by the External Review Organization to Aetna. Aetna is responsible for the cost of sending this information to the External Review Organization.

No Assignment

The rights or benefits under this Plan may not be assigned by a participant or beneficiary. Any assignment will be treated as a direction to pay benefits to an assignee rather than as an assignment of rights.

Limited Authorization of Payments

To the extent allowed by the claims administrator, you may authorize your claims administrator to make payments directly to a health care provider for covered services. Further, even without such authorization, a claims administrator may make direct payments to a health care provider for covered services according to the claims administrator’s rules and procedures at the applicable time.

Authorization of payments to a health care provider or direct payments to a health care provider are not assignment of benefits. Even though you may authorize a health care provider to receive a payment or reimbursement of covered services and even though a claims administrator may pay a health care provider directly for payments or reimbursements of covered services, in no event will any such authorizations, payments or reimbursements to or on behalf of a health care provider cause the provider to become a plan participant or plan beneficiary (or assignee of a participant or beneficiary) under ERISA.

The provision in this SPD is deemed to be notice to any and all individuals to whom notice may be required, and no additional notice of the above provisions is needed for a provider or otherwise.

No Assignment of Rights and Benefits

Your rights and benefits under a medical option cannot be assigned, sold or transferred to any person, including your health care provider. For this purpose, your plan rights and benefits include, without limitation, the right to file an administrative appeal (internal and external), the right to sue following a denied administrative appeal and any other plan rights and benefits, whether actual or potential. Any purported assignments of rights and/or benefits under the Plan will be void and will not apply to the Plan. Further, a payment or reimbursement of covered services by a claims administrator to a health care provider will not waive the application of this provision. The application of this provision does not affect your right to appoint an authorized representative.

The provision in this SPD is deemed to be notice to any and all individuals to whom notice may be required, and no additional notice of the above provisions is needed for a provider or otherwise.

Health Care Provider Agreements Not Binding on the Plan

Sometimes your health care provider requests that you sign various agreements and other documentation as a condition of receiving health care services from the provider. Any agreement, assignment or other document executed by you and a health care provider (or executed by parties that include you and a health care provider but that do not include the plan administrator) are not binding on and will have no legal effect whatsoever on the Plan or any claims administrator. Further, a payment or reimbursement of covered services by a claims administrator to a health care provider (whether pursuant to an authorization or otherwise) will not waive the application of this provision.

Recovery of Excess Payments

Whenever payments have been made in excess of the amount necessary to satisfy the provisions of this plan, the Plan has the right to recover these excess payments from any individual (including you, your family members and a provider), insurance company or other entity or organization to whom the excess payments were made—or to withhold payment, if necessary, on future benefits until the overpayment is recovered. Whenever payments have been made based on inaccurate, misleading or fraudulent information provided by you or your family member, the Plan will exercise all available legal rights to recover the overpayment, including its right to withhold payment on future benefits or offset future benefits to the extent of the overpayment until the overpayment is recovered.

Claims fiduciary

The claims fiduciary is the person to whom all appeals are filed. The claims fiduciary is Aetna for medical mandatory appeals, Magellan for mandatory and voluntary appeals for all mental health and substance abuse appeals, and Express Scripts for all prescription drug mandatory and voluntary appeals. You may contact the claims fiduciary as follows:

Medical Mandatory and Voluntary Appeals:

Mandatory and Voluntary Mental Health and Substance Abuse Related Appeals:

Prescription Drug Mandatory and Voluntary Appeals:

Eligibility Appeals

Aetna
P. O. Box 14463
Lexington KY 40512

Magellan Healthcare
P.O. Box 2128
Maryland Heights,
Missouri, 63043

Express Scripts
P.O. Box 66587
St. Louis, MO 63166-6587
Attn: Administrative Appeals Dept.

Administrator-Benefits

ExxonMobil Medical Plan

P.O. Box 64111

Spring, TX 77387-4111

 

Note: For initial claims incurred before January 1, 2021, the Administrator-Benefits is the claims fiduciary for medical voluntary appeals.

