This is your guide to the benefits available through the ExxonMobil Retiree Medical Plan Cigna Open Access Plus-In Network (OAPIN) Network Only option (Cigna or Cigna option), administered by Cigna Health and Life Insurance Company (CHLIC). Please read it carefully and refer to it when you need information about how the Cigna option 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 guide, call the Cigna Customer Service toll-free number on your ID card.

Tips for new plan participants

• Keep this guide where you can easily refer to it.
• Keep your ID card(s) in your wallet.
• Keep your Primary Care Physician’s name and number readily accessible.
• Emergencies are covered anytime, anywhere, 24 hours a day.

Important information

THIS IS NOT AN INSURED BENEFIT PLAN. THE BENEFITS DESCRIBED IN THIS BOOKLET OR ANY RIDER ATTACHED HERETO ARE FUNDED BY CONTRIBUTIONS MADE BY PARTICIPANTS AND PARTICIPATING EMPLOYERS RESPONSIBLE FOR BENEFIT PAYMENTS. CIGNA HEALTH AND LIFE INSURANCE COMPANY (CHLIC) PROVIDES CLAIM ADMINISTRATION SERVICES TO THE CIGNA OPTION, BUT CHLIC DOES NOT INSURE THE BENEFITS DESCRIBED.

Cigna offers access to care from participating in network physicians and facilities. You are encouraged to choose a Primary Care Physician (PCP) to coordinate your care, and pay either a copayment or coinsurance (your portion of the charges) for most services, up to an annual out-of-pocket maximum. You don't have to complete a claim form. 

References in this document to "Cigna" refer to Cigna Health and Life Insurance Company (CHLIC), a subsidiary of Cigna Corporation.

Information sources

Information sources for the ExxonMobil Retiree Medical Plan - Cigna OAPIN Network Only option

When you need information, you may contact:

Phone numbers:
Cigna Customer Service
800-818-9440
Available 24 hours a day, 7 days a week

Address:
Cigna
P. O. Box 182223
Chattanooga, TN 37422-7223

You can search for network providers through Cigna.com or by logging into MyCigna.com.

Phone numbers:
ExxonMobil Benefits Service Center
800-682-2847

Monday – Friday 8:00 a.m. to 6:00 p.m. (U.S. Eastern Time), except certain holidays
www.exxonmobil.com/benefits

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

You can also access plan information on ExxonMobil Family, the Human Resources Internet Site at www.exxonmobilfamily.com.

Plan at a glance

Plan at a glance for the ExxonMobil Employee Retiree Plan - Cigna OAPIN Network Only option

The Plan participants have access to a network of participating Primary Care Physicians (PCPs), specialists and hospitals that meet Cigna’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.

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 Cigna Home Delivery Pharmacy for long-term prescriptions, and through Cigna Home Delivery Pharmacy 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 for Cigna Participating Providers within the OAPIN network. Inpatient and intensive outpatient care must be preauthorized. Your PCP is responsible for obtaining authorization from Cigna for all in-network covered services. 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 pay an amount of coinsurance. 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 Cigna 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 Cigna 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 CIGNA OAPIN option. See Benefit summary.

Eligibility and enrollment

Eligibility and enrollment details for the Retiree Medical Plan - Cigna Network Only option

Most U.S. retirees, survivors and their eligible family members who reside in the Cigna service area are eligible for this Cigna option. The retiree’s home address zip code is used to determine whether the retiree resides in the service area and is therefore eligible for the Cigna option.

Generally you are eligible if:

• You are a retiree.
• You are a survivor/surviving spouse, which means an eligible family member of a deceased retiree, or employee.
• You are a Long Term Disability Retiree and are not eligible to be enrolled in Medicare Part A or B.
• Being an 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 to be enrolled in Medicare.

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 ExxonMobil Benefits Service Center.
• Your totally and continuously disabled child(ren) aged 26 or over who is 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 to be enrolled in 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 Definitions 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 Cigna OAPIN Option 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 family member 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 (MPO).

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 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

Effective January 1, 2019, retirees have three opportunities to enroll in the ExxonMobil Retiree Medical Plan:

1. At retirement, or
2. Upon loss of other employer coverage, or
3. 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 one of the following changes 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 can enroll either online or by phone. To enroll online, go to www.exxonmobil.com/benefits. To enroll by phone, call the ExxonMobil Benefits Service Center at 800-682-2847.

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 ExxonMobil 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 ExxonMobil Benefits Service Center, you may 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...	As a retiree you may...
Marriage	Add your spouse and any new eligible family members.
Divorce – Retiree and spouse enrolled in ExxonMobil health plans	You are 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	You or your spouse lose eligibility under the Retiree Medical Plan options but may enroll in the Medicare Primary Option (MPO).
Your disabled child (aged 26 or over) becomes entitled to enroll in Medicare as their primary coverage, whether or not they enroll in Medicare	Your child loses eligibility under the ExxonMobil Retiree Medical plans.
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 Cigna option, as an employee, you will maintain your claims, deductibles and out-of-pocket history as a retiree.  However, 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 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.

NOTE: Effective January 1, 2019, 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 coverage for the Retiree Medical Plan - Cigna 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 Retiree Medical Plan option. This provision also applies to a significant increase in health care deductible or copayment.

If the cost for coverage under your spouse's health 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 OAPIN 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 POS II option. 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 Cigna Customer Service 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 to be enrolled in Medicare

If you are a retiree, you and your family members who are not eligible to be enrolled in Medicare can continue to participate in the Retiree Medical Plan.  When you (as a retiree) or a covered spouse of a retiree becomes eligible to be enrolled in 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 may be eligible to enroll in the Medicare Primary Option. If you fail to enroll in the MPO when first eligible, then you or your covered spouse 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 to be enrolled in Medicare. Upon eligibility to be enrolled in Medicare, your spouse can continue coverage through the Medicare  Primary Option (MPO).

Children of deceased employees or 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

When coverage ends for the Retiree Medical Plan - Cigna option

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 to be enrolled in  Medicare and for the Medicare Primary Option (MPO),
• Your former employer discontinues participation in the Plan,

OR

The date:

• You do not make any required contribution,
• You are rehired by Exxon Mobil 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. If you do not complete your change within 60 days, any contributions you make for ineligible family members will not be refunded.

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 1^st 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.

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. 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. This includes failing to provide timely notification of when a covered family member loses eligibility, e.g, spouse loses eligibility due to divorce.

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

Information on how the Retiree Medical Plan - Cigna OAPIN Network Only option works

Network only benefits

To receive In-Network Medical Benefits, services must be provided by a Cigna Network Provider. A Cigna Network Provider is an institution, facility, agency or health care professional, which has contracted directly or indirectly with Cigna. Providers qualifying as Participating Providers may change from time to time. A list of the current Participating Providers is located online at www.mycigna.com. The Provider Organization is a network of Participating Providers.

If you see a doctor who does not participate in the Cigna Network, you’ll be responsible for all associated costs.

