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Aetna Select Network Only Option

Summary plan description of the ExxonMobil Retiree Medical Plan - Aetna Select Network Only option as of January 1, 2022

This is your guide to the benefits available through the ExxonMobil Retiree Medical Plan Aetna Select Network Only option (Aetna Select, or the Plan). 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 in this guide.

Tips for New Plan Participants

  • Keep this guide where you can easily refer to it.
  • Keep your ID card(s) in your wallet.
  • Enter your Primary Care Physician’s name and number in your telephone.
  • Emergencies are covered anywhere, 24 hours a day. See In case of medical emergency for emergency care guidelines.
  • All non-emergency specialty and hospital services require a prior referral from your Primary Care Physician.

Important information

THIS IS NOT AN INSURED BENEFIT PLAN. THE BENEFITS DESCRIBED IN THIS GUIDE OR ANY RIDER ATTACHED HERETO ARE SELF-FUNDED BY EXXONMOBIL WHICH IS RESPONSIBLE FOR THEIR PAYMENT. AETNA LIFE INSURANCE COMPANY (AETNA) PROVIDES CLAIM ADMINISTRATION SERVICES TO THE PLAN, BUT AETNA DOES NOT INSURE THE BENEFITS DESCRIBED. 

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, govern.  Part 4 of the EMRMP is intended as the sole document that sets out the benefits provided through the Aetna Select option. You may obtain copies of these documents by making a written request to the Administrator-Benefits. ExxonMobil reserves the right at any time to change in any way or terminate any benefit.

This guide covers the major features of the Aetna Select administered by Aetna Life Insurance Company, effective January 1, 2022. The plan description has been designed to provide a clear and understandable summary of the Plan, and with the Provider directory serves as the Summary Plan Description (SPD) required for plans subject to ERISA.

The Aetna Select option administered by Aetna Life Insurance Company is 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. This option is governed by federal laws, not state insurance laws.

Information sources

Information sources for the Retiree Medical Plan - Aetna Select option works

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

For claims administration:

Contact Aetna for medical/surgical 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 pre-determinations, and providers participating in the Aetna Select network. Aetna also provides hospital pre-certification 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 pre-determinations, 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 pre-certification review for certain pharmacy services, medications, and equipment. Ask to speak to a Therapeutic Resource Center (TRC) pharmacist for ongoing consultation and referral services.

For benefits administration:

References to Benefits Administration throughout this SPD pertain to the ExxonMobil Benefits Service Center. Contact the Benefits Services Center for benefits administration information, including enrollment and eligibility inquiries.

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
PO Box 14463,
Lexington, KY 40512

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: www.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

To visit Express Scripts website: www.express-scripts.com.

ExxonMobil Benefits Service Center
Monday – Friday 8:00 a.m. to 6:00 p.m.
(U.S. Eastern Time), except certain holidays Toll-Free: 1-800-682-2847
or 800-TDD-TDD4 (833-8334) for hearing impaired

ExxonMobil Benefits Service Center
P. O. Box 18025
Norfolk, VA 23501-1867

ExxonMobil sponsored sites - Access to plan-related information including claim forms for retirees, survivors, and their family members.

  • ExxonMobil Family, the Human Resources Internet Site — Can be accessed by everyone at www.exxonmobilfamily.com.
  • Retiree Online Community Internet Site — Can be accessed by retirees and survivors only at www.emretiree.com.
  • ExxonMobil Benefits Service Center Internet Site — Can be accessed by everyone at www.exxonmobil.com/benefits.

Plan at a glance

Plan at a glance on the Retiree Medical Plan - Aetna Select Option

The Plan covers medically necessary and preventive treatment, care and services, that are not otherwise excluded.

The Plan participants have access to a network of participating Primary Care Physicians (PCPs), specialists and hospitals that meet Aetna’s requirements for quality and service. These providers are independent physicians and facilities that are monitored for quality of care, patient satisfaction, cost-effectiveness of treatment, office standards and ongoing training.

Each participant in the Plan must select a Primary Care Physician (PCP) when they enroll.  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.  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 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

Network providers file claims for you. You are responsible for ensuring that claims for non-network care are filed.  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 Aetna Select 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  Aetna Select 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 Aetna Select option. See Benefit summary.

Eligibility and enrollment

Eligibility and enrollment details for the ExxonMobil Retiree Medical Plan - Aetna Select option

Most U.S. retirees, survivors and their eligible family members who reside in the Aetna Select service area are eligible to participate. The service area is determined by the retiree's home address zip code.

Generally you are eligible if:

  • You are a retiree.
  • You are a survivor/surviving spouse, which means an eligible family member of a deceased employee or retiree.
  • You are a Long Term Disability Retiree and are not eligible for Medicare Part A or B.
  • You are a Long Term expatriate with U.S. Company-sponsored green card (also called permanent resident visas or PRVs) who retires/retired at the end of your current U.S. assignment on or after July 1, 2020 and remain in the U.S. with a valid PRV. If you choose not to enroll, there will be no opportunity to enroll at a later point in time during retirement.

You are not eligible if:

  • You participate in any other employer medical plan to which ExxonMobil contributes.
  • You are eligible for coverage under the ExxonMobil Medical Plan.
  • 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.
  • You are eligible for Medicare as your primary plan.

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 (even if Medicare eligible). 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 Benefits Service Center.
  • Your totally and continuously disabled child(ren) aged 26 or over incapable of self-sustaining employment by reason of mental or physical disability that occurred prior to otherwise losing eligibility,  meets the Internal Revenue Service's definition of a dependent, and is not eligible to be enrolled in Medicare as their primary medical plan.
  • A child or spouse of a Medicare-eligible retiree or survivor enrolled in the Medicare Supplement Plan or Medicare Primary option, as long as that spouse or child (aged 26 or over) is not eligible for Medicare.
  • If you, your dependent, or your spouse become eligible for Medicare, you need to give notice of this event to the ExxonMobil Benefits Service Center (EMBSC) for purposes of benefits coordination.

Effective January 1, 2019, a totally and continuously disabled child over age 26 of a retiree, deceased retiree, or deceased employee who is entitled to be enrolled in Medicare as their primary medical plan is not eligible for coverage under the ExxonMobil Retiree Medical Plan, or any other ExxonMobil health plan available to retirees (such as Dental and Vision coverage).

More complete definitions of Eligible Family Members and Child appear in the Key Terms section of this guide.

Suspended retiree

A person who becomes a retiree due to incapacity within the meaning of the ExxonMobil Disability Plan and who begins long-term disability benefits under that plan, but whose benefits stop because the person is no longer incapacitated, is a suspended retiree and not eligible for coverage until the earlier of the date the person:

  • Reaches age 55, or
  • Begins his or her benefit under the ExxonMobil Pension Plan at which time the person is again considered a retiree and may enroll.

The family members of a deceased suspended retiree will be eligible for coverage under this Plan only after the occurrence of the earlier of the following:

  • The date the suspended retiree would have attained age 55, or
  • The date a survivor/surviving spouse begins receiving a benefit due to the suspended retiree's accrued benefit from the ExxonMobil Pension Plan.

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:

  • Individual Only (Retiree, Spouse, Surviving Spouse, Surviving Child),
  • Retiree and spouse,
  • Individual and child(ren), or
  • Retiree and family.

There are also classes of coverage for surviving spouses and family members of deceased employees and retirees, and spouses and family members of retirees covered by the Medicare Primary Option and the Medicare Supplement Plan option.

Each class of coverage described in this section has its own contribution rate. Retirees and survivors receiving monthly benefit checks from ExxonMobil pay by deductions from these checks on an after-tax basis. Other retirees or survivors and participants with continuation coverage pay by check or by monthly draft on their bank account.

Double coverage

No one can be covered more than once in the Retiree Medical Plan.  You and a family member cannot both enroll as retirees and elect coverage for each other as eligible family members. If you and your spouse or adult child are both retirees, you may both be eligible for coverage. Each of you can be covered as an individual retiree, or one of you can be covered as the retiree 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.

How to enroll

Retirees have three opportunities to enroll in the ExxonMobil Retiree Medical Plan:

  • At retirement, or
  • Upon loss of other employer coverage, or
  • When first eligible to be enrolled in Medicare as your primary plan.

There is no opportunity to enroll yourself in the Plan at any other time, including during annual enrollment.

Eligible family members may be added to your coverage at one of the three enrollment opportunities listed above or if you experience a change in status. Eligible family members cannot be added to your coverage at any other time, including during annual enrollment.

All enrollments must be completed within 60 days of the enrollment event. Coverage is effective the first of the month following receipt of your election by the ExxonMobil Benefits Service Center (EMBSC), 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.

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 required time period, coverage for the family members will be cancelled the first of the following month. If you enroll family members who are not eligible for the Plan, for instance, by covering children who do not meet the eligibility requirements, you may lose eligibility for yourself and your family under all ExxonMobil health plans.

You may cancel your coverage at any time; however, you may not re-enroll unless you experience a corresponding change in status or you wait until one of the enrollment opportunities listed above. Coverage will be terminated at the end of the month in which your elected change has been received.

Eligible family members may also be removed from your coverage at any time; however, they may not be reinstated unless you experience a corresponding change in status or you wait until one of the enrollment opportunities listed above.

Note: You are required to remove family members who are no longer eligible for coverage at the time of loss of eligibility. To remove an ineligible family member (a divorced spouse for example) you are required to notify the Benefits Service Center within 60 days of the loss of eligibility or your ineligible family members will not be entitled to COBRA benefits continuation. If you fail to notify the Benefits Service Center, you may also lose eligibility for yourself and your family under all ExxonMobil health plans. In addition, you will be required to reimburse the Plans for any claims paid after the loss of eligibility for any ineligible person(s).

Post-Retirement changes in status

If this event occurs...

You may...

Marriage

Add your spouse and any new eligible family members.

Divorce – Retiree and spouse enrolled in ExxonMobil health plans

You required to remove coverage for your former spouse and any stepchild(ren).

Divorce – Retiree loses coverage under spouse’s health plans

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

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

Add new eligible family members.

Death of a spouse

You must remove coverage for any stepchild(ren) unless you are their court appointed legal guardian or sole managing conservator.

You or a family member loses eligibility under another employer's group health plan

Enroll yourself and add eligible family members.

You lose eligibility because of a change in your employment status, e.g., retiree to rehired employee.

Your Retiree Medical Plan participation will automatically be suspended at the date of rehire and you will be covered under the ExxonMobil Medical Plan.

You gain eligibility because of a change in your employment status, e.g., employee to retiree.

Enroll yourself and add eligible family members.

You change your residence affecting your eligibility to participate in your elected Retiree Medical Plan option

Change your Retiree Medical Plan option.

You or your spouse become entitled to enroll in Medicare as your primary plan

You or your spouse lose eligibility under the Retiree Medical Plan options but may enroll in the Medicare Primary Option.

Your disabled child (aged 26 or over) becomes entitled to enroll in Medicare as their primary plan, even if your child is not actually enrolled in Medicare

You must remove coverage for your child.

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

Add new eligible family members.