Administrator-Benefits
ExxonMobil Medical Plan
P.O. Box 64111
Spring, TX 77387-4111

The Administrator-Benefits determination of eligibility is final and no mandatory or voluntary appeals are available, including decisions regarding whether a child age 26 or older meets the clinical definition of totally and continuously disabled. All decisions by Magellan or Aetna confirming a dependent no longer meets the clinical definition of totally and continuously disabled are final.

Federal Notices

Federal Notices for the ExxonMobil Employee Medical Plan - POS II A and POS II B options

Women's Health and Cancer Rights Act of 1998

If you have a mastectomy, at any time, and decide to have breast reconstruction, based on consultation with your attending physician, the following benefits will be subject to the same percentage co-payment and deductibles which apply to other plan benefits:

  • Reconstruction of the breast on which the mastectomy was performed,
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance,
  • Prostheses, and
  • Services for physical complications in all stages of mastectomy, including lymphedema.

The above benefits will be provided subject to the same deductibles, co-payments and limits applicable to other covered services.

If you have any questions about your benefits please contact Aetna Member Services.

Coverage for maternity hospital stay

Under federal law, the Plan may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section, or require that a provider obtain authorization from the Plan for prescribing a length of stay not in excess of the above periods. The law generally does not prohibit an attending provider of the mother or newborn, in consultation with the mother, from discharging the mother or newborn earlier than 48 or 96 hours, as applicable.

Administrative and ERISA information

Administration and ERISA information for the ExxonMobil Employee Medical Plan - POS II A and POS II B options

This section contains technical information about the Plan and identifies its administrator. It also contains a summary of your rights with respect to the Plan and instructions about how you can submit an appeal if your claim for benefits is denied.

The formal name of the Plan is the ExxonMobil Medical Plan.

Plan sponsor and participating affiliates

The ExxonMobil Medical Plan is sponsored by:

Exxon Mobil Corporation
5959 Las Colinas Blvd
Irving, TX 75039-2298

All of Exxon Mobil Corporation's divisions and most of the major U.S. affiliates participate in the ExxonMobil Medical Plan. A complete list of participating affiliates is available from the Administrator-Benefits upon written request. 

Certain employees covered by collective bargaining agreements do not participate in the Plan.

Basic Plan information

Plan name

ExxonMobil Medical Plan

This SPD describes the POS II A and B options.

Plan sponsor and participating affiliates

The ExxonMobil Medical Plan is sponsored by:

Exxon Mobil Corporation

5959 Las Colinas Blvd.
Irving, Texas 75039-2298

All of Exxon Mobil Corporation's divisions and most of the major U.S. affiliates participate in the ExxonMobil Medical Plan. A complete list of participating affiliates is available from the Administrator-Benefits upon written request.

Certain employees covered by collective bargaining agreements do not participate in the Plan.

Plan numbers

The ExxonMobil Medical Plan is identified with government agencies under two numbers: the Employer Identification Number, 13-5409005, and the Plan Number (PN), 538.

Plan administrators

Various aspects of the Plan are administered by various parties. The Administrator of the Plan shall have the full power to control and manage all aspects of the Plan in accordance with its terms and all applicable laws. The Administrator may allocate or delegate its responsibilities for the administration of the Plan to others and employ others to carry out or give advice with respect to its responsibilities under the Plan, including administrative services of the following nature: Claim Administration; Cost Containment; Financial; Banking and Billing Administration. Benefits provided under this plan are funded by ExxonMobil.

The Plan Administrator for the ExxonMobil Medical Plan is the Administrator-Benefits. The Administrator-Benefits is the Manager-Global Benefits Design, Exxon Mobil Corporation. You may contact the Administrator-Benefits at the following address. Legal process may be served upon the Administrator-Benefits c/o Exxon Mobil Corporation by serving the Corporation's Registered Agent for Service of Process, Corporation Service Company (CSC).