If you have a life-threatening medical emergency, go to your nearest hospital emergency department. Emergency services are covered at the In-Network benefit level until your medical condition is stabilized.

If you are unable to locate a Cigna Network Provider in your area who can provide you with a service or supply that is covered under the Cigna OAPIN option, you must call your Cigna Customer Services to obtain authorization for Out-of-Network Provider coverage. If you obtain authorization for services provided by an Out-of-Network Provider, those services will be covered at the In-Network benefit level.

Copayments

You share in the cost of most medical services and supplies. For some services and supplies, such as doctor’s visits, your share of the cost is a fixed dollar amount. This is called a copayment or copay. Your copay amount is printed on your plan ID card.

You won’t always pay a copay for medical services or supplies. Some services and supplies, such as preventive medications and your annual physical, are at no additional cost to you. And some services are subject to coinsurance.

Coinsurance

For some medical services and supplies, such as hospital stays and outpatient surgeries, your share of the cost is a percentage of the negotiated fees for services received. This is called coinsurance. The Plan pays 90% of the allowable expense and you pay 10%, until your annual out-of-pocket limit is reached.

Allowable expense

The allowable expense or allowed amount is the portion of billed charges for medical services and supplies that is considered eligible for payment by the Plan, before this amount is reduced by your copayment or coinsurance amount.

For most covered services, the allowed amount is the contracted rate between the Provider Organization and the participating Network Provider. Contracted rates vary among providers in the same service area. You can find network providers and compare costs on MyCigna.com or by calling Cigna Customer Service.

Note: You are responsible for any billed charges above the allowed amount, for example the difference in cost between a private and semi-private hospital room, and these additional charges do not accumulate towards your annual out-of-pocket limit.

Annual out-of-pocket limit

Your out-of-pocket limit is the maximum amount you could pay for covered expenses in a Contract Year. Your out-of-pocket limit includes your portion of the allowable expenses for covered medical services, supplies, and medications, including copays and coinsurance. Once your out-of-pocket maximum has been reached, benefits for covered expenses are payable at 100%.

Note: Monthly contributions, charges above the allowed amount for covered services, and charges for services that are not covered under the Cigna option do not accumulate towards your annual out-of-pocket limit.

Balance bill protection

Sometimes covered services are performed by a Non-Network Provider without your knowledge or ability to choose a participating provider, for example in an emergency situation or when you receive care in a network facility but a network physician is unavailable. When this happens, covered expenses are payable at the In-Network benefits level, and the allowable expense is limited to what is reasonable and customary for similar services in the same geographic area.

Most non-network charges will fall within reasonable and customary limits. However, if you receive a balance bill for the difference between a Non-Network Provider’s billed charges and what is considered reasonable and customary for covered services under the Cigna option, and you did not voluntarily elect to receive services from the Non-Network Provider, call Cigna Customer Service. The full or partial balance bill may qualify as a “hidden” allowable expense eligible for payment by the Plan.

Lifetime maximum benefit

The total maximum benefit per covered person is unlimited.

Contract year

Contract Year means a period from January 1 to December 31 each calendar year.

Benefits for in-network medical care

This Cigna OAPIN option pays the following benefits for in-network care:

• 100% Coverage for Preventive Care Services
  Medically-necessary preventive care services, including screenings and immunizations, as well as certain maintenance medications, including statins and contraception, will be covered at no additional cost.  
• Copay for Physician Visits
  The copays per visit for physician visits are $25 for primary care and $40 for specialists.
• Copays for Urgent Care and Emergency Room Visits
  The copays per visit for Urgent Care are $60 and $150 for Emergency Room visits.    
• 90% Coverage for Inpatient and Outpatient Care
  Inpatient and outpatient care, including surgeries and other pre-scheduled medical procedures, will be covered at 90% of the negotiated network fee for service. You are responsible for paying 10% of the cost of covered inpatient and outpatient medical services, until the combined medical/pharmacy annual out-of-pocket maximum is reached.
• Combined Out-of-Pocket Maximum
  The combined annual out-of-pocket limit for 2022 is $3,000 per individual and $6,000 per family. Out-of-pocket expenses for both covered medical and pharmacy will count towards the same annual maximum, after which the Plan will pay for covered services and prescriptions at no additional cost.

Referrals

Your PCP will provide your primary care and, when medically necessary, your PCP may refer you to other in network doctors or facilities for treatment. The referral is important because it is how your PCP arranges for you to receive necessary, appropriate care and follow-up treatment. While your plan does not require a referral from your PCP for you to see specialty doctors, you will want to coordinate such care with your PCP.  Also, certain services do require prior authorization from Cigna. In such case, your doctor will coordinate the prior authorization process with Cigna on your behalf. You will not be required, nor expected, to manually track the prior authorization.

Prior authorization/preauthorized

The term Prior Authorization means the approval that a Participating Provider must receive from Cigna in order for certain services and benefits to be covered under the Cigna OAPIN Option. Your PCP is responsible for obtaining authorization from Cigna for in-network covered services. 

Services that require Prior Authorization include, but are not limited to:

• Inpatient Hospital Services,
• Inpatient Services at any Other Participating Healthcare Facility,
• Outpatient Facility Services,
• Magnetic Resonance Imaging (MRI),
• Nonemergency Ambulance,
• Organ Transplant Services,
• Mental Health/Substance Use Disorder Treatment

Direct access for obstetric/gynecological services

You are allowed direct access to a licensed/certified Participating Provider for covered obstetric/gynecological services. There is no requirement to obtain an authorization of care from the Plan or from your Primary Care Physician for visits to a Participating Provider of your choice for pregnancy, well-woman gynecological exams, primary and preventive gynecological care, and acute gynecological conditions. Make sure that the OB/GYN is a Participating Provider prior to each visit and that any services that the OB/GYN requests will be In-Network under the Cigna OAPIN option

Health Management programs

Details on ExxonMobil's 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 Cigna 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 costs. 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 1-800-564-9286, 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 Advocate 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. Your Health Advocate could refer you to a Condition Management nurse if you are identified as needing treatment for a condition that is included in the program.

Condition management programs available include 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.

If you do not see your condition listed, please contact Cigna to check if your chronic condition can be managed by a nurse.

Cancer Care

Targeted outreach through health advocate nurses, case managers and digital coaching to provide personalized care management. Nurses are licensed, registered with clinical oncology experience. They can provide valuable education and guidance and are available 24 hours a day, seven days a week to help you through your cancer treatment.

Your Oncology Nurse will help set goals for treatment and medication, find in-network doctors and facilities, help with getting a second opinion and educate on diagnosis and treatment plan, what to expect, pain management, online researches and digital engagement tools. In addition, your nurse will look for ways to maximize benefits, barriers to care and offer solutions as well as treatment alternatives (i.e. clinical trails).

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 the Cigna MyConsult program. 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.

Cleveland Clinic MyConsult
800-223-2273 ext. 43223 (7 a.m. – 4 p.m. CT)
MyCigna.com (click the MyConsult link)

Musculoskeletal Conditions Support

Way too many of us have pain or problems with our musculoskeletal system — neck, back, shoulder, hip, knee or ankle. Surgery should rarely be the first option, especially for those of us who have chronic issues that are worsening slowly.