Changes at retirement

If you were enrolled in the ExxonMobil Medical Plan, your enrollment and your covered family members will transfer to the ExxonMobil Retiree Medical Plan. If you were enrolled in the Aetna Select option as an employee, you will maintain claims, deductibles and out of pocket history as a retiree. However, as a retiree, you will pay your contributions on an after-tax basis via payroll deduction (if eligible), check, or bank draft.

If you are not covered by a medical plan to which ExxonMobil contributes and would like to enroll in the ExxonMobil Retiree Medical Plan, or if you would like to change your Retiree Medical Plan option, you may must do so within 60 days of your retirement date. Coverage is effective the first of the month following receipt of your election by the 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 Retiree Medical Plan option to another available option. Changes elected during annual enrollment take effect the first of the following year.

Retirees cannot enroll in health benefits or add eligible family members during annual enrollment. Eligible family members can only be added to your coverage at one of the enrollment opportunities listed above or if you experience a corresponding change in status.

Do not wait to remove a family member who loses eligibility; they should be removed as soon as their eligibility is lost. For consequences for covering an ineligible family member, see Loss of Eligibility.

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.

Changing your coverage

Changing your coverage on the Retiree Medical Plan - Aetna Select option

Other situations that may affect your coverage

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 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 medical 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.

Transfer or change residence

If you move from one location to another, and the move makes you no longer eligible for the selected Retiree Medical Plan option (e.g., move out of the Aetna Select service area), you may change from your current Plan option to one that is available in your new location.

Addition or improvement of plan options

If a new Retiree 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 plan option providing similar coverage or to drop 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 Aetna Select options.  You may also discontinue medical coverage altogether. 

If a covered family member lives away from home

Coverage depends on whether the plan option you are enrolled in as a retiree 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 or your covered spouse become eligible for Medicare

If you are a retiree, you and your family members who are not eligible for Medicare participate in the Retiree Medical Plan. When you (as a retiree) or a covered spouse of a retiree becomes eligible for Medicare as your primary plan, you or your spouse will no longer be eligible for the POS II, Aetna Select and Cigna OAPIN options in the Retiree Medical Plan, but you or your spouse may be eligible to enroll in the Medicare Primary Option (MPO). If you fail to enroll in the MPO when first eligible, then you will not be able to enroll at a later time without proof of having other employer provided medical coverage immediately prior to enrollment. 

If you die

If you die while enrolled, your covered eligible family members can continue coverage through the Retiree Medical Plan. Eligibility continues for your spouse until your spouse remarries, or becomes eligible for Medicare.  Upon eligibility for Medicare as their primary plan, your spouse can continue coverage through the Medicare Primary Option.

Children of deceased retirees may continue participation as long as they are an eligible family member and are not eligible to be enrolled in Medicare as their primary medical plan. If your surviving spouse remarries, eligibility for your stepchildren also ends. Special rules may apply to family members of individuals who become retirees due to disability. See Suspended Retiree below.

If you become a suspended retiree

If you are a retiree and you would otherwise lose coverage because you have become a suspended retiree under the ExxonMobil Disability Plan, you may continue coverage for yourself and all your family members who were eligible for Medical Plan participation before you became a suspended retiree for either 12 or 18 months.

Coverage continues for 12 months from the date coverage would otherwise end if you received transition benefits under the ExxonMobil Disability Plan.

However, if you did not receive transition benefits under the ExxonMobil Disability Plan, coverage continues for 18 months from the date coverage would otherwise end. The cost of this continued coverage is 102% of the combined participant and company contributions.

When coverage ends

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 die,
  • You elect not to participate,
  • A family member ceases to be eligible (for example, a child reaches age 26),
  • You become a suspended retiree,
  • You are no longer eligible for benefits under this Plan (e.g. as a surviving spouse, you re-marry),
  • You, as a retiree, or your eligible family member becomes eligible for Medicare and for the Medicare Primary Option,
  • Your former employer discontinues participation in the Plan,

OR

The date:

  • You do not make any required contribution,
  • You are rehired by Exxon Mobil Corporation after retirement as an employee or non-regular employee,
  • The Retiree Medical Plan ends,
  • 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 Benefits Service Center when your enrolled spouse or family member is no longer eligible for coverage. To end coverage for your spouse or family member when no longer eligible, contact the ExxonMobil Benefits Service Center. If you do not complete your change within 60 days, any contributions you make for ineligible family members will not be refunded.

  • Could not afford to pay premiums during the grace period; or
  • Need for prescription medicines or other plan services.
  • The ExxonMobil Benefits Service Center is the appointed designee reviewing reinstatement requests and making good cause determinations

    Cancellation and Reinstatement Process effective January 1, 2022

    Cancellation of EMRMP due to non-payment of premiums:

    Cancellations due to non-payment of plan premiums will be prospective, with a 3 month grace period starting 1st month of unpaid contributions, so participants may pay owed contributions within that grace period to avoid cancellation. For example, if retiree has not made payments for their January, February, and March premiums during that 3 month timeframe, coverage will be cancelled effective April 1.

    How to Avoid Cancellation due to Nonpayment of Premiums

    The ExxonMobil Benefits Service Center (EMBSC) offers the convenience of paying your benefits premiums through either direct debit or deduction from your monthly pension payment (if applicable). To set up either payment method, visit www.exxonmobil.com/benefits:

    Direct Debit: click on “Health & Welfare,” then on “More,” and lastly on “Update Premium Payment Information.”

    Monthly Pension Payment Deduction: click on “Library,” then on “Documents & Forms,” then on “Forms,” and lastly on “Pension Deduction Authorization Form. Return your completed form to the shown address.

    For assistance, call the EMBSC at 1-800-682-2847

    Reinstatement of EMRMP:

    Once your coverage has been terminated, you can request to be reinstated upon showing good cause.  The EMRMP (or its designee) will review requests for reinstatements on a case-by-case basis. If an individual has been involuntarily disenrolled for failure to pay plan premiums, they may request reinstatement no later than 60 calendar days following the effective date of disenrollment.

    Reinstatement for good cause will occur only when:

    1. Reinstatement is requested no later than 60 calendar days following the effective date of disenrollment (in the example, 60 days from April 1)
    2. The individual has been determined to meet the criteria specified below (i.e., receives a favorable determination); and
    3. Within three (3) months of disenrollment for nonpayment of plan premiums, the individual pays in full the plan premiums owed at the time they were disenrolled (in the example, within 3 months from April 1).

    If you fail to pay premiums within the grace period, your coverage is terminated, and you fail to show good cause, you and your eligible dependents will not have an opportunity to re-enroll at a future date in the EMRMP. You are still responsible for paying all owed premiums incurred during the grace period in which you were still part of the EMRMP.

    Requests for reinstatement must be accompanied by a credible statement (verbal or written) explaining the unforeseen and uncontrollable circumstances causing the failure to make timely payment. An individual may make only one reinstatement request for good cause in the 60-day period. Generally, these circumstances constitute good cause:

    • A serious illness, institutionalization, and/or hospitalization of the member or their authorized representative (i.e. the individual responsible for the member’s financial affairs), that lasted for a significant portion of the grace period for plan premium payment;
    • Prolonged illness that is not chronic in nature, a serious (unexpected) complication to a chronic condition or rapid deterioration of the health of the member, a spouse, another person living in the same household, person providing caregiver services to the member, or the member’s authorized representative (i.e., the individual responsible for the member’s financial affairs) that occurs during the grace period for the plan premium payment;
    • Recent death of a spouse, immediate family member, person living in the same household or person providing caregiver services to the member, or the member’s authorized representative (i.e., the individual responsible for the member’s financial affairs); or
    • Home was severely damaged by a fire, natural disaster, or other unexpected event, such that the member or the member’s authorized representative was prevented from making arrangement for payment during the grace period for plan premium;
    • An extreme weather-related, public safety, or other unforeseen event declared as a Federal or state level of emergency prevented premium payment at any point during the plan premium grace period. For example, the member’s bank or U.S. Post Office closes for a significant portion of the grace period.

    There may be situations in addition to those listed above that result in favorable good cause determinations. If an individual presents a circumstance which is not captured in the listed examples, it must meet the regulatory standards of being outside of the member’s control or unexpected such that the member could not have reasonably foreseen its occurrence, and this circumstance must be the cause for the non-payment of plan premiums. The Plan expects non-listed circumstances will be rare.

    Examples of circumstances that do not constitute good cause include:

    • Allegation that bills or warning notices were not received due to unreported change of address, out of town for vacation, visiting out of town family, etc.;
    • Authorized representative did not pay timely on member’s behalf;
    • Lack of understanding of the ramifications of not paying plan premiums;
    • Could not afford to pay premiums during the grace period; or
    • Need for prescription medicines or other plan services.
    • The ExxonMobil Benefits Service Center is the appointed designee reviewing reinstatement requests and making good cause determinations

    Loss of eligibility

    Fraud against the Plan

    Everyone in your family may lose eligibility for Retiree Medical Plan coverage if you file claims for benefits to which you are not entitled. Coverage may also be terminated if you refuse to repay amounts erroneously paid by the Retiree 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 Retiree 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 coverage. Termination may be retro-active to the date of coverage.

    In the event a retiree is rehired and is eligible for the ExxonMobil Medical Plan, the retiree and eligible family members are no longer eligible for the EMRMP and coverage is rescinded for all periods during which the retiree is employed. The rehired retiree and eligible family members will be enrolled retroactively in the EMMP until the earlier of failure to comply with the administrative requirements of the EMMP or re-employment ends. Any claims paid during such periods of employment under the EMRMP will be reprocessed under the EMMP.

    Basic Plan features

    Basic features of the Retiree Medical Plan - Aetna Select option

    The Plan generally covers only medically necessary care and services.

    Plan participants have access to a network of participating Primary Care Physicians (PCPs), specialists and hospitals that meet Aetna’s requirements for quality and service. These providers are independent physicians and facilities that are monitored for quality of care, patient satisfaction, cost effectiveness of treatment, office standards and ongoing training.

    Each participant in the Plan must select a Primary Care Physician (PCP) when they enroll. When choosing a PCP, use the aetna.com website to select an individual physician. You may not select a physician group as your PCP. Your PCP serves as your guide to care in today's complex medical system and will coordinate and monitor your overall care.

    Participants may update their PCP by calling Member Services or through aetna.com

    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 established, nationally accepted governmental and/or professional society recommendations, as well as other recognized sources. These CPBs may be found on the Aetna website at www.aetna.com.

    Precertification

    Precertification or preauthorization is a mandatory review of inpatient admissions and select ambulatory procedures or services in advance of treatment, to confirm medical necessity based on clinical criteria and benefits eligible under the Plan. If you are using a network provider, the provider will perform the precertification process on your behalf.

    For more information on precertification for medical/surgical procedures and services, see the National Precertification List on the Aetna member website. To find a list of mental health treatments requiring precertification, including inpatient and intensive outpatient services, visit the Magellan website.