For appeals of eligibility or enrollment issues Administrator-Benefits P.O. Box 64111
Spring, TX 77387-4111

For service of legal process:

Corporation Service Co.
211 East 7th Street, Suite 620
Austin, Texas 78701-3218

Authority of administrator-benefits

The Administrator-Benefits (and those to whom the Administrator-Benefits has delegated authority) has the full and final discretionary authority to determine eligibility for benefits, to construe and interpret the terms of the Plan in its application to any participant or beneficiary, and to decide any and all claim appeals.

NOTE: Effective January 1, 2021, no appeals of eligibility will be available regarding decisions that a  dependent child no longer meets the clinical definition of totally and continuously disabled. All decisions by Magellan or Aetna confirming a dependent no longer meets the clinical definition of totally and continuously disabled are final.

Type of plan

The ExxonMobil Medical Plan is a welfare plan under ERISA providing medical benefits.

Plan year

The plan year is the calendar year.

Collective bargaining agreements

Eligibility for participation in the ExxonMobil Medical Plan by represented employees is governed by Collective Bargaining Agreements. A copy of the plan documents are available for examination upon written request.

Funding

The Plan is funded through contributions by the Employer and/or plan participants. Benefits under the EMMP are funded through participant and company contributions. Each year, ExxonMobil determines the rates of required participant contributions to the Medical Plan. These rates are based on past and projected plan experience. This plan is self-funded by ExxonMobil. (See Self-funded in the Key terms.)

Claims administrator

The claims administrator provides information about claims payment. The claims administrator is Aetna for medical claims, Magellan  for mental health and substance abuse claims and Express Scripts for prescription drug claims.

No implied promises

Nothing in this SPD says or implies that participation in the Plan is a guarantee of continued employment with the company.

Future of the Plan

The company reserves the right at any time and for any reason to terminate, suspend, withdraw, amend or modify the ExxonMobil Medical Plan or any of its provisions. If any changes are made in the future, you will be notified in accordance with legal requirements. In the event the ExxonMobil Medical Plan is terminated, you will have the right to elect continuation coverage, as described in the COBRA section of this guide, in any other health plan maintained by ExxonMobil or its controlled group

Key terms

List of key terms in the ExxonMobil Employee Medical Plan - POS II A and POS II B options

Barred employee

An employee who is covered by a collective bargaining agreement except to the extent participation is provided under such agreement.

Beneficiary

The person or entity that receives benefits when you die. The Plan provides a standard list of beneficiaries but you may name another beneficiary if you wish.

Benefit service

Generally, all the time from the first day of employment until you leave the company's employment. Excluded are:

  • Unauthorized absences,
  • Leaves of absence of over 30 days (except military leaves or leave under the Federal Family and Medical Leave Act),
  • Certain absences from which you do not return,
  • Periods when you work as a non-regular employee, as a special agreement person, in a service station, car wash, or car-care center operations, or
  • When you are covered by a contract that requires the company to contribute to a different benefit program, unless a special authorization credits the service.

Benefit predetermination

The review of proposed treatment or services before the expense is incurred to determine if, and to what extent, charges will be covered by the Plan. 

Case management

Review provided by medical professionals who consult with the patient and/or care providers to determine effective, cost-efficient ways to treat illnesses and utilize plan benefits.

Change in status

Life or work event that allows you to make changes to your elections during the plan year and outside of annual enrollment.

Child

A person under age 26 who is:

  • A natural or legally adopted child of an employee,
  • A grandchild, niece, nephew, cousin, or other child related by blood or marriage to an employee, or the spouse of an employee (separately or together) is the sole court appointed legal guardian or sole managing conservator,
  • A child for whom the employee has assumed a legal obligation for support immediately prior to the child's adoption by the employee or,
  • A stepchild of an employee.

Child does not include a foster child.