Hinge Health offers at no cost to you the right program and care for different joint and muscle pain needs that will help you feel better, reduce pain and learn helpful physical therapy exercises: 

• 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

Centers of Excellence

Centers of Excellence ("COE") 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 are not available for all illnesses and all conditions or procedures relevant to a disease state. For instance, at this time there are COEs for pancreatic cancer, but there is insufficient information available to select COEs for lung cancer. Changes to identified COEs may occur in the future. If you would like to learn more about different COE options you will need to contact the 24-hour nurse line who will put you in contact with a Health Advocate who will be able to discuss different options with you. 

Participation in a COE program is voluntary, and designed to direct participants to nationally recognized facilities with more positive outcomes. A COE-recommended treatment plan, however, must meet the Retiree Medical 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. If access to a clinically appropriate COE requires the patient to travel 75 or more miles, the Retiree Medical Plan will reimburse reasonable transportation costs for you and a caregiver. The Retiree Medical 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.

Please note that a specific cancer diagnosis must occur before you are eligible for travel benefits.

If you decide not to use a COE, you will not incur additional out-of-pocket costs for choosing another hospital in the Cigna network

Eligible services under the Plan

Covered expenses and limitations on the ExxonMobil Retiree Medical Plan - Cigna OAPIN Network Only option

Covered expenses

The term Covered Expenses means the expenses incurred by or on behalf of a covered person for the charges listed below. Expenses incurred for such charges are considered Covered Expenses to the extent that the services or supplies provided are recommended by a Physician and are essential for the necessary care and treatment of an Injury or Sickness. For expenses incurred for such charges to be considered Covered Expenses, the services or supplies provided must be Medically Necessary.

No Cigna Option benefits are payable unless the services or supplies are Covered Expenses recommended by and received from, or approved by, Participating Providers and are authorized by the Provider Organization, except in the case of Emergency Services. For Emergency Services from non-participating providers, participants must submit a claim no later than 60 days after the first Emergency Service is provided or as soon as reasonably possible. The claim should contain an itemized statement of treatment, expenses, and diagnosis.

Other limitations are shown in the General limitations section.

Preventive care and wellness

This section describes the eligible health services and supplies available under your plan when you are well.

Routine physical exams

Covered services include office visits to your physician, PCP or other health professional for routine physical exams. This includes routine vision (through age 18) and hearing screenings (through age 21) given as part of the exam. A routine exam is a medical exam given by a physician for a reason other than to diagnose or treat a suspected or identified illness or injury.

Preventive care immunizations

Covered health services include immunizations for infectious diseases, but does not include coverage of immunizations that are not considered preventive care, such as those for employment or travel.

Well woman preventive visits

Covered health services include routine well woman preventive exam office visit, including pap smears, general pelvic exams, and manual breast exams which are given for a reason other than to diagnose or treat a suspected or identified illness or injury.

Preventive screening and counseling services

Covered health services include screening and counseling by your health professional for some conditions. These include obesity, substance use disorders, use of tobacco products, sexually transmitted infection counseling and genetic risk counseling for breast and ovarian cancer.

Routine cancer screenings

Covered health services include the following routine cancer screenings:

• Mammograms
• Prostate specific antigen (PSA) tests
• Colonoscopies which includes removal of polyps performed during a screening procedure, and a pathology exam on any removed polyps
• Lung cancer screenings

Prenatal care

Covered health services include the routine prenatal physical exams to monitor maternal weight, blood pressure, fetal heart rate, and fundal height. Note that some prenatal care is billed at the coinsurance rate (reference the Benefit Summary section for more information).

Breast feeding durable medical equipment

Coverage includes renting or buying durable medical equipment you need to pump and store breast milk as follows:

• Breast pump:
• Renting a hospital grade electric pump while your newborn child is confined in a hospital.
• The buying of:
• An electric breast pump (non-hospital grade). Your plan will cover this cost once per pregnancy, or
• A manual breast pump. Your plan will cover this cost once per pregnancy.
• Breast pump supplies and accessories
• These are limited to only one purchase per pregnancy in any year where a covered female would not qualify for the purchase of a new pump.
• Coverage for the purchase of breast pump equipment is limited to one item of equipment, for the same or similar purpose, and the accessories and supplies needed to operate the item.
• You are responsible for the entire cost of any pieces of the same or similar equipment you purchase or rent for personal convenience or mobility.

Family planning services – female contraceptives

Covered family planning services include counseling services provided by your provider on contraceptive methods, contraceptive devices, and voluntary sterilization (tubal litigation).

Physicians and other health professionals

Physician services

• Charges made by a Physician or a Psychologist for professional services.
• Charges made by a Nurse, other than a member of your family or your Eligible Family Member's family, for professional services.
• Charges made for Telemedicine general medical services and/or behavioral health services provided by Cigna’s designated telemedicine providers as permissible under applicable state and local law. To learn more or initiate services, visit AmwellforCigna.com or call 1-855-667-9722 or MDLIVE at MDLIVEforCigna.com or call 1-888-726-3171.

Alternatives to physician office visits (walk-in clinic)

Covered services include health care services provided in contracted convenience care clinics (for unscheduled, non-medical emergency illnesses and injuries and for immunizations, where administration is within the scope of the clinic’s license).

Hospital and other facility care

Hospital care

• Charges made by a Hospital, on its own behalf, for Bed and Board and other Necessary Services and Supplies; except that for any day of Hospital In Patient Stay, Covered Expenses will not include that portion of charges for Bed and Board which is more than the Hospital’s negotiated rate for a semi-private room.
• Charges made by a Hospital, on its own behalf, for medical care and treatment received as an outpatient.
• Charges made by a Free-standing Surgical Facility, on its own behalf, for medical care and treatment.

Alternatives to hospital stays

Outpatient surgery and physician surgical services

• Charges made for varicose veins surgery when medically necessary.
• If multiple outpatient services are provided on the same day they constitute one visit, but a separate Copayment will apply to the services provided by each provider.

Home health care

• Charges made for Home Health Care Services when you; (a) require skilled care; (b) are unable to obtain the required care as an ambulatory outpatient; and (c) do not require in patient stay in a Hospital or Other Health Care Facility. Home Health Care Services are provided only if Cigna has determined that the home is a medically appropriate setting. If you are a minor or an adult who is dependent upon others for non-skilled care (e.g., bathing, eating, toileting), Home Health Services will only be provided for you during times when there is a family member or care giver present in the home to meet your non-skilled care needs. Home Health Services are those skilled health care services that can be provided during visits by Other Health Care Professionals. The services of a home health aide are covered when rendered in direct support of skilled health care services provided by Other Health Professionals. A visit is defined as a period of 2 hours or less. Home Health Services are subject to a maximum of 16 hours in total per day. Necessary consumable medical supplies and home infusion therapy administered or used by Other Health Professionals in providing Home Health Services are covered. Home Health Services do not include services by a person who is a member of your family or your Eligible Family Member's family or who normally resides in your house or your Eligible Family Member's house even if that person is an Other Health Professional. Physical, occupational, and other Short-Term Rehabilitative Therapy services provided in the home are not subject to the Home Health Services benefit limitations in the Schedule, but are subject to the benefit limitations described under Short-Term Rehabilitative Therapy Maximum shown in the In-Network Benefits Schedule.
• Covered Expenses do not include charges made by a Home Health Care Agency for: (a) care or treatment which is not stated in the Home Health Care Plan; (b) the services of a person who is a member of your family or your Eligible Family Member's family or who normally lives in your home or your Eligible Family Member's home; or (c) a period when a person is not under the continuing care of a Physician.