    The Primary Care Physician

    As a participant in the Plan, you will become a partner with your participating PCP in preventive medicine. The following physicians are considered PCPs: Internists, General Practitioners, Pediatricians, and Family Practitioners. Consult your PCP whenever you have questions about your health. Your PCP will provide your primary care and, when medically necessary, your PCP will refer you to other doctors or facilities for treatment. Even if your PCP provides services in a facility as the attending physician, a referral for the facility is required for services rendered at the facility to be covered. The referral is important because it is how your PCP arranges for you to receive necessary, appropriate care and follow up treatment. Except for PCP, Obstetricians/Gynecologists, and emergency services, you must have a prior written or electronic referral from your PCP to receive coverage for all services and any necessary follow up treatment.

    Participating specialists are required to send reports back to your PCP to keep your PCP informed of any treatment plans ordered by the specialist.

    Primary and preventive care

    Your PCP can provide preventive care and treat you for illnesses and injuries. The Plan covers routine physical exams, well-baby care, immunizations and allergy shots provided by your PCP.

    You may also obtain routine vision exams and gynecological exams from participating providers without a referral from your PCP. You are responsible for the copayment stated in the Benefits summary.

    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.

    Specialty and facility care

    Your PCP may refer you to a specialist or facility for treatment or for covered preventive care services, when medically necessary. Except for those benefits described in this guide as direct access benefits and emergency care, you must have a prior written or electronic referral submitted to Aetna from your PCP prior to services being rendered in order to receive coverage for any services the specialist or facility provides.

    When your PCP refers you to a participating specialist or facility for covered services, you will be responsible for the copayment shown in the Benefits summary.

    To avoid costly and unnecessary bills, follow these steps:

    • Consult your PCP first when you need routine medical care. If your PCP deems it medically necessary, you will get a written or electronic referral to a participating specialist or facility. You have one year from the date the referral is issued to complete your visit, unless a different timeframe is specified, as long as you remain an eligible participant in the Plan. Your referral is also valid for the number of services your PCP has approved. For direct access benefits, you may contact the participating provider directly, without a referral.
    • Certain services require both a referral from your PCP and  prior authorization from Aetna. Your PCP is responsible for obtaining authorization from Aetna for in-network covered services.
    • All services provided by a non-participating provider require prior authorization by Aetna.
    • Review the referral with your PCP. Understand what specialist services are being recommended and why.
    • Present the referral to the participating provider. Except for direct access benefits, any additional treatments or tests that are covered benefits require another referral from your PCP. The referral is necessary to have these services approved for payment. Without the referral, you are responsible for payment for these services.
    • If it is not an emergency and you go to a doctor or facility without your PCP’s prior written or electronic referral, you must pay the bill yourself.
    • Your PCP may refer you to a nonparticipating provider for covered services that are not available within the network. Services from nonparticipating providers require prior by Aetna. When properly authorized, these services are covered after the applicable out-of-pocket expenses.
    • Reciprocity applies. See Key Terms.

    Remember, you cannot request referrals after you visit a specialist or hospital. Therefore, to receive maximum coverage, you need to contact your PCP and get authorization from Aetna (when applicable) before seeking specialty or hospital care.

    Some PCPs are affiliated with integrated delivery systems (IDS) or other provider groups (such as Independent Practice Associations and Physician-Hospital Associations). If your PCP participates in such an arrangement, you will usually be referred to specialists and hospitals within that system or group. However, if your medical needs extend beyond the scope of the participating providers, you may ask to have services provided by out-of-network physicians or facilities. Services provided by out-of-network providers may require prior authorization from Aetna and/or the IDS or other provider group. Check with your PCP or call the Member Services number that appears on your ID card to find out if prior authorization is necessary. 

    Provider information

    To find Aetna 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.

    To find Magellan network providers in your area, use the search tool on the Magellan website or call Magellan Member Services.

    Your ID cards

    When you join the Plan, you and each enrolled member of your family receive a member ID card from Aetna for the Medical Plan. Your ID card lists the name of the Aetna PCP you have chosen. New enrollees in the Plan should select their PCP as soon as possible, as Aetna Select ID cards will not be sent until a PCP has been selected. If you change your PCP, you automatically will receive a new card displaying the change. Temporary ID cards can be requested by contacting Aetna Member Services. You will also receive separate Express Scripts ID cards - ESI will send one member ID card for single coverage, and two member ID cards for family coverage (any coverage for more than employee only). Temporary ID cards can be requested by logging into Express Scripts customer website at www.express-scripts.com, or call Express Scripts member services at 800 695-4116.

    Always carry your ID cards with you, including your prescription drug card (Express Scripts or Medco). Your cards identify you as a plan participant when you receive services from participating providers or when you receive emergency services at non-participating facilities. If your cards are lost or stolen, please notify Aetna and Express Scripts immediately. 

    Health Management Programs

    Additional integrated programs are available to you and your family members 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 Aetna Select participants include a 24-Hour Nurse Line, Medical and Behavioral Health Advocates, Condition Management Programs, Cancer Care Program, 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, prescribe medication or give specific medical instruction. Topics discussed during your call may include services and expenses not covered under the Plan.

    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. 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.2ndMD.com/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 (IOE) 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. If you would like to learn more about different COE/IOE options you will need to contact the 24-hour nurse line and ask to be put in contact with a Health Advocate who will be able to discuss different options with you.

    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 services under the Plan

    Eligible services under the Plan on the Retiree Medical Plan - Aetna Select option

    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.  

    Routine physical exams

    Eligible health services include office visits to your  PCP or Obstetrician/Gynecologist for routine physical exams.

    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, PCP, obstetrician (OB), gynecologist (GYN) or OB/GYN. This includes pap smears. 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 PCP 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

    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, PCP’s, OB's, GYN's, or OB/GYN’s office.

    Physicians and other health professionals

    Physician services

    Physician services include: non-routine office visits with your PCP during both office and non-office hours - including Telemedicine, non-routine home visits by your PCP, treatment for illness and injury and injections, including routine allergy desensitization injections at PCP'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

    Emergency care while traveling for business or a personal vacation:

    If you require emergency medical care while traveling for business or a personal vacation, the Plan will cover your emergency treatment 24 hours a day, 7 days a week, anywhere in the world. 

    Covered expenses are subject to the Plan’s applicable coinsurance, copays and/or deductibles.

    If you are traveling outside the United States, unless you have made other arrangements with the emergency medical providers, you will be required to pay the medical bills and then submit the claims to Aetna for reimbursement. The ExxonMobil Plans do not directly reimburse medical providers located outside the United States.

    For reimbursement, submit the itemized bills along with a claim form. If the original bills are in a foreign language, you should obtain an English translation if possible. Bills must be submitted in the appropriate foreign currency. The claims administrator will convert the bill to U.S. dollars as of the date of service.

    Aetna has adopted the following definition of an emergency medical condition from the Balanced Budget Act (BBA) of 1997:

    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
    • Poisoning
    • Severe shortness of breath
    • Uncontrolled or severe bleeding
    • Suspected overdose of medication
    • Severe burns
    • High fever (especially in infants)
    • Loss of consciousness

    For both medical and mental health/substance abuse emergencies, whether you are in or out of Aetna’s or Magellan’s service areas respectively, we ask that you follow the guidelines below when you believe you may need emergency care.

    • Call your PCP first, if possible (in the case of mental health and substance abuse emergency care participants should call the Magellan telephone number on their ID card as soon as reasonably possible and a clinical care manager will assist with next steps). Your PCP is required to provide urgent care and emergency coverage 24 hours a day, including weekends and holidays. However, if a delay would be detrimental to your health, seek the nearest emergency facility, or dial 911 or your local emergency response service.
    • After assessing and stabilizing your condition, the emergency facility should contact your PCP so they can assist the treating physician by supplying information about your medical history.
    • If you are admitted to an inpatient facility, notify your PCP as soon as reasonably possible. The emergency room copayment will be waived if you are admitted to the hospital.
    • All follow-up care must be coordinated by your PCP.
    • If you go to an emergency facility for treatment that Aetna determines is non-emergency in nature, you will be responsible for the bill. The Plan does not cover non-emergency use of the emergency room.

    Follow-up care after emergencies

    Urgent care Treatment that you obtain outside of your service area for an urgent medical condition is covered if:
    • The service is a covered benefit,
    • You could not reasonably have anticipated the need for the care prior to leaving the network service area, and
    • A delay in receiving care until you could return and obtain care from a participating network provider would have caused serious deterioration in your health.

    Aetna has adopted the following definition of urgent medical condition:

    • Urgent medical condition – means a medical condition for which care is medically necessary and immediately required because of unforeseen illness, injury or condition, and it is not reasonable, given the circumstances, to delay care in order to obtain the services through your home service area or from your PCP.
    • Some examples of urgent medical conditions are:
      • Severe vomiting,
      • Earaches,
      • Sore throat, or
      • Fever.

    Follow-up care provided by your PCP is covered, subject to the office visit copayment. Other follow-up care by participating specialists is fully covered with a prior written or electronic referral from your PCP, subject to the specialist copay shown in the Benefits schedule. If you are in your service area, you must use a participating urgent care center.

    Telemedicine services

    Telemedicine services are available through the designated service provider (Teladoc) for non-emergency medical and behavioral health conditions such as cold/flu symptoms, stomach aches, common childhood illnesses, depression, stress and anxiety. Services are available 24/7 via phone or video chat. You pay a primary care visit copayment each time you use the service. Call 1-855-Teladoc (835-2362) or visit Teladoc.com/Aetna.
     

    What to do outside your Aetna service area

    Emergency care

    If a participant goes to a hospital emergency room for a medical emergency, any medical provider can be utilized (Aetna preferred or non-preferred) and the emergency room copay will apply.
     

    Urgent care

    For urgent care, if you are out of your service area, participants can use a non-network urgent care provider or go to an emergency room. Non-emergency or non-urgent use of an urgent care provider is not covered. Urgent care may be obtained from a walk-in clinic, or an urgent care center. An urgent medical condition that occurs outside your Aetna service area can be treated in any of the above settings.

    If, after reviewing information submitted to Aetna by the provider(s) who supplied your care, the nature of the urgent or emergency problem does not clearly qualify for coverage, it may be necessary to provide additional information.

    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.

    Fertility Services

    Infertility services to diagnose and treat the underlying medical cause of infertility, however, Comprehensive Infertility Services, fertility prescriptions, and Advanced Reproductive Technologies (ART) are not covered. You may obtain the following basic infertility services from a participating gynecologist or infertility specialist without a referral from your PCP:

    • initial evaluation, including history, physical exam and laboratory studies performed at an appropriate participating laboratory,
    • evaluation of ovulatory function,
    • ultrasound of ovaries at an appropriate participating radiology facility,
    • postcoital test,
    • hysterosalpingogram,
    • endometrial biopsy, and
    • hysteroscopy,
    • Semen analysis at an appropriate participating laboratory is covered for male plan participants; a referral from your PCP is necessary.

    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.

    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
    • 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 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.

    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.

    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. Subluxation services must be consistent with Aetna’s guidelines for spinal manipulation to correct a muscular skeletal problem or subluxation that could be documented by diagnostic X-rays performed by a participating radiologist. Chiropractic care limited to 20 visits per year.

    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.
    • We determine 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.