Claims administrator / processor 

Aetna Life Insurance Company, or affiliates, for claims other than outpatient prescription drugs, and Express Scripts for retail and home delivery of outpatient prescription drugs.

Copayments and coinsurance

Your share of covered services (including out-patient prescription drugs) and mental health and substance abuse expenses. For some services, such as hospital stays, the coinsurance will be a percentage of the cost of the service once the deductible has been satisfied. For other services, such as office visits to a POS II provider, the copayment will be a fixed amount. For outpatient prescription drugs there is a percentage copayment up to a per-prescription maximum.

Covered medical expense

  • For treatment of injury or sickness — a medically necessary expense incurred by a covered person that is not excluded from coverage, and
  • For treatment of mental health or substance abuse — a medically necessary expense that is certified in advance of actual treatment or an out-of-network inpatient treatment, that is provided according to the terms of the Plan, and that is not otherwise excluded from coverage.

Covered person 

Any person identified on the books of the employer as an employee, extended part-time employee, eligible family member, or survivor who:

  • Complies with the established enrollment requirements and makes any required contributions, and
  • Is not eligible for any other medical plan to which ExxonMobil contributes on their behalf.

Custodial care

Care that helps meet personal needs and daily living activities. Such care, even if ordered by a doctor and performed by a licensed medical professional such as a nurse, is not covered by the Plan.

Deductible

The amount of covered expenses you must pay each calendar year before the Plan begins sharing the cost. Fixed amount copayments do not apply toward this amount. Outpatient prescription drug copayments are not subject to nor do they count toward the annual deductible. The deductible is applied to your claims in the order Aetna processes them, not when the provider collects the money from you. This means if you pay your deductible to one provider, it may not be applied to your annual deductible if Aetna has received and processed other claims first. Please be sure to always get an itemized bill and retain proof of your payment, should you need to recover money from your provider.

Eligible employees

Most U.S. dollar-paid employees of Exxon Mobil Corporation and participating affiliates are eligible. The person must be classified on the employer's books and records as an employee.

The following are not eligible to participate in the Plan: leased employees as defined in the Internal Revenue Code, or special agreement persons as defined in the plan document. Generally, special-agreement persons are persons paid by the company on a commission basis, persons working for an unaffiliated company that provides services to the company, and persons working for the company pursuant to a contract that excludes coverage of benefits.

Eligible family members

Eligible family members are generally your:

  • Spouse,
  • A child who is described in any one of the following paragraphs (1) through (3):
  1. has not reached the end of the month during which age 26 is attained, or 
  2. is totally and continuously disabled and incapable of self-sustaining employment by reason of mental or physical disability, provided the child:
    (a) meets the Internal Revenue Service's definition of a dependent, and
    (b) was covered as an eligible family member under this Plan immediately prior to age 26 when the child's eligibility would have otherwise ceased, and    
    (c) met the clinical definition of totally and continuously disabled before age 26 and continues to meet the clinical definition through subsequent periodic reassessment reviews, or           
  3. is recognized under a qualified medical child support order as having a right to coverage under this Plan.

A child aged 26 or over who was disabled but who no longer meets the requirements of paragraphs two (2) above, ceases to be an eligible family member 60 days following the date on which the applicable requirement is not met.

Please note: An eligible employee's parents are not eligible to be covered.

Expatriate employees

Expatriate employees include service-oriented employees employed by non-U.S., non-participating employers who are temporarily working in the United States either under a visa that requires coverage by an ExxonMobil plan of such employee while in the United States or in an assignment in the United States and the terms of the assignment require proof of adequate medical coverage. Expatriate employees include regular employees working on an assignment outside the United States where the terms of the assignment require proof of adequate medical coverage.