Hospice care

• Charges made for you or a covered family member who has been diagnosed as having six months or fewer to live, due to Terminal Illness, for the following Hospice Care Services provided under a Hospice Care Program: (a) by a Hospice Facility for Bed and Board and Services and Supplies, except that, for any day of admission in a private room, Covered Expenses will not include that portion of charges which is more than the Hospice Bed and Board Limit shown in the In-Network Benefits Schedule; (b) by a Hospice Facility for services provided on an outpatient basis; (c) by a Physician for professional services; (d) by a Psychologist, social worker, family counselor or ordained minister for individual and family counseling, including bereavement counseling within one year after the person's death; (e) for pain relief treatment, including drugs, medicines and medical supplies; (f) by a Home Health Care Agency for: part-time or intermittent nursing care by or under the supervision of a Nurse; or part-time or intermittent services of a Home Health Aide; (g) physical, occupational and speech therapy; and (h) medical supplies; drugs and medicines lawfully dispensed only on the written prescription of a Physician; and laboratory services; but only to the extent such charges would have been payable under the Cigna Option if the person had remained or been admitted to a Hospital or Hospice Facility.
• The following charges for Hospice Care Services are not included as Covered Expenses:
  • For the services of a person who is a member of your family or your Eligible Family Member's family or who normally resides in your house or your Eligible Family Member's house;
  • For any period when you or your Eligible Family Member is not under the care of a Physician;
  • For services or supplies not listed in the Hospice Care Program;
  • For any curative or life-prolonging procedures;
  • To the extent that any other benefits are payable for those expenses under the Cigna Option;
  • For services or supplies that are primarily to aid you or your Eligible Family Member in daily living;
  • For more than three bereavement counseling sessions;
  • For services for respite care; or
  • For nutritional supplements, non-prescription drugs or substances, medical supplies, vitamins or minerals, except as required by applicable law.

Skilled nursing facility

• Charges made by a Skilled Nursing Facility, on its own behalf, for medical care and treatment; except that for any day of Skilled Nursing Facility stay, Covered Expenses will not include that portion which is more than the Skilled Nursing Facility Limit shown in the In-Network Benefits Schedule; nor will benefits be payable for more than the maximum number of days shown in the In-Network Benefits Schedule. Benefits for Rehabilitative Hospitals and Sub-Acute Facilities are also included.

Emergency services and urgent care

• Charges made for Emergency Services and Urgent Care

Specific conditions

Maternity and related newborn care

Covered services include prenatal and postpartum care and obstetrical services. After your child is born, eligible health services include:

• 3 days of inpatient care in a hospital or birthing center after a vaginal delivery
• 5 days of inpatient care in a hospital or birthing center after a cesarean delivery
• A shorter stay, if the attending physician, with the consent of the mother, discharges the mother or newborn earlier

A birthing center is a facility specifically licensed as a freestanding birthing center by applicable state and federal laws to provide prenatal care, delivery and immediate postpartum care.

Coverage also includes the services and supplies needed for circumcision by a provider.

Mental health treatment

• Charges made for Mental Health Services:
• Charges made by a facility licensed to furnish mental health services, on its own behalf, for care and treatment of mental illness provided on an inpatient or outpatient basis.
• Mental health services are services that are required to treat a disorder that impairs the behavior, emotional reaction or thought processes. In determining benefits payable, charges made for the treatment of any physiological conditions related to Mental Health will not be considered to be charges made for treatment of Mental Health.
• Inpatient mental health services are services provided by a facility designated for the treatment and evaluation of Mental Illness. In lieu of hospitalization and upon authorization by Cigna, coverage can be provided in a participating Psychiatric Day Treatment Center, Crisis Stabilization Unit, or Residential Treatment Center for Children and Adolescents.
• Outpatient mental health services are services of participating providers qualified to treat Mental Illness on an outpatient basis for treatment of conditions such as: anxiety or depression interfering with daily functioning; emotional adjustment or concerns related to chronic conditions, such as psychosis or depression; emotional reactions associated with marital problems or divorce; child/adolescent problems of conduct or poor impulse control; affective disorders; suicidal or homicidal threats or acts; eating disorders; acute exacerbation of chronic mental illness (crisis intervention and relapse prevention). Coverage will also be provided for outpatient testing and assessment as authorized.
• Adjunctive group therapy can be utilized for treatment of depression, stress, phobia or other emotional disorders as authorized.

Substance related disorders treatment

• Charges made by a facility licensed to furnish treatment of alcohol and drug abuse, on its own behalf, for care and treatment provided on an inpatient or outpatient basis.
• Substance use disorder is defined as the psychological or physical dependence on alcohol or other mind-altering drugs requiring diagnosis, care, and treatment. To determine benefits payable, charges made for the treatment of any physiological conditions related to rehabilitation services for alcohol or drug abuse or addiction will not be considered to be charges made for treatment of substance use disorder.

Prior Mental Health/Substance Use Disorder Treatment

Examples of expenses or services that are not Allowable Expenses include, but are not limited to the following:

• An expense or service or a portion of an expense or service that is not covered by any of the plans is not an Allowable Expense.
• If you are confined to a private Hospital room and no Group Health Plan provides coverage for more than a semiprivate room, the difference in cost between a private and semiprivate room is not an Allowable Expense.
• If you are covered by two or more Group Health Plans that provide services or supplies on the basis of reasonable and customary fees, any amount in excess of the highest reasonable and customary fee is not an Allowable Expense.
• If you are covered by one Group Health Plan that provides services or supplies on the basis of reasonable and customary fees and one Group Health Plan that provides services and supplies on the basis of negotiated fees, the Primary Group Health Plan’s fee arrangement shall be the Allowable Expense.
• If your benefits are reduced under the Primary Group Health Plan (through the imposition of a higher copayment amount, higher coinsurance percentage, a deductible and/or a penalty) because you did not comply with Group Health Plan provisions or because you did not use a preferred provider, the amount of the reduction is not an Allowable Expense. Such Group Health Plan provisions include second surgical opinions and precertification of admissions or services.