    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 on the Retiree Medical Plan - Aetna Select option

    Your mental health/substance abuse benefits will be administered by Magellan Healthcare. The Aetna network is not used for mental health or substance abuse care. Magellan Healthcare provides precertification of inpatient (which may be required) treatment, provider referral, ongoing consultation and review, and case management for mental health and substance abuse treatment. You do not need a referral from your PCP to obtain care from participating mental health and substance abuse providers. Instead, when you need mental health or substance abuse treatment, call the Magellan Healthcare telephone number shown on your ID card. A clinical care manager will assess your situation and refer you to participating providers, as needed.

    Behavioral health treatment

    The Plan covers the following services for behavioral health treatment:

    • Inpatient medical, nursing, counseling and therapeutic services in a hospital or non-hospital residential facility, appropriately licensed by the Department of Health or its equivalent.
    • Intensive outpatient programs providing 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. Requires precertification by Magellan.
    • Applied Behavior Analysis (ABA) for the treatment of autism spectrum disorder. Requires precertification by Magellan.
    • Short-term evaluation and crisis intervention mental health services provided on an outpatient basis.

    Treatment of substance abuse

    The Plan covers the following services for treatment of substance abuse:

    • Inpatient care for detoxification, including medical treatment and referral services for substance abuse or addiction.
    • Inpatient medical, nursing, counseling and therapeutic rehabilitation services for substance abuse or dependency in an appropriately licensed facility.
    • Outpatient visits for substance abuse detoxification. Benefits include diagnosis, medical treatment and medical referral services by your PCP.
    • Outpatient visits to a participating behavioral health provider for diagnostic, medical or therapeutic rehabilitation services for substance abuse.
    • Outpatient treatment for substance abuse or dependency must be provided in accordance with an individualized treatment plan.

    The Aetna Select option includes a number of provisions specific to mental health and substance abuse treatment. When determining whether a service or supply is medically necessary, Magellan 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.

    Prescription drug program

    Prescription drug program on the Retiree Medical Plan - Aetna Select option

    The Plan pays, subject to any limitations specified under Your Benefits, the cost incurred for outpatient prescription drugs that are obtained from a participating pharmacy. Express Scripts is the pharmacy benefit manager for your prescription drugs.  You must present your Express Scripts or Medco ID card and make the copayment shown in the Benefits Summary for each prescription at the time the prescription is dispensed.

    The Plan covers the costs of prescription drugs, in excess of the copayment, that are:

    • Medically necessary for the care and treatment of an illness or injury, as determined by Express Scripts,
    • Prescribed in writing by a physician who is licensed to prescribe federal legend prescription drugs or medicines, and
    • Not listed under Prescription Drug Exclusions and Limitations, below.

    Non-emergency prescriptions must be filled at a participating pharmacy. Generic drugs may be substituted for brand-name products where permitted by law.

    Coverage is based upon Express Scripts’ formulary. The formulary includes both brand-name and generic drugs and is designed to provide access to quality, affordable outpatient prescription drug benefits. You can reduce your co-payment by using a covered generic or brand-name drug that appears on the formulary. Your co-payment will be highest if your physician prescribes a covered drug that does not appear on the formulary.

    Long-term or 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, 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.

    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. 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.

    Emergency prescriptions

    You may not have access to a participating pharmacy in an emergency or urgent care situation, or if you are traveling outside of the Plan’s service area. If you must have a prescription filled in such situations, the Plan will reimburse you as follows:

    • Non-Participating Pharmacy – You must pay the pharmacy directly for the full cost of the prescription and you will be responsible for submitting a request for reimbursement in writing to the pharmacy benefit manager with a receipt for the cost of the prescription. The pharmacy benefit manager will directly reimburse the Member 100% of the prescription, less the applicable copay.  Coverage for items obtained from non-participating pharmacies is limited to items obtained in connection with covered Emergency and Out-of-Area Urgent Care services.  Contact Express Scripts Member Services for more information.
    • Participating Pharmacy - When you obtain an emergency or urgent care prescription at a participating pharmacy (including an out-of-area participating pharmacy), you must pay the applicable copay. The pharmacy benefit manager will not reimburse claims submitted as a direct reimbursement request from a Member for a prescription purchased at a participating retail pharmacy except upon professional review and approval by the pharmacy benefit manager.

    Covered drugs

    The Plan covers the following:

    • Outpatient prescription drugs when prescribed by a provider who is licensed to prescribe federal legend drugs or medicines, subject to the terms, limitations and exclusions described in this booklet.
    • FDA-approved prescription drugs when the off-label use of the drug has not been approved by the FDA to treat the condition in question, provided that:
    • the drug is recognized for treatment of the condition in one of the standard reference compendia (the United States Pharmacopoeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information), or
    • the safety and effectiveness of use for the condition has been adequately demonstrated by at least one study published in a nationally recognized peer reviewed journal.
    • Diabetic supplies as follows:
    • diabetic needles and syringes
    • alcohol swabs
    • test strips for glucose monitoring and/or visual reading
    • diabetic test agents
    • lancets (and lancing devices)
    • insulin
    • prescriptive and nonprescriptive oral agents for controlling blood sugar levels
    • glucagon emergency kits
    • Smoking Cessation aids and drugs prescribed by a physician.
    • Oral and implantable contraceptive drugs and contraceptive devices.
    • Injectable contraceptives (Depo-Provera).
    • Growth hormone therapy, when pre-certified by Express Scripts

    Prescription drug exclusions and limitations

    Prescription drug exclusions

    The following services and supplies are not covered by the Plan, and a medical exception is not available for coverage:

    • Any drug that does not, by federal or state law, require a prescription order (such as an over-the- counter drug), even when a prescription is written.
    • Any drug that is not medically necessary.
    • Charges for the administration or injection of a prescription drug or insulin.
    • Cosmetics and any drugs used for cosmetic purposes or to promote hair growth, including (but not limited to) health and beauty aids.
    • Any prescription for which the actual charge to you is less than the copayment.
    • Any prescription for which no charge is made to you.
    • Insulin pumps or tubing for insulin pumps.
    • Medication which is to be taken by you or administered to you, in whole or part, while you are a patient in a licensed hospital or similar facility.
    • Take-home prescriptions dispensed from a hospital pharmacy upon discharge from the hospital, unless the hospital pharmacy is a participating retail pharmacy.
    • Any medication that is consumed or administered at the place where it is dispensed.
    • Immunization or immunological agents, including, but not limited to:
    • biological sera.
    • blood, blood plasma or other blood products administered on an outpatient basis.
    • allergy sera and testing materials.
    • Drugs used for the purpose of weight reduction, including the treatment of obesity.
    • Any prescription refilled in excess of the number specified by the physician, or any refill dispensed after one year from the physician’s original order.
    • Drugs labeled Caution - Limited by Federal Law to Investigational Use and experimental drugs.
    • Drugs prescribed for uses other than the uses approved by the FDA under the Food, Drug and Cosmetic Law and regulations.
    • Medical supplies, devices and equipment, and non-medical supplies and substances, regardless of their intended use.
    • Prescription drugs purchased prior to the effective date, or after the termination date, of coverage under this Plan.
    • Replacement of lost or stolen prescriptions.
    • Performance and athletic performance lifestyle-enhancement drugs and supplies.
    • Smoking-cessation aids or drugs unless prescribed by a physician.
    • Test agents and devices, except diabetic test strips.
    • Needles and syringes, except diabetic needles and syringes.
    • Any drug or device that terminates a pregnancy.
    • Prophylactic drugs for travel.
    • Nutritional supplements.
    • Medication packaged in unit dose form (except those approved by payment by Express Scripts).

    Prescription drug limitations

    The following limitations apply to the prescription drug coverage:

    • A participating retail or home delivery pharmacy may refuse to fill a prescription order or refill when, in the professional judgment of the pharmacist, the prescription should not be filled.
    • Prescriptions may be filled only at a participating retail or home delivery pharmacy, except in the event of emergency or urgent care. Plan participants will not be reimbursed for out-of-pocket prescription purchases from a non-participating pharmacy in non-emergency, non-urgent care situations.
    • Plan participants must present their ID cards at the time each prescription is filled to verify coverage. If you do not present your ID card, your purchase may not be covered by the Plan, except in emergency and urgent care situations, and you may be required to pay the entire cost of the prescription.
    • The Plan is not responsible for the cost of any prescription drug for which the actual charge to the plan participant is less than the required copayment or for any drug for which no charge is made to the recipient.
    • Plan participants will be charged the non-formulary prescription drugs copayment for prescription drugs covered on an exception basis.
    • For maintenance medications (those taken on a regular basis to treat ongoing conditions like allergies, asthma, diabetes, heart conditions, etc.), the Plan will provide coverage for three fills at a retail pharmacy; for subsequent short-term fills, the participant will be responsible for 100% of the cost.  Any long-term refill that is submitted to the Express Scripts home delivery pharmacy will be subject to long-term delivery pharmacy copayments.
    • When a clinically equivalent generic is available, and a brand name drug is purchased, the copayment will be equal to the generic copayment amount plus the difference in the cost of the brand name drug and the generic.  The difference in cost will not count toward the annual out-of-pocket maximum for 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.

    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 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; 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 class 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 Center

    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.

    Exclusions

    for the Retiree Medical Plan - Aetna Select option

    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.

    The Plan does not cover the following services and supplies:

    General exclusions

    • Any services or supplies that are not medically necessary, as determined by Aetna.
    • 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.  
    • Care for conditions that, by state or local law, must be treated in a public facility.
    • Court-ordered services and services required by court order as a condition of parole or probation, unless medically necessary and provided by participating providers upon referral from your PCP.
    • Expenses that are the legal responsibility of Medicare or a third party payer.
    • Experimental and investigational services and procedures; ineffective surgical, medical, psychiatric, or dental treatments or procedures; research studies, or other experimental or investigational health care procedures or pharmacological regimes, as determined by Aetna, unless approved by Aetna in advance. This exclusion will not apply to drugs:
    • that have been granted treatment investigational new drug (IND) or Group c/treatment IND status,
    • that are being studied at the Phase III level in a national clinical trial sponsored by the National Cancer Institute, or
    • that Aetna has determined, based upon scientific evidence, demonstrate effectiveness or show promise of being effective for the condition.
    • Refer to the Key Terms section for a definition of experimental or investigational.
    • Health services, including those related to pregnancy that are provided before your coverage is effective or after your coverage has been terminated.
    • Treatment in a federal, state or governmental facility, including care and treatment provided in a nonparticipating hospital owned or operated by any federal, state or other governmental entity, except to the extent required by applicable laws.
    • Treatment of illnesses, injuries or disabilities related to military service for which you are entitled to receive treatment at government facilities that are reasonably available to you.
    • Treatment of injuries sustained while committing a felony.
    • Treatment of sickness or injury covered by a worker’s compensation act or occupational disease law, or by United States Longshoreman’s and Harbor Worker’s Compensation Act.
    • Services not covered by the Plan, even when your PCP has issued a referral for those services.
    • Services or supplies covered by any automobile insurance policy, up to the policy’s amount of coverage limitation.
    • Services provided by your close relative (your spouse, child, brother, sister, or the parent of you or your spouse) for which, in the absence of coverage, no charge would be made.
    • Services required by a third party, including (but not limited to) physical examinations, diagnostic services and immunizations in connection with:
      • obtaining or continuing employment,
      • obtaining or maintaining any license issued by a municipality, state or federal government,
      • securing insurance coverage,
      • travel, and
      • school admissions or attendance, including examinations required to participate in athletics, unless the service is considered to be part of an appropriate schedule of wellness services.
    • Services and supplies that are not medically necessary.
    • Services you are not legally obligated to pay for in the absence of this coverage.