Experimental or investigational

A medical treatment or procedure, or a drug, device, or biological product, is experimental or investigational if any of the following apply:

  • The drug, device, or biological product cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA), and approval for marketing has not been given at the time it is furnished; [Note: Approval means all forms of acceptance by the FDA].
  • Reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis, or
  • Reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product or medical treatment or procedure, is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis. Reliable evidence shall mean only:
  • Peer reviewed, published reports and articles in the authoritative medical and scientific literature,
  • The written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, or biological product or medical treatment or procedure, or
  • The written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or medical treatment or procedure.

Explanation of benefits (EOB)

The summary you receive after your claim is processed. Codes referred to on the EOB are explained on the document.

Extended-care facility 

An institution that meets the following criteria:

  • Provides 24-hour skilled nursing care and related services for the rehabilitation of injured or sick persons.
  • Has policies developed with the advice of and subject to the review of professional personnel to cover nursing care and related services.
  • Has a physician, a registered professional nurse or a medical staff responsible for the execution of such policies.
  • Requires that every patient be under the care of a physician and makes a physician available to furnish medical care in an emergency.
  • Maintains clinical records on each patient and has appropriate methods for dispensing drugs and biologicals.
  • Provides for periodic review by a group of physicians to examine the need for admissions, adequacy of care, duration of stay and the medical necessity of continuing stay of patients.
  • Is licensed pursuant to law or is approved by an appropriate authority as qualifying for licensing.
  • Does not include a place that is primarily for custodial care.

Extended part-time employee

An employee who is classified as a non-regular employee but who has been designated as an Extended Part-Time employee under his or her employer's employment policies relating to flexible work arrangements.

ExxonMobil Medical Plan

The Plan sponsored by Exxon Mobil Corporation which provides medical benefits for eligible employees and their family members.

ExxonMobil Retiree Medical Plan (EMRMP)

The Plan sponsored by Exxon Mobil Corporation which provides medical benefits for eligible retirees, survivors and their family members, and includes the Retiree Medical Plan (RMP) and the Medicare Primary Option (MPO) as parts.

Hospital

An institution which:

  • Is licensed as a hospital (if licensing is required),
  • Is operated pursuant to law for the care and treatment of sick and injured persons,
  • Provides 24-hour nursing care and has facilities both for diagnosis and surgery, except in the case of a hospital primarily concerned with the treatment of chronic conditions, and
  • Is not a hotel, rest home, nursing home, convalescent home, place for custodial care, or home for the aged.

For purposes of this definition, hospital shall also mean, with respect to treatment of substance abuse, a treatment facility, residential facility, or a clinic licensed or approved for such treatment by the appropriate authority for the jurisdiction in which the facility or clinic is located.

Medical necessity or medically necessary

  • Legal,
  • Ordered by a physician for medical treatment,
  • Reasonably required for the treatment or management of the condition for which it is ordered, and
  • Commonly and customarily prescribed by the United States medical community as treatment or management of the condition for which it is ordered.

Magellan may use its guidelines in an initial determination of whether a mental health service or supply is medically necessary.

When determining medical necessity, Clinical Policy Bulletins (CPBs) published by Aetna, the claims administrator may be used.

CPBs are based on objective, credible sources, such as the scientific literature, guidelines, consensus statements and expert opinions. These CPBs may be found on the Aetna website at https://www.aetna.com/health-care-professionals/clinical-policy-bulletins.html

Medical pre-certification 

Certification obtained prior to a hospital inpatient stay (including mental health and substance abuse) to give notice of inpatient admission and the proposed care. If you do not pre-certify a non-POS II provider or non-Mental Health PPO hospital stay, you will be responsible for the first $500 of eligible expenses. Refer to the Aetna National Precertification list for details of services requiring precertification.

Medical POS II (point of service)

A network of established physicians, hospitals and other medical care providers whose credentials have been screened according to Aetna's standards and who have agreed to provide their services at negotiated rates. The POS II option is a network specifically selected by the Plan — it is part of Aetna's Choice® POS II. This network is referred to in this SPD as the Medical POS II.