Reconstructive surgery and supplies

• Charges made for cosmetic procedures, when medically necessary as defined by Cigna’s clinical guidelines
• Charges made for reconstructive surgery following a mastectomy; benefits include:  (a) surgical services for reconstruction of the breast on which surgery was performed; (b) surgical services for reconstruction of the non-diseased breast to produce symmetrical appearance; (c) postoperative breast prostheses; and (d) mastectomy bras and external prosthetics, limited to the lowest cost alternative available that meets external prosthetic placement needs. During all stages of mastectomy, treatment of physical complications, including lymphedema therapy are covered.
• Charges made for reconstructive surgery or therapy to repair or correct a severe facial disfigurement or severe physical deformity (other than abnormalities of the jaw related to TMJ disorder) provided that (a) the surgery or therapy restores or improves function; or (b) reconstruction is required as a result of medically necessary non-cosmetic surgery; or (c) the surgery or therapy is performed prior to age 19 and is required as a result of the congenital absence or agenesis (lack of formation or development) of a body part including, but not limited to:  microtia, amastia, and Poland Syndrome. Repeat or subsequent surgeries for the same condition are covered only when there is the probability of significant additional improvement as determined by Cigna.

Transplant services

• Charges made for human organ and tissue transplant services at designated facilities through the United States. All Organ Transplant Services listed below, other than cornea, kidney and autologous bone marrow/stem cell transplants are available when received at a qualified or provisional Cigna Lifesource Organ Transplant Network facility. The transplants that are covered at Participating Provider facilities, other than a Cigna Lifesource Organ Transplant Network facility are cornea, kidney and autologous bone marrow/stem cell transplants.
• Coverage is subject to the following conditions and limitations:
• Charges made for human organ and tissue Transplant services which include solid organ and bone marrow/stem cell procedures at designated facilities throughout the United States or its territories. This coverage is subject to the following conditions and limitations.
• Transplant services include the recipient’s medical, surgical and Hospital services; inpatient immunosuppressive medications; and costs for organ or bone marrow/stem cell procurement. Transplant services are covered only if they are required to perform any of the following human to human organ or tissue transplants: allogeneic bone marrow/stem cell, autologous bone marrow/stem cell, cornea, heart, heart/lung, kidney, kidney/pancreas, liver, lung, pancreas or intestine which includes small bowel-liver or multi-visceral.
• All Transplant services, other than cornea, are covered at 90% when received at Cigna LIFESOURCE Transplant Network® facilities. Cornea transplants are not covered at Cigna LIFESOURCE Transplant Network® facilities. Transplant services, including cornea, received at participating facilities specifically contracted with Cigna for those Transplant services, other than Cigna LIFESOURCE Transplant Network® facilities, are payable at the In-Network level. Transplant services received at any other facilities, including Non-Participating Providers and Participating Providers not specifically contracted with Cigna for Transplant services, are not covered.
• Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation (refer to Transplant Travel Services), hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary. Costs related to the search for, and identification of a bone marrow or stem cell donor for an allogeneic transplant are also covered.
• Charges made for nontaxable travel expenses incurred by you in connection with a preapproved organ/tissue transplant are covered subject to the following conditions and limitations. Transplant travel benefits are not available for cornea transplants. Benefits for transportation and lodging are available to you only if you are the recipient of a preapproved organ/tissue transplant from a designated Cigna LIFESOURCE Transplant Network® facility. The term recipient is defined to include a person receiving authorized transplant related services during any of the following: evaluation, candidacy, transplant event, or posttransplant care. Travel expenses for the person receiving the transplant will include charges for: transportation to and from the transplant site (including charges for a rental car used during a period of care at the transplant facility); and lodging while at, or traveling to and from the transplant site.
• In addition to your coverage for the charges associated with the items above, such charges will also be considered covered travel expenses for one companion to accompany you. The term companion includes your spouse, a member of your family, your legal guardian, or any person not related to you, but actively involved as your caregiver who is at least 18 years of age. The following are specifically excluded travel expenses: any expenses that if reimbursed would be taxable income, travel costs incurred due to travel within 60 miles of your home; food and meals; laundry bills; telephone bills; alcohol or tobacco products; and charges for transportation that exceed coach class rates.
• These benefits are only available when the covered person is the recipient of an organ/tissue transplant. Travel expenses for the designated live donor for a covered recipient are covered subject to the same conditions and limitations noted above. Charges for the expenses of a donor companion are not covered. No benefits are available when the covered person is a donor.

These benefits are only available when the covered person is the recipient of an organ/tissue transplant. Travel expenses for the designated live donor for a covered recipient are covered subject to the same conditions and limitations noted above.  Charges for the expenses of a donor companion are not covered.  No benefits are available when the covered person is a donor

Outpatient diagnostic testing

Diagnostic complex imaging services

Charges made for complex imaging services by a provider, including:

• Inpatient substance use disorder rehabilitation services are services provided In-Network for rehabilitation, while you or your eligible Family Member are admitted to a Hospital, requiring diagnosis and treatment of abuse or addiction to alcohol and/or drugs. Inpatient Substance Use Disorder Services include Partial Hospitalization sessions.

• Outpatient substance use disorder rehabilitation services are services provided for the diagnosis and treatment of abuse or addiction to alcohol and/or drugs, while you or your eligible Family Member is not admitted to a Hospital, including outpatient rehabilitation in an individual, group, structured group or in a Substance Use Disorder Intensive Outpatient Structured Therapy Program.  A Substance Use Disorder Outpatient Structured Therapy Program consists of distinct levels or phases of treatment that are provided by a certified/licensed substance use disorder program. Intensive Outpatient Structured Therapy programs provide a combination of individual, family and/or group therapy.

• Substance use disorder detoxification services are detoxification and related medical ancillary services provided when required for the diagnosis and treatment of addiction to alcohol and/or drugs. Cigna will decide, based on the Medical Necessity of each situation, whether such services will be provided in an inpatient or outpatient setting.

Complex imaging for preoperative testing is covered under this benefit.

Diagnostic lab work and radiological services

• Charges made for anesthetics and their administration; diagnostic x-ray and laboratory examinations; x-ray, radium, and radioactive isotope treatment; chemotherapy; blood transfusions; oxygen and other gases and their administration; formulas for infants (less than one year of age) with PKU, Maple Disease, Histidinemia or Homocystinuria.

Short-term rehabilitation services

• Charges made for Short-Term Rehabilitative Therapy that is part of a rehabilitation program which is medically necessary, including physical, speech, occupational, cognitive, cardiac rehabilitation and pulmonary rehabilitation therapy, when provided in the most medically appropriate setting. Services are provided on an outpatient basis are limited to sixty (60) days per Contract Year for any combination of these therapies, but only if significant improvement can be expected. The maximum day limit for Rehabilitative Therapy does not apply to occupational therapy, physical therapy or speech therapy prescribed for the treatment of covered mental health conditions, including Autism Spectrum Disorder, Down syndrome, cerebral palsy, fetal alcohol syndrome, muscular dystrophy, and other covered developmental delays.
• The following benefit limitations apply to Short-Term Rehabilitative Therapy and Chiropractic Care services:
  • Services which are considered custodial or educational in nature are not covered.
  • Occupational therapy provided only for purposes of enabling performance of the activities of daily living is not covered.