    Physicians and other health professionals

    • 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.
    • Any service in connection with, or required by, a procedure or benefit not covered by the Plan.
    • 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.

    Hospital and other facility care

    • Ambulance services, when used for non-emergency transportation.
    • Cosmetic surgery or surgical procedures primarily for the purpose of changing the appearance of any part of the body to improve appearance or self-esteem. However, the Plan covers the following:
      • reconstructive surgery to correct the results of an injury.
      • surgery to treat congenital defects (such as cleft lip and cleft palate) to restore normal bodily function.
      • surgery to reconstruct a breast after a mastectomy that was done to treat a condition, or as a continuation of a staged reconstructive procedure.
    • Inpatient care for serious mental illness which is not provided in a hospital or mental health treatment facility.
    • Outpatient supplies, including (but not limited to) outpatient medical consumable or disposable supplies such as syringes, incontinence pads, elastic stockings and reagent strips, (except as described under Prescription Drugs).
    • Personal comfort or convenience items, including services and supplies that are not directly related to medical care, such as guest meals and accommodations, barber services, telephone charges, radio and television rentals, homemaker services, travel expenses, take-home supplies, and other similar items and services.
    • Private duty nursing care, unless preauthorized.
    • Radial keratotomy, including related procedures designed to surgically correct refractive errors.
    • Surgical operations, procedures or treatment of obesity, except when approved in advance by Aetna. Bariatric surgery is excluded in all events and will not be pre-authorized

    Specific conditions

    • Applied Behavior Analysis (ABA) for Autism spectrum disorder conditions.
    • Acupuncture and acupuncture therapy, except when performed by a participating physician as a form of anesthesia in connection with covered surgery.
    • Biofeedback, except as specifically approved by Aetna.
    • Blood, blood plasma, or other blood derivatives or substitutes.
    • Breast augmentation and otoplasties, including treatment of gynecomastia.
    • Care furnished to provide a safe surrounding, including the charges for providing a surrounding free from exposure that can worsen the condition or injury.
    • Contact Lens Fitting.
    • Custodial care and rest cures.
    • Dental care and treatment, including (but not limited to):
      • care, filling, removal or replacement of teeth,
      • dental services related to the gums,
      • apicoectomy (dental root resection),
      • orthodontics,
      • root canal treatment,
      • soft tissue impactions,
      • alveolectomy,
      • augmentation and vestibuloplasty treatment of periodontal disease,
      • prosthetic restoration of dental implants, and
      • dental implants.
    • Elective abortions.
    • Fertility benefits provided by Progyny.
    • Hair analysis.
    • Hearing aids. Even though this Plan does not provide coverage for hearing aids, if you are considering the purchase of hearing aids, you may be able to lower your out-of-pocket expenses through the Amplifon Hearing Health Care (formerly HearPo) Discount Program 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, you can visit www.aetna.com or call Amplifon Hearing Health Care (formerly HearPo) at 1-877-301-0840 or Hearing Care Solutions at 1-866-344-7756 and identify yourself as an Aetna member.
    • Home births.
    • Home uterine activity monitoring.
    • Household equipment, including (but not limited to) the purchase or rental of exercise cycles, air purifiers, central or unit air conditioners, water purifiers, hypo-allergenic pillows, mattresses or waterbeds, is not covered. Improvements to your home or place of work, including (but not limited to) ramps, elevators, handrails, stair glides and swimming pools, are not covered.
    • Hypnotherapy, except when approved in advance by Aetna.
    • Incidental charges.
    • Implantable drugs.
    • Maintenance, replacement, or repair for continuously rented Durable Medical Equipment (DME), frequently serviced DME, or oxygen equipment are not covered as a separate expense under the Plan.
    • Orthoptics (a technique of eye exercises designed to correct the visual axes of eyes not properly coordinated for binocular vision).
    • Orthotics (except for diabetes).  If for diabetes, the orthotic must be coordinated by the PCP. Contact Aetna Member services for preauthorization.
    • Recreational, educational and sleep therapy, including any related diagnostic testing.
    • Religious, marital and sex counseling, including related services and treatment.
    • Reversal of voluntary sterilizations, including related follow-up care and treatment of complications of such procedures.
    • Routine hand and foot care services, including routine reduction of nails, calluses and corns.
    • Routine hearing exam.
    • Special education, including lessons in sign language to instruct a plan participant whose ability to speak has been lost or impaired to function without that ability.
    • Special medical reports, including those not directly related to the medical treatment of a plan participant (such as employment or insurance physicals) and reports prepared in connection with litigation.
    • Specific injectable drugs, including:
      • experimental drugs or medications, or drugs or medications that have not been proven safe and effective for a specific condition or approved for a mode of treatment by the FDA and the National Institutes of Health,
      • needles, syringes and other injectable aids (except as described under Prescription Drugs),
      • drugs related to treatments not covered by the Plan, and
      • performance-enhancing steroids.
    • Specific non-standard allergy services and supplies, including (but not limited to):
      • cytotoxicity testing (Bryan’s Test),
      • treatment of non-specific candida sensitivity, and
      • urine auto injections.
    • Therapy or rehabilitation, including (but not limited to):
      • primal therapy
      • chelation therapy
      • rolfing
      • psychodrama
      • megavitamin therapy
      • purging
      • bioenergetic therapy
      • vision perception training
      • carbon dioxide therapy
      • Thermograms and thermography.
    • Treatment, including therapy, supplies and counseling, for sexual dysfunctions or inadequacies that do not have a physiological or organic basis.
    • Treatment of temporomandibular joint (TMJ) syndrome, with the exception of diagnostic and surgical treatment, including (but not limited to):
      • treatment performed by placing a prosthesis directly on the teeth,
      • non-surgical medical and dental services, and
      • therapeutic services related to TMJ.
    • Weight reduction programs and dietary supplements.

    Continuation coverage

    Continuation coverage on the Retiree Medical Plan –Aetna Select Network only option

    Introduction

    You are required to be given the information in this section because you are covered under a group health plan (the Retiree 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 Retiree Plan section.

    Your spouse and your family members may have other options available when they lose group health coverage. For example, they may be eligible to buy an individual plan through the Health Insurance Marketplace.  By enrolling in coverage through the Marketplace, y the costs of monthly premiums may be lower.  Additionally, they may qualify for a 30-day special enrollment period for another group health plan for which they 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:

    • Exxon, ExxonMobil, Mobil, XTO or Superior Oil Retirees, or their Survivors, or their covered family members contact ExxonMobil Benefits (http://www.exxonmobil.com/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 the spouse of a retiree, you will be entitled to elect COBRA if you lose coverage under the Plan because any of the following qualifying events happens:

    • The retiree dies,
    • You become divorced from the retiree.  Also, if the retiree 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 retiree’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 retiree dies,
    • The child stops being eligible for coverage under the Plan as a child.

    When is COBRA coverage available?

    When the qualifying event is the death of a retiree, 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 retiree 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 retirees or survivors may give notice of qualifying events by logging onto ExxonMobil Benefits located or by calling eh ExxonMobil Benefits Service Center.

    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 retirees 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.

    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.

    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 become eligible for and enroll in Medicare Part A , Part B or both.
    • Exxon Mobil Corporation no longer provides group health coverage to any of its 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 retiree during a period of COBRA coverage is considered to be a qualified beneficiary provided that, if the covered retiree is a qualified beneficiary, the covered retiree 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 retiree. To be enrolled in the Plan, the child must satisfy the otherwise-applicable Plan eligibility requirements (for example, regarding age).

    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. 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 the 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 to the Benefits Service Center.

    Contacts for COBRA rights under the ExxonMobil Retiree Medical Plan

    The following sets out the contact numbers based on your status under the Retiree 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.

    Retirees 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

    Coordination of benefits

    Coordination of benefits on the Retiree Medical Plan - Aetna Select Option

    If you have coverage under other group plans, the benefits from the other plans will be taken into account if you have a claim. This may mean a reduction in benefits under the EMRMP.

    Benefits available through other group plans and/or no-fault automobile coverage will be coordinated with the EMRMP. Other group plans include any other plan of dental or medical coverage provided by:

    • Group insurance or any other arrangement of group coverage for individuals, whether or not the plan is insured, and
    • No-fault and traditional fault auto insurance, including medical payments coverage provided on other than a group basis, to the extent allowed by law.

    To find out if benefits under the EMRMP will be reduced, Aetna must first determine which plan pays benefits first. The determination of which plan pays first is made as follows:

    • The plan without a coordination of benefits (COB) provision determines its benefits before the plan that has such a provision.
    • The plan that covers a person other than as a dependent determines its benefits before the plan that covers the person as a dependent. If the person is eligible for Medicare and is not actively working, the Medicare Secondary Payer rules will apply. Under the Medicare Secondary Payer rules, the order of benefits will be determined as follows:
    • The plan that covers the person as a dependent of a working spouse will pay first,
    • Medicare will pay second, and
    • The plan that covers the person as a retired employee will pay third.
    • Except for children of divorced or separated parents, the plan of the parent whose birthday occurs earlier in the calendar year pays first. When both parents’ birthdays occur on the same day, the plan that has covered the parent the longest pays first. If the other plan doesn’t have the parent birthday rule, the other plan’s COB rule applies.
    • When the parents of a child are divorced or separated:
    • If there is a court decree which states that the parents will share joint custody of a child, without stating that one of the parents is responsible for the health care expenses of the child, the parent birthday rule, immediately above, applies.
    • If a court decree gives financial responsibility for the child’s medical, dental or other health care expenses to one of the parents, the plan covering the child as that parent’s dependent determines its benefits before any other plan that covers the child as a dependent.
    • If there is no such court decree, the order of benefits will be determined as follows:
    • the plan of the natural parent with whom the child resides,
    • the plan of the stepparent with whom the child resides,
    • the plan of the natural parent with whom the child does not reside, or
    • the plan of the stepparent with whom the child does not reside.
    • If an individual has coverage as an active employee or dependent of such employee, and also as retired or laid-off employee, the plan that covers the individual as an active employee or dependent of such employee is primary.
    • The benefits of a plan which covers a person under a right of continuation under federal or state laws will be determined after the benefits of any other plan which does not cover the person under a right of continuation.
    • If the above rules do not establish an order of payment, the plan that has covered the person for the longest time will pay benefits first.

    If it is determined that the other plan pays first, the benefits paid under the EMRMP will be reduced. Aetna will calculate this reduced amount as follows:

    • The amount normally reimbursed for covered benefits under the EMRMP,

    Less

    • Benefits payable from your other plan(s).

    If your other plan(s) provides benefits in the form of services rather than cash payments, the cash value of the services will be used in the calculation.

    Incorrect computation of benefits

    If you believe that the amount of benefit you receive from the Retiree Medical 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 payment

    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.