Mental health condition 

Neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or behavioral disorder or disturbance with a diagnosis code from the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (5th ed. 2013) (DSM-V), or its successor publication, and which is appropriately treated by the Mental Health Network. Such a condition will be considered a mental health condition, regardless of any organic or physical cause or contributing factor.

Mental health preferred provider organization (MHPPO)

A nationwide network of providers and facilities whose credentials have been screened by Magellan and who provide treatment for mental health and substance abuse conditions at negotiated rates.

Mental health provider 

A person, including a psychiatrist, psychologist, psychiatric nurse or social worker, therapist, or other clinician with at least a master's degree, who provides inpatient or outpatient treatment for a mental health condition, who is licensed in the state of practice and who is acting within the scope of that license (if applicable). If the person is not subject to a licensing requirement, the person must provide treatment consistent with that which would be provided by the type of providers listed above.

Network

Providers and facilities that participate in the Medical POS II network or Mental Health PPO network available under the EMMP POS II option.

Non-network

Providers and facilities located in the Medical POS II or Mental Health PPO network areas, but which do not participate in a network available under this Plan.

Nurse

A registered graduate nurse (RN), a licensed vocational nurse (LVN), or a licensed practical nurse (LPN).

Out-of-network area

Geographic areas that do not fall within the Medical POS II or Mental Health PPO network.

Out-of-pocket limit 

The amount of covered medical expenses you pay in one year before the Plan begins paying 100%. The EMMP POS II A and B options have different out-of-pocket limits. The out-of-pocket limit is accumulated in the order Aetna processes the claims. After the out-of-pocket limit is reached, the Plan pays 100% of most covered expenses for the remainder of that  Calendar year. Certain expenses that you pay do not apply to the out-of-pocket limit. The annual deductible and your percentage copayments for eligible expenses apply to the out-of-pocket limit. The following charges do not apply to the out-of-pocket limit:

  • Charges above reasonable and customary limits.
  • Charges not covered by the Plan.
  • Charge of $500 for non-compliance with medical pre-admission review process.
  • Charge of $500 for failure to pre-certify inpatient non-network and out-of-network mental health or substance abuse services.
  • Copayments for outpatient prescription drugs.
  • Charges for a private hospital room above the cost of the hospital's most common rate for a semiprivate room.

Outpatient prescription drug

A prescription drug or medicine obtained through either a retail pharmacy or through a mail service prescription program (including insulin and associated diabetic supplies if acquired through a prescription). A prescription drug or medicine, including injections, obtained or administered in a physician's office or in a hospital are not considered outpatient prescription drugs.

Physician

Physician means a person acting within the scope of his or her license and holding the degree of Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (O.D.), or Doctor of Chiropractic (D.C.), or who is duly licensed as an Orthoptist, a Physician Assistant or Nurse Practitioner. Primary Care Physician means a Physician engaged in general practice, family practice, internal medicine, pediatrics or obstetrics/gynecology who provides basic health services to covered persons.

Pre-determination

A written pre-determination request will result in a detailed response as to whether a treatment or service is covered under the Plan and whether the proposed cost is within reasonable and customary limits, thus ensuring all parties are aware of the financial consequences, providing all circumstances described in the request remain unchanged. Please note that a pre-determination, either verbal or written, is not a guarantee of payment, as claims are paid based on the actual services rendered and in accordance with Plan provisions.

Primary participant 

The term primary participant refers to the participant whose identification number is used. The primary participant is the employee, retiree, survivor or an individual who elected COBRA coverage. Covered family members use the primary participant's identification number to access all medical benefits.

Private duty nursing

Continuous, substantial and complex in-home nursing care requiring services that can only be provided by a licensed medical professional, has been prescribed by a treating physician, provided on an hourly basis and is determined to be medically necessary. Private duty nursing provides more individual and continuous skilled care than the care that can be provided in a skilled nurse visit through a home health agency.