Other services

• Nutritional Evaluation and counseling from a Participating Provider is offered when diet is part of the medical management of a documented disease, including morbid obesity.  

Ambulance service

Charges are covered for licensed ambulance service to or from the nearest Hospital where the needed medical care and treatment can be provided.

Durable medical equipment (DME)

• Charges made for the purchase or rental of Durable Medical Equipment that is ordered or prescribed by a Physician and provided by a vendor approved by Cigna for use outside a Hospital or Other Health Care facility. Coverage for repair, replacement or duplicate equipment is provided only when required due to anatomical change and/or reasonable wear and tear. All maintenance and repairs that result from misuse are your responsibility. Durable Medical Equipment is defined as items which are designed for and able to withstand repeated use by more than one person; customarily serve a medical purpose; generally are not useful in the absence of Injury or Sickness; are appropriate for use in the home; and are not disposable. Such equipment includes, but is not limited to, crutches, hospital beds, wheel chairs, and dialysis machines. Charges made for or in connection with approved organ transplant services, including immunosuppressive medication; organ procurement costs; and donor's medical costs. The amount payable for donor's medical costs will be reduced by the amount payable for those costs from any other plan. Certain transplants will not be covered based on General Limitations. Contact Cigna before you incur any such costs.

Non-routine/non-preventive care hearing exams

Hearing exams of a non-routine or non-preventive nature are subject to the copayment for an office visit.

Prosthetic devices

• Charges for the purchase, maintenance or repair of internal prosthetic medical appliances consisting of permanent or temporary internal aids and supports for defective body parts; specifically intraocular lenses, artificial heart valves, cardiac pacemakers, artificial joints, intrauterine devices and other surgical materials such as screw nails sutures, and wire mesh; excluding all other prostheses.
• Charges for external breast prostheses incidental to a mastectomy (the Copayments and Maximums for external prostheses do not apply to breast prostheses).
• Charges made for the initial purchase and fitting of external prosthetic devices ordered or prescribed by a Physician which are to be used as replacements or substitutes for missing body parts and are necessary for the alleviation or correction of Sickness, Injury or congenital defect. External prosthetic devices shall include:

• Basic limb prosthetics; terminal devices such as hands or hooks; braces and splints; non-foot orthoses. Only the following non-foot orthoses are covered: (a) rigid and semirigid custom fabricated orthoses, (b) semirigid prefabricated and flexible orthoses; and (c) rigid prefabricated orthoses including preparation, fitting and basic additions, such as bars and joints.

• Custom foot orthotic. Custom foot orthotics are only covered as follows:
• For covered persons with impaired peripheral sensation and/or altered peripheral circulation (e.g. diabetic neuropathy and peripheral vascular disease).
• When the foot orthotic is an integral part of a leg brace and it is necessary for the proper functioning of the brace.
• When the foot orthotic is for use as a replacement or substitute for a missing part of the foot (e.g. amputation) and is necessary for the alleviation or correction of illness, injury, or congenital defect.
• For covered persons with neurologic or neuromuscular condition (e.g. cerebral palsy, hemiplegia, spina bifida) producing spasticity, malalignment, or pathological positioning of the foot and there is reasonable expectation of improvement.

• The following are specifically excluded:
• External power enhancements or power controls for prosthetic limbs and terminal devices;
• Orthotic shoes, shoe additions, procedures for foot orthopedic shoes, shoe modifications and transfers; and
• Orthoses primarily used for cosmetic rather than functional reasons.
• Replacement and repair of external prosthetic appliances is covered only when required due to reasonable wear and tear and/or anatomical change. All maintenance and repairs that result from the covered person's misuse are the covered person's responsibility.

Spinal manipulation

Charges made for services that are provided by a Participating chiropractic Physician when provided in an outpatient setting. Services of a chiropractic Physician include the management of neuro musculoskeletal conditions through manipulation and ancillary physiological treatment that is rendered to restore motion, reduce pain and improve function. Such coverage is available only for rehabilitation following injuries, surgery or medical conditions

Prescription drug benefits

If you or any one of your Family Members, while covered for these benefits, incurs expenses for charges made by a Participating Pharmacy for Prescription Drugs for an Injury or a Sickness, Cigna will pay that portion of the expense remaining after you or your Family Member has paid the required Copayment shown in the Benefit Summary.

Covered expenses will include only Medically Necessary Prescription Drugs and Related Supplies.

Covered charges will include those Prescription Drugs lawfully dispensed upon the written prescription of a Participating Physician or licensed Dentist, at a Participating Pharmacy. Coverage for Prescription Drugs is subject to a Copayment. The Copayment amount will never exceed the cost of the drug.

Benefits include coverage of insulin, insulin needles and syringes, glucose test strips and lancets.

If you or any one of your Family Members, while covered for these benefits, is issued a Prescription for a Prescription Drug as part of the rendering of Emergency Services and the prescription cannot reasonably be filled by a Participating Pharmacy, such prescription will be covered as if filled by a Participating Pharmacy.

Limitations

Each prescription drug order or refill will be limited as follows:

• Up to a consecutive thirty (30)-day supply at a Participating Retail Pharmacy, unless limited by the drug manufacturer's packaging;
• Up to a consecutive ninety (90)-day supply at a Participating Retail or Cigna Home Delivery Pharmacy, unless limited by the drug manufacturer's packaging, or
• To a dosage limit as determined by the Cigna HealthCare Pharmacy and Therapeutics Committee.
• If two or more prescriptions or refills are dispensed at the same time a Copayment must be paid for each prescription order or refill.
• When a treatment regimen contains more than one type of drug and the drugs are packaged together for the convenience of the covered person, a co-insurance will apply to each type of drug.
• For maintenance medications, as determined by Cigna, and generally drugs taken on a regular basis to treat ongoing conditions, Cigna will provide coverage for two fills for 30 days at a retail pharmacy.  For additional refills, these maintenance medications will only be covered when members order a 90-day supply through a Participating Retail Cigna Home Delivery Pharmacy.
• Cigna will also apply, step therapy (prior authorization program) rules for certain medications as identified by Cigna.  Individuals affected by these rules will be contacted directly by Cigna.
• When both a generic and a name brand drug are available, and the participant receives the name brand drug, the member is responsible for the applicable copay and the difference in cost between the name brand drug and the generic drug. 