    Right of recovery (subrogation and/or reimbursement)

    If you or a covered family member receives benefits from this plan as the result of an illness or injury caused by another person, the EMRMP has the right to be reimbursed for those benefits from any settlement or payment you receive from the person who caused the illness or injury. This means the EMRMP may recover costs from all sources (including insurance coverage) potentially responsible for making any payment to you or your covered family member as a result of an injury or illness, including:

    • Uninsured motorist coverage,
    • Underinsured motorist coverage,
    • Personal umbrella coverage,
    • Med-pay coverage,
    • Workers’ Compensation coverage,
    • No-fault automobile coverage, or
    • Any first party insurance coverage.

    What you need to know

    Here are some important points about the right of subrogation:

    The Plan has a lien on any payments you receive.

    The EMRMP automatically has a lien, to the extent of any benefits it has paid, on any payment you’ve received from a third party, his/her insurer or any other source. The lien is in the amount of benefits paid by Aetna under this plan for treatment of the illness, injury or condition for which the other person is responsible.

    Your cooperation is required.

    You may not do anything to interfere or affect the EMRMP’s subrogation rights.

    You also must fully cooperate with the EMRMP’s efforts to recover benefits it has paid. This includes providing all information requested by the Claims Administrator or its representatives. As part of this process, Aetna may ask you to complete and submit certain applications or other forms or statements. If you fail to provide this information, it will be considered a breach of contract and may result in the termination of your health benefits or the instigation of legal action against you.

    You must notify Aetna.

    If a lawsuit or any other claim is filed to recover damages due to injuries sustained by you or a covered family member, you must notify Aetna. This must be done within 30 days of the date the notice of the lawsuit or claim is given to a person, including an attorney.

    The Plan is paid first.

    The EMRMP’s subrogation rights are a first priority claim against all potentially responsible person(s), and must be paid before any other claim for damages.

    The Plan is entitled to full reimbursement.

    The EMRMP is entitled to full reimbursement first from any payments made by any responsible person(s). This reimbursement must be made, even if the payment is not enough to compensate you or your covered family member in part or in whole for damages. The terms of this plan provision apply and the EMRMP is entitled to full recovery whether or not any liability for payment is admitted by any potentially responsible person(s), and whether or not the settlement or judgment you receive identifies the medical benefits provided by the plan. The EMRMP may be reimbursed from any and all settlements and judgments, even those for pain and suffering or non-economic damages only.

    Aetna chooses the court for any legal action.

    Any legal action or proceeding with respect to this provision may be brought in any court of competent jurisdiction Aetna selects. When you receive benefits under this plan, you agree to this rule and waive whatever rights you have by reason of your present or future place of residence.

    The Plan is not responsible for your attorneys’ fees.

    The EMRMP is not required to participate in or pay attorney fees to the attorney you hire to pursue your claim for damages.

    Interpreting this provision.

    If there is any question about the meaning or intent of this plan provision or any of its terms, the EMRMP will have the sole authority and discretion to resolve all disputes as to how this provision will be interpreted.

    Claims

    Filing claims for the Retiree Medical Plan - Aetna Select option

    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 found in the Key Terms section of 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.

    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.

    Grievances

    Quality of care or operational issues arise if you are dissatisfied with the service received from Aetna or want to complain about a participating provider. To make a complaint about a quality of care or operational issue (called a grievance), call or write to Member Services within 30 days of the incident. Include a detailed description of the matter and include copies of any records or documents that you think are relevant to the matter. Aetna will review the information and provide you with a written decision within 30 calendar days of the receipt of the grievance, unless additional information is needed, but cannot be obtained within this time frame. The notice of the decision will specify what you need to do to seek an additional review.

    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 for appeal must be made 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 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
    • You have exhausted the applicable appeal process.

    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.

    Claims fiduciary

    For the purpose of section 503 of Title 1 of the Employee Retirement Income Security Act of 1974, as amended (ERISA), the claims fiduciary is the person with complete authority to review all denied claims for benefits under the Plan. The claims fiduciary is Aetna for both medical Level One and Level Two and voluntary 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 Level One, Level Two, and Voluntary Appeals:

    Mandatory and Voluntary Mental Health and Substance Abuse Appeals:

    Prescription Drug Mandatory and Voluntary Appeals:

    Eligibility Appeals

    Aetna
    PO 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.
    800-946-3979

    Administrator-Benefits

    ExxonMobil Medical Plan

    P.O. Box 18025
    Norfolk, VA 23501-1867

    This includes, but is not limited to, determining whether hospital or medical treatment is, or is not, medically necessary. In exercising its fiduciary responsibility, each claims fiduciary has discretionary authority on appeal to:

    • Determine whether, and to what extent, you and your covered family members are entitled to benefits, and
    • Construe any disputed or doubtful terms of the Plan.

    Each claims fiduciary has the right to adopt reasonable policies, procedures, rules and interpretations of the Plan to promote orderly and efficient administration. A claims fiduciary may not act arbitrarily and capriciously, which would be an abuse of its discretionary authority.

    The EMRMP is responsible for making reports and disclosures required by ERISA, including the creation, distribution and final content of:

    • Summary Plan Descriptions,
    • Summary of Material Modifications, and
    • Summary Annual Reports.

    Member Services

    Member Services information for the Retiree Medical Plan - Aetna Select option

    Member Services department

    Health Concierges (HCs) (customer service representatives ) are trained to answer your questions and to assist you in using the Plan properly and efficiently.

    Call the Member Services toll-free number on your ID card to:

    • Ask questions about benefits, referrals and coverage,
    • Change your PCP, or
    • Notify Aetna about an emergency.

    Please call your PCP’s office directly with questions about appointments, hours of service, referrals or medical matters.

    Also, you must notify the Benefits Service Center of changes that might affect your eligibility and enrollment status, such as changes in your name or telephone number.

    Internet access

    You can access Aetna on the internet at www.aetna.com to conduct business with the Member Services department electronically.

    When you visit the Member Services site, you can:

    • Find answers to common questions,
    • Change your PCP,
    • Order a new ID card, or
    • Contact the Member Services department with questions.

    Please be sure to include your ID number and e-mail address.

    Rights and responsibilities

    Rights and responsibilities on the Retiree Medical Plan - Aetna Select Option

    Your rights and responsibilities

    As a plan participant, you have a right to:

    • Get up-to-date information about the doctors and hospitals participating in the Plan.
    • Obtain primary and preventive care from the PCP you chose from the Plan’s network.
    • Change your PCP to another available PCP who participates in the Aetna network.
    • Obtain covered care from participating specialists, hospitals and other providers.
    • Be referred to participating specialists who are experienced in treating your chronic illness.
    • Be told by your doctors how to make appointments and get health care during and after office hours.
    • Be told how to get in touch with your PCP or a back-up doctor 24 hours a day, every day.
    • Call 911 (or any available area emergency response service) or go to the nearest emergency facility in a situation that might be life-threatening.
    • Be treated with respect for your privacy and dignity.
    • Have your medical records kept private, except when required by law or contract, or with your approval.
    • Help your doctor make decisions about your health care.
    • Discuss with your doctor your condition and all care alternatives, including potential risks and benefits, even if a care option is not covered.
    • Know that your doctor cannot be penalized for filing a complaint or appeal.
    • Know how the Plan decides what services are covered.
    • Know how your doctors are compensated for the services they provide. If you would like more information about Aetna’s physician compensation arrangements, visit their website at www.aetna.com. Select DocFind from the drop-down menu under Quick Tools, then under How do I learn more about, select the type of plan you’re enrolled in.
    • Get up-to-date information about the services covered by the Plan — for instance, what is and is not covered and any applicable limitations or exclusions.
    • Get information about copayments and fees you must pay.
    • Be told how to file a complaint, grievance or appeal with the Plan.
    • Receive a prompt reply when you ask the Plan questions or request information.
    • Obtain your doctor’s help in decisions about the need for services and in the grievance process.
    • Suggest changes in the Plan’s policies and services.

    As a plan participant, you have a right to:

    • Choose a PCP from the Plan’s network and form an ongoing patient-doctor relationship.
    • Help your doctor make decisions about your health care.
    • Tell your PCP if you do not understand the treatment you receive and ask if you do not understand how to care for your illness.
    • Follow the directions and advice you and your doctors have agreed upon.
    • Tell your doctor promptly when you have unexpected problems or symptoms.
    • Consult with your PCP for non-emergency referrals to specialist or hospital care.
    • See the specialists your PCP refers you to.
    • Make sure you have the appropriate authorization for certain services, including inpatient hospitalization and out-of-network treatment.
    • Call your PCP before getting care at an emergency facility, unless a delay would be detrimental to your health.
    • Understand that participating doctors and other health care providers who care for you are not employees of Aetna and that Aetna does not control them.
    • Show your ID card to providers before getting care from them.
    • Pay the copayments required by the Plan.
    • Call Member Services if you do not understand how to use your benefits.
    • Promptly follow the Plan’s grievance procedures if you believe you need to submit a grievance.
    • Give correct and complete information to doctors and other health care providers who care for you.
    • Treat doctors and all providers, their staff, and the staff of the Plan with respect.
    • Advise Aetna about other medical coverage you or your family members may have. Not be involved in dishonest activity directed to the Plan or any provider. Read and understand your Plan and benefits. Know the copayments and what services are covered and what services are not covered.

    Federal notices

    Federal notices related to the Retiree Medical Plan - Aetna Select option

    A note regarding the ExxonMobil Retiree Medical Plan

    The Retiree Medical Plan (RMP) is a retiree only plan. A retiree only health plan is exempt all the insurance mandates of PPACA and exempt from HIPAA portability. As a retiree only plan the RMP will not include the consumer protections of PPACA that apply to the other plans.

    Coverage for maternity hospital stay

    Under federal law, the Plan may not restrict benefits for 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 caesarean 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.  

    The Women’s Health and Cancer Rights Act

    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 copayment 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, copayments and limits applicable to other covered services.

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

    Administrative and ERISA information

    Administrative and ERISA information for the Retiree Medical Plan - Aetna Select option

    Basic Plan information

    Plan name

    The ExxonMobil Retiree Medical Plan

    Plan sponsor and participating affiliates

    The ExxonMobil Retiree 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 Retiree Medical Plans. A complete list of participating affiliates is available from the Administrator-Benefits upon written request.

    Plan numbers

    The ExxonMobil Retiree Medical Plan is identified with government agencies under two numbers:

    The Employer Identification Number (EIN), 13-5409005, and the Plan Number (PN), 540.

    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 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 ExxonMobil 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 18025
    Norfolk, VA 23501-1867

    For service of legal process:

    Corporation Service Co.
    211 East 7th Street, Suite 620
    Austin, TX 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 Retiree Medical Plan in its application to any participant or beneficiary, and to decide any and all claim appeals.

    NOTE: Effective January 1, 2019, 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 Retiree Medical Plan is a  welfare plan under ERISA providing medical benefits.

    Plan year

    The plan year is the calendar year.