Qualified Medical Child Support Order 

A Qualified Medical Child Support Order (QMCSO) is a court decree under which a court order mandates health coverage for a child. A QMCSO must include, at a minimum:

  • Name and address of the employee covered by the health plan.
  • The name and address of each child for whom coverage is mandated.
  • A reasonable description for the coverage to be provided.
  • The time period of coverage.
  • The name of each health plan to which the order applies.

You may obtain, without charge, a copy of the Plan's procedures governing QMCSO determinations by written request to the Administrator-Benefits.

Reasonable and customary limits

Allowable amounts for services are determined by reasonable and customary (R&C) limits. Aetna uses the industry-wide standard for R&C limits. Aetna’s network is based on a percentage of the Medicare allowable rate or on reasonable & customary limits for the geographical area as determined by Aetna.

Regular employee 

An employee of a participating employer, whether or not the person is a director, who, as determined by the participating employer, regularly works a full-time schedule, and is not employed on a temporary basis. The definition includes a person who regularly works a full-time schedule but who, for a limited period of time, is approved for a part-time regular work arrangement under the participating employer's work rules relating to part-time work for regular employees.

Retiree

Generally, a person at least 55 years old who retires as a regular employee with 15 or more years of benefit service or someone who is retired by the company and entitled to long-term disability benefits under the ExxonMobil Disability Plan after 15 or more years of benefit service, regardless of age.

Retirees who have been rehired as regular or non-regular employees are not eligible for the ExxonMobil Retiree Medical Plan.

Retiree Medical Plan

One of the parts of the ExxonMobil Retiree Medical Plan which provides medical benefits for Pre-Medicare eligible retirees, survivors and their family members. It includes the Retiree Medical POS II and other self-funded options.

Room and board

Room, board, general-duty nursing and any other services regularly furnished by the hospital as a condition of being hospitalized. It does not include professional services of physicians or private-duty nursing.

Self-Funded

Type of plan in which the employer takes on most or all of the cost of benefit claims and the insurance company manages the payments.

Spouse; marriage

All references to marriage shall mean a marriage that is legally recognized under the laws of the state or other jurisdiction in which the marriage takes place, consistent with U.S. federal tax law. All references to a spouse or a married person shall refer to individuals who have such a marriage.

Surgical procedure 

This term refers to the following:

  • A cutting operation.
  • Suturing a wound.
  • Treating a fracture.
  • Reduction of a dislocation.
  • Radiotherapy (excluding radioactive isotope therapy) if used in lieu of a cutting operation for removal of a tumor.
  • Electrocauterization.
  • Diagnostic and therapeutic endoscopic procedures.
  • Injection treatment of certain conditions.
  • Laser treatments.

Note: Minor procedures such as biopsies or removal of moles or warts, even if performed in a doctor's office, are considered surgery.

Survivor/ surviving spouse

A surviving unmarried spouse or child of a deceased ExxonMobil regular employee or retiree.

Trainee 

An employee who is classified as a non-regular employee, but who has been characterized as a Trainee and has graduated from high school.  This definition does not apply to individuals not on the U.S. payroll who are in the U.S. on a trainee assignment and are not on an expatriate assignment into the U.S. 

Urgent care 

Conditions or services that are non-preventative or non-routine and needed in order to prevent the serious deterioration of a person's health following an unforeseen illness, injury or condition. Urgent care includes conditions that could not be adequately managed without immediate care or treatment but do not require the level of care provided in an emergency room. Treatment of such a condition outside of an emergency room is paid according to the network status of the provider or facility. For example, out-of-network urgent care furnished by an out-of-network provider or facility is reimbursed at the out-of-network benefit level.

Year

Calendar year, January 1 through December 31.

2022 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
2022 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

 

Reasonable and Customary charges apply

100% coverage

 

Reasonable and Customary charges apply

 

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. 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
2022 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

$400 / $800

$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

 

Reasonable and Customary charges apply

100% coverage

 

Reasonable and Customary charges apply

 

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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