Exclusions

No payment will be made for the following expenses:

• Drugs or medications available over the counter for which state or federal laws do not require a prescription or medication that is equivalent (in strength, regardless of form) to an over the counter drug or medication.
• Injectable drugs or medicines, including injectable infertility drugs other than injectables included on the Formulary, used to treat diabetes, acute migraine headaches, anaphylactic reactions, vitamin deficiencies and injectables used for anticoagulation. However, upon prior authorization by Cigna, injectable drugs may be covered subject to the required Copayment;
• Any drugs that are labeled as experimental or investigational.
• Food and Drug Administration (FDA) approved prescription drugs used for purposes other than those approved by the FDA unless the drug is recognized for the treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopeia Drug Information, the American Medical Association Drug Evaluations, or The American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peer-reviewed national professional medical journal.
• Prescription and nonprescription supplies (such as ostomy supplies), devices, and appliances other than syringes used in conjunction with injectable medications and glucose test strips.
• Prescription drugs or medications used for treatment of sexual dysfunction, including, but not limited to erectile dysfunction, delayed ejaculation, anorgasmy and decreased libido.
• Prescription vitamins (other than prenatal vitamins), dietary supplements and fluoride products, except for formulas prescribed by a Participating Physician as necessary for the treatment of phenylketonuria or similar inheritable conditions that may cause or result in mental or physical disability.
• Prescription drugs used for cosmetic purposes such as: drugs used to reduce wrinkles, drugs to promote hair growth, drugs used to control perspiration, and fade cream products.
• Diet pills, or appetite suppressants (anorectics).
• Prescription smoking cessation products above the dosage limit as determined by Cigna HealthCare Pharmacy, and Therapeutics Committee.
• Immunization agents, biological products for allergy immunization, biological sera, blood, blood plasma and other blood products or fractions and medications used for travel prophylaxis, with the exception of malaria prophylactic drugs.  Malaria prophylactic drugs are covered.
• Replacement of Prescription Drugs due to loss or theft except as part of disaster relief efforts.
• Medications used to enhance athletic performance.
• Medications which are to be taken by or administered to a participant while the participant is a patient in a licensed Hospital, skilled nursing facility, rest home or similar institution with a facility dispensing pharmaceuticals on it premises.
• Prescriptions more than one year from the original date of issue.
• A drug class in which at least one of the drugs is available over the counter and the drugs in the class are deemed to be therapeutically equivalent as determined by the Pharmacy and Therapeutics Committee (such as antihistamines).
• All newly FDA approved drugs, prior to review by the Pharmacy, and Therapeutics Committee.
• Norplant, and other implantable contraceptive products.

General limitations

Medical benefits

No payment will be made for expenses incurred for you or any one of your Family Members:

• For or in connection with an Injury arising out of, or in the course of, any employment for wage or profit.
• For or in connection with a Sickness which is covered under any workers' compensation or similar law.
• For charges made by a Hospital owned or operated by or which provides care or performs services for the United States Government, if such charges are directly related to a military-service-connected Sickness or Injury.
• To the extent that payment is unlawful where the person resides when the expenses are incurred:
• For charges which the person is not legally required to pay.
• For charges for unnecessary care, treatment, or surgery.
• For or in connection with Custodial Services, education, or training.
• To the extent that you or any one of your Family Members is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid.
• For experimental drugs or substances not approved by the Food and Drug Administration, or for drugs labeled: Caution - limited by federal law to investigational use.
• For or in connection with experimental procedures or treatment methods not approved by the American Medical Association or the appropriate medical specialty society.
• For charges made by a Physician for or in connection with surgery which exceed the following maximum when two or more surgical procedures are performed at one time: the maximum amount payable will be the amount otherwise payable for the most expensive procedure, and 1/2 of the amount otherwise payable for all other surgical procedures.
• For or in connection with in vitro fertilization, artificial insemination, GIFT (Gamete Intrafallopian Transfer), ZIFT (Zygote Intrafallopian Transfer), or similar procedures.
• For charges made by an assistant surgeon / co-surgeons that does not meet: a) the scheduled surgery being in a participating facility and b) participating primary surgeon.
• For charges made for or in connection with the purchase or replacement of contact lenses except as specifically provided under Exclusive Provider Medical Benefits, however, the purchase of the first pair of contact lenses that follows cataract surgery will be covered.
• For charges made for or in connection with routine refractions, eye exercises and for surgical treatment for the correction of a refractive error, including radial keratotomy, when eyeglasses or contact lenses may be worn.
• For charges for supplies, care, treatment or surgery which are not considered essential for the necessary care and treatment of an Injury or Sickness, as determined by Cigna.
• For charges made for or in connection with tired, weak or strained feet for which treatment consists of routine foot care, including but not limited to, the removal of calluses and corns or the trimming of nails unless medically necessary.
• For or in connection with speech therapy, if such therapy is (a) used to improve speech skills that have not fully developed, (b) can be considered custodial or educational, or (c) is intended to maintain speech communication, speech therapy which is not restorative in nature will not be covered.
• For charges made by any covered provider who is a member of your family or your Eligible Family Member's family.
• No payment will be made for expenses incurred for you or any one of your Family Members to the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with:
  • A no-fault insurance law; or
  • An uninsured motorist insurance law.
  • Cigna will take into account any adjustment option chosen under such part by you or any one of your Family Members.
• For charges which would not have been made if the person had no insurance;
• To the extent that you or any one of your Family Members is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid,
• For Experimental, Investigational or Unproven Services which are medical, surgical, psychiatric, substance use disorder or other healthcare technologies, supplies, treatments, procedures, drug therapies, or devices that are determined by Cigna , to be:
  • not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not recognized for the treatment of the particular indication in one of the standard reference compendia (The United States Pharmacopeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information) or in medical literature. Medical literature means scientific studies published in a peer-reviewed national professional journal, or
  • the subject of review or approval by an Institutional Review Board for the proposed use, or
  • the subject of an ongoing clinical trial that meets the definition of a phase I, II, or III Clinical Trial as set forth in the FDA regulations, regardless of whether the trial is subject to FDA oversight, or
  • not demonstrated, through existing peer-reviewed literature, to be safe and effective for treating, or diagnosing the condition or illness for which its use is proposed.
• For expenses incurred outside the United States or Canada, unless you or your Family Member is a U.S., or Canadian resident and the charges are incurred while traveling on business or for pleasure.
• For non-medical ancillary services, including but not limited to, vocational rehabilitation, behavioral training, sleep therapy, employment counseling, driving safety and services, training, custodial care, or educational therapy for learning, intellectual or developmental disabilities.
• For medical treatment when payment is denied by a Primary Group Health Plan because treatment was received from a non-participating provider;
• For charges which you are not obligated to pay or for which you are not billed or for which you would not have been billed except that they were covered under this plan.
• For medical and Hospital care and costs for the infant child of an Eligible Family Member, unless that infant child is otherwise eligible under this Cigna option.

Anything not specifically listed as included in Covered expenses and limitations section, is excluded.

Exclusions

What your plan doesn’t cover

Covered Expenses will not include, and no payment will be made for, expenses incurred:

Physicians and other health professionals

• For routine physical examinations not required for health reasons including, but not limited to, employment, insurance, government license, court-ordered, forensic or custodial evaluations.
• Unless otherwise covered as a basic benefit, reports, evaluations, physical examinations, or hospitalization not required for health reasons including, but not limited to, employment, insurance or government licenses, and court ordered, forensic or custodial evaluations.
• For which benefits are not payable according to the General limitations section; except that the following will not apply to this section: (a) limitations with respect to a maximum for multiple surgical procedures, an allowable charge for an assistant surgeon or co-surgeon and covered providers being family members; (b) the limitation, if any, with respect to a child under 15 days old; and (c) any certification or second opinion requirements shown in the In-Network Benefits Schedule.