    Funding

    The Plan is funded through participant and company contributions. Each year, ExxonMobil determines the rates of required participant contributions to the ExxonMobil Retiree Medical Plan. These rates are based on past and projected plan experience.  Participant contributions are paid to a Trustee who manages the funds under the terms of a Trust Agreement between ExxonMobil and the Trustee. The Trustee for the EMRMP Plan is:

    The Northern Trust Company
    50 S. LaSalle
    Chicago, IL 6067

    Claims processor

    Aetna Life Insurance Company is the claims processor and claims fiduciary.

    No implied promises

    Nothing in this guide says or implies that participation in the ExxonMobil Retiree Medical Plan is a guarantee of continued employment with the company.

    If the ExxonMobil Retiree Medical Plan is amended or terminated

    The company reserves the right at any time and for any reason to terminate, suspend, withdraw, amend or modify the Retiree Medical Plan or any of its provisions. If any reductions in benefits are made in the future, you will be notified within sixty (60) days of the signing of the amendment. In the event the ExxonMobil Retiree 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 Exxon Mobil Corporation or its controlled group.

    Your rights under ERISA

    As a participant in the ExxonMobil Retiree Medical Plan, you have certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all participants shall be entitled to:

    Receive information about your plan and benefits

    Examine, without charge, at the office of the Administrator-Benefits and at other specified locations, such as worksites, and union halls, all documents governing the ExxonMobil Retiree Medical Plan, including a copy of the latest annual report (Form 5500 Series) filed by the ExxonMobil Retiree Medical Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.

    Obtain, upon written request to the Administrator-Benefits, copies of documents governing the operation of the Retiree Medical Plan including collective bargaining agreements and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Descriptions. The Administrator may require a reasonable charge for the copies.

    Receive a summary of the Plan’s annual financial report. (The Administrator-Benefits is required by law to furnish each participant with a copy of this Summary Annual Report.)

    Prudent actions by plan fiduciaries

    In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called fiduciaries, of the ExxonMobil Retiree Medical Plan have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a plan benefit or exercising your rights under ERISA.

    Enforce your rights

    If your claim for a benefit is denied or ignored in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.

    Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of the Plan documents or the latest Summary Annual Report from the Plan, and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Administrator-Benefits to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator.

    If you have a claim and an appeal for benefits, which are both denied or ignored, in whole or in part, you may file suit in a state or Federal court.  Such lawsuit must be filed in the United States District Court for the Southern District of Texas, Houston, Texas, or in the United States District Court for the federal judicial district where the employee currently works.  If a retiree or terminee, the suit must be filed in the last location worked prior to termination of employment.  Beneficiaries must also file in the same federal judicial district that the employee or retiree would be required to file.  Any such lawsuits must be brought within one year of the date on which an appeal was denied.

    The court will decide who should pay court costs and legal fees.  If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

    Assistance with your questions

    If you have any questions about the Plan, you should contact the Plan Administrator. If you have any questions about your rights under ERISA, or if you need assistance in obtaining documents from the Administrator-Benefits, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

    Key terms

    A list of key terms in the Retiree Medical Plan - Aetna Select option

    Annual out-of-pocket limit

    Expenses you pay for medical services apply towards the annual out-of-pocket maximum including both outpatient and inpatient mental health and substance abuse treatment.  The annual out-of-pocket maximum is accumulated in the order the claims are processed.

    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 leaves 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, 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.

    The Benefits Service Center

    The following sets out the contact numbers based on your status under the ExxonMobil Retiree Medical Plan. It is your responsibility to contact the correct Benefits Service Center entity with any required notices and address changes. If your status is not listed, call the ExxonMobil Benefits Service Center for assistance at 1-800-682-2847.

    Phone Numbers:
    Retirees and Survivors call:
    ExxonMobil Benefits Service Center
    Monday - Friday 8:00 a.m. to 6:00 p.m. (U.S. Eastern Time), 
    except certain holidays 
    Toll-Free: 1-800-682-2847 
    or 800-TDD-TDD4 (833-8334) for hearing impaired

    Address:
    ExxonMobil Benefits Service Center
    P.O. Box 18025, Norfolk, VA 23501-1867

    Benefits administration / ExxonMobil sponsored sites

    Access to plan-related information including claim forms for employees, retirees, survivors, and their family members.

    • ExxonMobil Family, the Human Resources Internet Site — Can be accessed from home by everyone at www.exxonmobilfamily.com.
    • Retiree Online Community Internet Site — Can be accessed from home by retirees and survivors only at www.emretiree.com.
    • ExxonMobil Benefits Service Center Internet Site — Can be accessed from home by everyone at www.exxonmobil.com/benefits

    Child

    A person under age 26 who is:

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

    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. For other services, such as routine office visits to an Aetna Select provider, the copayment will be a fixed amount. For outpatient prescription drugs there is a percentage copayment up to a per-prescription maximum.

    Cosmetic surgery

    Means any surgery or procedure that is not medically necessary and whose primary purpose is to improve or change the appearance of any portion of the body to improve self-esteem, but which does not:

    • Restore bodily function,
    • Correct a diseased state, physical appearance or disfigurement caused by an accident or birth defect, or
    • Correct or naturally improve a physiological function.

    Covered services and supplies (covered expenses)

    Means the types of medically necessary services and supplies described in Your Benefits.

    Custodial care

    Means any service or supply, including room and board, which:

    • Is furnished mainly to help you meet your routine daily needs, or
    • Can be furnished by someone who has no professional health care training or skills, or
    • Is at a level such that you have reached the maximum level of physical or mental function and are not likely to make further significant progress. 

    Detoxification

    Means the process whereby an alcohol-intoxicated, alcohol-dependent or drug-dependent person is assisted in a facility licensed by the state in which it operates, through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or drug, alcohol or drug dependent factor, or alcohol in combination with drugs as determined by a licensed physician, while keeping physiological risk to the patient at a minimum.

    Durable medical equipment (DME)

    Means equipment determined to be:

    • Designed and able to withstand repeated use,
    • Made for and used primarily in the treatment of a condition or injury,
    • Generally not useful in the absence of an illness or injury,
    • Suitable for use while not admitted in a hospital,
    • Not for use in altering air quality or temperature, and
    • Not for exercise or training.

    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 (even if Medicare eligible), or
    • is aged 26 or over and totally and continuously disabled and incapable of self-sustaining employment by reason of mental or, physical disability, provided the child:

    2. meets the Internal Revenue Service's definition of a dependent, and

    • was covered as an eligible family member under this Plan or the ExxonMobil Medical Plan immediately prior to the birthday on which the child's eligibility would have otherwise ceased, and
    • met the clinical definition of totally and continuously disabled before such birthday and continues to meet the clinical definition through subsequent periodic reassessment reviews, and
    • is not eligible to be enrolled in Medicare as their primary medical plan, 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 paragraph (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 retiree's parents are not eligible to be covered.

    Emergency

    Means 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.
    • With respect to emergency services furnished in a hospital emergency department, the Plan does not require prior authorization for such services if you arrive at the emergency medical department with symptoms that reasonably suggest an emergency condition, based on the judgment of a prudent layperson, regardless of whether the hospital is a participating provider. All medically necessary procedures performed during the evaluation (triage and treatment of an emergency medical condition) are covered by the Plan.

    Experimental or investigational

    Means services or supplies that are determined by Aetna to be experimental. A drug, device, procedure or treatment will be determined to be experimental if:

    • There are not sufficient outcomes data available from controlled clinical trials published in the peer reviewed literature to substantiate its safety and effectiveness for the condition or injury involved, or
    • Required FDA approval has not been granted for marketing, or
    • A recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental or for research purposes, or
    • The written protocol(s) used by the treating facility or the protocol(s) of any other facility studying substantially the same drug, device, procedure or treatment or the written informed consent used by the treating facility or by another facility studying the same drug, device, procedure or treatment states that it is experimental or for research purposes, or
    • It is not of proven benefit for the specific diagnosis or treatment of your particular condition, or
    • It is not generally recognized by the medical community as effective or appropriate for the specific diagnosis or treatment of your particular condition, or
    • It is provided or performed in special settings for research purposes.

    ExxonMobil Retiree Medical Plan (EMRMP)

    The Plan sponsored by ExxonMobil which provides medical benefits for eligible retirees, survivors and their family members, and includes the Retiree Medical Plan (RMP), the Medicare Primary Option (MPO) and the Medicare Supplement plan (or MSP).

    Home health services

    Means those items and services provided by participating providers as an alternative to hospitalization.

    Hospice care

    Means a program of care that is:

    • Provided by a hospital, skilled nursing facility, hospice or duly licensed hospice care agency, and
    • Focused on palliative rather than curative treatment for a plan participant who has a medical condition and a prognosis of less than 6 months to live.

    Hospital

    Means an institution rendering inpatient and outpatient services, accredited as a hospital by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), the Bureau of Hospitals of the American Osteopathic Association, or as otherwise determined by Aetna as meeting reasonable standards. A hospital may be a general, acute care, rehabilitation or specialty institution.

    Incidental Charges

    Charges for services that are considered an integral component of the primary procedure.  Aetna’s standard for determining incidental charges is based on the Current Procedural Terminology (CPT) codes and guidelines authored and revised by the American Medical Association. CPT coding is the most widely accepted format, by both government and private health insurance programs, in reporting physician procedures, including guidelines explaining that services commonly carried out as an integral component of a total service or procedure should not be reported as a separate procedure. 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.  For example: Your provider administers an immunization and submits separate charges: one for the medication administered in the immunization and another for administering the shot.

    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 pre-authorized non-participating provider or if you have signed a statement in the provider's office saying you will be responsible for incidental charges.

    Infertility

    • For a female who is under age 35, the inability to conceive after one year or more without contraception or 12 cycles of artificial insemination.
    • For a female who is age 35 or older, the inability to conceive after six months without contraception or six cycles of artificial insemination.

    Medical services

    Means those professional services of physicians or other health professionals, including medical, surgical, diagnostic, therapeutic and preventive services authorized by Aetna.

    Medically necessary

    Means services that are appropriate and consistent with the diagnosis in accordance with accepted medical standards, as described in the Your Benefits section of this booklet. To be medically necessary, the service or supply must:

    • Be care or treatment as likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply, as to both the illness, injury, or mental health condition involved and your overall health condition,
    • Be care or services related to diagnosis or treatment of an existing illness or injury, except for covered periodic health evaluations and preventive and well-baby care, as determined by Aetna,
    • Be a diagnostic procedure, indicated by the health status of the plan participant, and be as likely to result in information that could affect the course of treatment as, and no more likely to produce a negative outcome than, any alternative service or supply, as to both the illness or injury involved and your overall health condition,
    • Include only those services and supplies that cannot be safely and satisfactorily provided at home, in a physician’s office, on an outpatient basis, or in any facility other than a hospital, when used in relation to inpatient hospital services, and
    • As to diagnosis, care and treatment be no more costly (taking into account all health expenses incurred in connection with the service or supply) than any equally effective service or supply in meeting the above tests.

    In determining whether a service or supply is medically necessary, Aetna will consider:

    • Information provided on your health status,
    • Applicable standard of care,
    • Aetna's Clinical Policy Bulletin's and other non-case specific materials, which shall be based on medical and Scientific Evidence,
    • Reports in peer reviewed medical literature,
    • Reports and guidelines published by nationally recognized health care organizations that include supporting scientific data,
    • Professional standards of safety and effectiveness which are generally recognized in the United States for diagnosis, care or treatment,
    • The opinion of health professionals in the generally recognized health specialty involved,
    • The opinion of the attending physicians, which has credence but does not overrule contrary opinions, and
    • Any other relevant information brought to Aetna’s attention

    In no event will the following services or supplies be considered medically necessary:

    • Services or supplies that do not require the technical skills of a medical, mental health or dental professional,
    • Custodial care, supportive care or rest cures,
    • Services or supplies furnished mainly for the personal comfort or convenience of the patient, any person caring for the patient, any person who is part of the patient’s family or any health care provider,
    • Services or supplies furnished solely because the plan participant is an inpatient on any day when their illness or injury could be diagnosed or treated safely and adequately on an outpatient basis,
    • Services furnished solely because of the setting if the service or supply could be furnished safely and adequately in a physician’s or dentist’s office or other less costly setting, or
    • Experimental services and supplies, as determined by Aetna.

    Mental health treatment facility

    A facility that:

    1. meets licensing standards,
    2. mainly provides a program for diagnosis, evaluation and treatment of acute mental or behavioral health condition,
    3. prepares and maintains a written plan of treatment for each patient based on medical, psychological and social needs,
    4. provides all normal infirmary level Medical Services or arranges with a Hospital for any other Medical Services that may be required,
    5. is under the supervision of a psychiatrist, and
    6. provides skilled nursing care by licensed nurses who are directed by a registered nurse.  

    Mental or behavioral health condition

    Means a condition which manifests signs and/or symptoms that are primarily mental or behavioral, for which the primary treatment is psychotherapy, psychotherapeutic methods or procedures, and/or the administration of psychotropic medication. Mental or behavioral health conditions include, but are not limited to:

    • Psychosis,
    • Affective disorders,
    • Anxiety disorders,
    • Personality disorders,
    • Obsessive-compulsive disorders,
    • Attention disorders with or without hyperactivity, and
    • Other psychological, emotional, nervous, behavioral or stress-related abnormalities associated with transient or permanent dysfunction of the brain or related neurohormonal systems, whether or not caused or in any way resulting from chemical imbalance, physical trauma, or a physical or medical condition.

    Outpatient

    Means:

    • A plan participant who is registered at a practitioner’s office or recognized health care facility, but not as an inpatient, or
    • Services and supplies provided in such a setting.

    Participating provider

    Means a provider that has entered into a contractual agreement with Aetna to provide services to plan participants.

    Pharmacy benefit manager

    Express Scripts is the pharmacy benefit manager for prescription drugs.

    Physician

    Means 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.

    Plan benefits

    Means the medical services, hospital services, and other services and care to which a plan participant is entitled, as described in this booklet.

    Plan participant

    Means a retiree or covered family member.

    Primary Care Physician (PCP)

    Means a Physician engaged in general practice, family practice, internal medicine, pediatrics or obstetrics/gynecology who provides basic health services to covered persons, initiates their referral for specialist care, and maintains continuity of patient care. Physician groups, nurse practitioners and physician assistants cannot be PCPs.

    Private duty nursing

    Continuous, substantial and complex skilled in-home nursing care in the home requiring services that can only be provided by a licensed medical professionals can provide, has been as 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.

    Provider

    Means a physician, health professional, hospital, skilled nursing facility, home health agency, or other recognized entity or person licensed to provide hospital or medical services to Plan participants.

    Reciprocity

    The Plan allows full reciprocity between Aetna Select networks, when members follow all administrative requirements such as obtaining referrals and authorizations.

    Referral

    Means specific written or electronic direction or instruction from a Plan participant’s PCP, in conformance with Aetna’s policies and procedures, which directs the plan participant to a participating provider for medically necessary care.

    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 (RMP)

    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 Retiree Medical Plan Aetna Select Option (as described in this SPD) and other self-funded options.

    Self-funded

    (As used in the ExxonMobil Medical Plan) - A self-funded option is an option set up by ExxonMobil to set aside funds to pay employees’ health claims. Because ExxonMobil has hired insurance companies to administer the claims for these plans, they may look just like fully insured plans but they are funded by ExxonMobil. For example, all Aetna Select options under the EMMP and EMRMP are self-funded. Aetna is responsible for processing claims and is the claims fiduciary (i.e., Aetna makes the final decision on claims under those plans). ExxonMobil is responsible for providing the funds to the Plan to pay health claims. This does not impact the way that your plan operates. The U.S. Department of Labor regulates self-funded plans, not the state. You may contact the Department of Labor at the address listed in the ERISA section: Assistance with Your Questions.

    Serious Mental Illness

    The following psychiatric illnesses as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM) V-R: schizophrenia; paranoid and other psychotic disorders; bipolar disorders (hypomanic; mixed, manic and depressive); major depressive disorders (single episode or recurrent); schizo-affective disorders (bipolar or depressive); pervasive developmental disorders; obsessive-compulsive disorders and depression in childhood and adolescence.

    Service area

    Means the geographic area, established by Aetna and approved by the appropriate regulatory authority, in which a Plan participant must live or otherwise meet the eligibility requirements in order to be eligible as a participant in the Plan. Eligibility is determined by the participant's home address zip code.

    Skilled nursing facility

    Means an institution or a distinct part of an institution that is licensed or approved under state or local law, and which is primarily engaged in providing skilled nursing care and related services as a skilled nursing facility, extended care facility, or nursing care facility approved by the Joint Commission on Accreditation of Health Care Organizations or the Bureau of Hospitals of the American Osteopathic Association, or as otherwise determined by Aetna to meet the reasonable standards applied by any of the aforesaid authorities.

    Specialist

    Means a physician who provides medical care in any generally accepted medical or surgical specialty or sub-specialty.

    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.

    Substance abuse

    Means any use of alcohol and/or drugs which produces a pattern of pathological use causing impairment in social or occupational functioning, or which produces physiological dependency evidenced by physical tolerance or withdrawal.

    Survivor/ surviving spouse

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

    Suspended retiree

    A person who becomes a retiree due to incapacity within the meaning of the ExxonMobil Disability Plan and who begins long-term disability benefits under that plan, but whose benefits stop because the person is no longer incapacitated. A person remains a suspended retiree until the earlier of the date the person:

    • Reaches age 55, or
    • Begins his or her benefit under the ExxonMobil Pension Plan, at which time, the person is again considered a retiree.

    The family members of a deceased suspended retiree will be eligible for coverage under this Plan only after the occurrence of the earlier of the following:

    • The date the suspended retiree would have attained age 55, or
    • The date a survivor begins receiving a benefit due to the suspended retiree's accrued benefit from the ExxonMobil Pension Plan.

    Terminal illness

    Means an illness of a Plan participant, which has been diagnosed by a physician and for which they have a prognosis of six (6) months or less to live.

    Urgent medical condition

    Means a medical condition for which care is medically necessary and immediately required because of unforeseen illness, injury or condition, and it is not reasonable, given the circumstances, to delay care in order to obtain the services through your home service area or from your PCP.

    2022 Benefits summary

    Benefits schedule for the Retiree Medical Plan - Aetna Select option

    All non-emergency specialty and hospital services require a prior referral from your PCP. Call member services to inquire if a referral is required prior to the services being rendered.

    Type of Service or Supply

    Benefit Level

    Lifetime Maximum

    No lifetime maximum

    Individual Annual Out-of-Pocket Maximum (Includes Pharmacy)

    $3,000

    Family Annual Out-of-Pocket Maximum Includes Pharmacy)

    $6,000

    If a retiree and one or more eligible family members are covered under this option, after one covered family member meets the individual out-of-pocket maximum, benefits for that individual are payable at 100% by the Plan. Once the family meets the family out-of-pocket maximum, benefits for all covered family members are payable at 100%.

    Preventive Care

    Preventive Care Office Visits

    No charge

    Routine Physicals & Immunizations

    No charge

    Well Woman Care (including Pap Smear Test)

    No charge (direct access / no referral)

    Mammograms

    No charge

    Well Baby Care (including Immunizations)

    No charge

    Prostate Cancer Screening

    No charge

    Primary Care

    PCP Office Visits - Including Telemedicine

    $25 copay per visit

    Allergy Treatment- Routine injections at PCP’s office, with or without physician encounter

    $25 copay per visit

    Eyeglasses/Contact Lenses

    Age 0-18 – one set of lenses and frames or contacts per calendar year Age 19 and over - one set of lenses and frames or contacts every 24 months

    Hearing Aids

    Not covered (See Exclusions section for information about the Amplifon Hearing Health Care (formerly HearPo) Discount Program and the Hearing Care Solutions Discount Program)

    Specialty And Outpatient Care

    Specialist Office Visits- Including Telemedicine

    $40 copay per visit

    Walk in Clinic (Retail Clinic)

    $40 copay per visit

    Prenatal Care (applies to standard global maternity services and initial visit)

    $40 copay per visit (no referral required)

    Maternity (childbirth/delivery services)

    90% coverage

    Allergy Testing

    $40 copay per visit

    Imaging (CT/PET scans, MRIs)

    90% coinsurance
    Some tests may require prior approval by Aetna

    Diagnostic X-rays and Outpatient Labs associated with an office visit

    No additional charge

    Therapy (speech, occupational, physical)

    $40 copay per visit

    Chiropractic Care

    $40 copay per visit - 20 visits per calendar year

    Outpatient Rehabilitation

    $40 copay per visit

    Home Health Care

    90% coinsurance

    Skilled Nursing Care

    90% coverage

    Prosthetic Devices

    90% coinsurance

    To see a list of procedures that require precertification, please reference the National Precertification List* on the Aetna member website.

    Inpatient Services(Precertification required)

    Hospital Room and Board and Other Inpatient Services

    90% coverage

    Skilled Nursing Facilities

    90% coverage

    Hospice Facility

    90% coverage

    Surgery and Anesthesia

    Inpatient Surgery

    90% coverage

    Outpatient Surgery

    90% coverage

    Mental Health and Substance Use Treatment

    Office Visit

    $25 or $40 copay per visit

    Outpatient Services

    90% coverage

    Inpatient Treatment (including residential treatment centers)

    90% coverage

    Urgent and Emergency Care

    Urgent Care

    $60 copay per visit

    Emergency Room

    $150 copay (waived if admitted)

    Ambulance

    90% coverage

    Prescription Drugs through Express Scripts(No annual maximum benefit)

    Annual out-of-pocket maximum

    Combined with medical out-of-pocket maximum

    Short-term (30-day supply)* **

    $15 copay – generic formulary drugs
    30% copay – brand-name formulary drugs. $145 maximum per prescription
    45% copay – non-formulary drugs. $165 maximum per prescription

    Long-term (90-day supply)*

    $30 copay – generic formulary drugs
    30% copay – brand-name formulary drugs. $145 maximum per prescription
    45% copay – non-formulary drugs. $165 maximum per prescription

    National Precertification List on the Aetna member website

    * 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.

    ** 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, 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.

    *** Formulary 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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