  Hospital and other facility care

• Care for health conditions, which are required by state or local law to be treated in a public facility.
• Assistance in the activities of daily living, including, but not limited to eating, bathing, dressing, or other custodial or self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care.
• For court ordered treatment or hospitalization, unless such treatment is prescribed by a Physician and listed under the Covered expenses section of this booklet.
• For non-medical ancillary services, including but not limited to vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back to school, work hardening, driving safety, and services, training, educational therapy or other non-medical ancillary services for learning, intellectual or developmental disabilities.
• For private Hospital rooms and/or private duty nursing unless determined by Cigna to be Medically Necessary
• For personal or comfort items such as personal care kits provided on admission to a Hospital, television, telephone, newborn infant photographs, complimentary meals, birth announcements, and other articles which are not for the specific treatment of an Injury or Sickness.

Specific conditions

• Autism Spectrum Disorder - Applied Behavior Analysis (ABA) for dependent children who are diagnosed with Autism Spectrum Disorder (ASD). Also not covered are custodial care, educational services, or services performed in an academic, vocational or recreational setting.
• Mental health and substance use disorder services exclusions: any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody or visitation evaluations unless Medically Necessary and otherwise covered under this plan.
• For Treatment/surgery of mandibular or maxillary prognathism, microprognathism or malocclusion, surgical augmentation for orthodontics, or maxillary constriction.
• For or in connection with treatment of the teeth or periodontium unless such expenses are incurred for: (a) charges made for a continuous course of Dental treatment started within six months of an Injury to sound natural teeth; or (b) charges made by a Hospital for Bed and Board or Necessary Services and Supplies; or (c) charges made by a Free-Standing Surgical Facility or the outpatient department of a Hospital in connection with surgery.
• For craniosacral therapy, panniculectomy and abdominoplasty, or prolotherapy.
• For temporomandibular joint dysfunction services.
• For bariatric surgery.
• For varicose vein treatment except when medically necessary.
• For in connection with procedures to reverse sterilization.
• For non-therapeutic or elective abortions.
• For rhinoplasty.

Specific therapies and tests

• For rehabilitative therapy by a licensed physical, occupational or speech therapist, or chiropractor, on an outpatient basis, limited to 60 days per Contract Year for any combination of these therapies but only if significant improvement can be expected as determined by the Cigna Medical Director. The maximum day limit for Rehabilitative Therapy does not apply to occupational therapy, physical therapy or speech therapy prescribed for the treatment of covered mental health conditions, including Autism Spectrum Disorder, Down syndrome, cerebral palsy, fetal alcohol syndrome, muscular dystrophy, and other covered developmental delays.
• For therapy to improve general physical condition if not Medically Necessary, including, but not limited to, routine, long-term chiropractic care, and rehabilitative services which are provided to reduce potential risk factors in patients in which significant therapeutic improvement is not expected.
• For amniocentesis, ultrasound, or any other procedures requested solely for gender determination of a fetus, unless Medically Necessary to determine the existence of a gender -linked genetic disorder.
• For genetic testing and therapy including germ line and somatic unless determined Medically Necessary by Cigna for the purpose of making treatment decisions.

Other services

• For Cosmetic Surgery or Therapy. Cosmetic Surgery or Therapy is defined as surgery or therapy performed to improve appearance or self-esteem, except for those that are primarily for the purpose of restoring a bodily function or surgery, which is medically necessary.
• Any services, except Emergencies, not provided upon the prior written approval of the Cigna Medical Director or rendered by Participating Providers.
• For hearing aids or examinations for prescription or fitting thereof, except as otherwise specified in this section.
• 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.
• Respite, shadow, or companion services.
• 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.
• Counseling for borderline intellectual functioning.
• Counseling for occupational problems.
• Counseling related to consciousness raising.
• Vocational or religious counseling.
• I.Q. testing.
• Custodial care, including but not limited to geriatric day care.
• Psychological testing on children requested by or for a school system.
• Occupational/recreational therapy programs even if combined with supportive therapy for age-related cognitive decline.
• For replacement of external prostheses due to wear and tear resulting from misuse or abuse, loss, theft or destruction; or for any biomechanical external prosthetic devices.
• For penile prostheses, unless Medically Necessary.
• For the following vision care service, by way of example, but not of limitation: services or items related to orthoptics or vision training; magnification vision aids; charges for tinting, antireflective coatings, prescription sunglasses or light sensitive lenses; an eye examination required by an employer as a condition of employment or which an employer is required to provide under a collective-bargaining agreement; any eye exam required by law; safety glasses or lenses required for employment; any non-prescription eyeglasses, lenses or contact lenses.
• The limitation with respect to routine eye refraction's in the General limitations section will not apply to coverage for complete eye examinations.
• For treatment by acupuncture.
• For artificial aids including, but not limited to, corrective orthopedic shoes, arch supports, elastic stockings, garter belts, corsets, hearing aids, dentures and wigs.
• For consumable medical supplies other than ostomy supplies and urinary catheters. Excluded supplies include, but are not limited to bandages and other disposable medical supplies, skin preparations and test strips, except as specified in the "Home Health Services" or "Breast Reconstruction and Breast Prostheses" sections of Covered expenses.
• For membership costs or fees associated with health clubs, weight loss programs and smoking cessation programs.
• For fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in Cigna’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery.
• For blood administration for the purpose of general improvement in physical condition.
• For the cost of biologicals that are immunizations or medications for the purpose of the travel, or to protect against occupational hazards and risks.
• For cosmetics, dietary supplements, health and beauty aids and nutritional formulae. However, nutritional formulae for infants (less than one year of age) are covered when required for:
(a) the treatment of inborn errors of metabolism or inherited metabolic disease (including disorders of amino acid and organic acid metabolism); or
(b) enteral feeding for which the nutritional formulae under state or federal law can be dispensed only through a Physician's prescription, and are Medically Necessary as the primary source of nutrition.



• For all noninjectable prescription drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in the Covered expenses section of this booklet.
• For which benefits are not payable according to the General limitations section.
• Any procedure, treatment or other type of coverage prohibited under federal, state, local or other applicable law.

Coordination of benefits

Coordination of benefits for the Retiree Medical Plan - Cigna option

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

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

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

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

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

Coverage of a child

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

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

Payments

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

Incorrect computation of benefits

If you believe that the amount of the benefit you receive from the Plan is incorrect, you should notify Cigna in writing or contact Cigna Customer Service.

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

Recovery of overpayment

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

This section applies if you or any one of your Family Members is covered under more than one group health plan and determines how benefits payable from all such group health plans will be coordinated. You should file all claims with each group health plan.

Effect on the benefits of this Cigna option

If this Cigna option is the Secondary Group Health Plan, this Group Health Plan may reduce benefits so that the total benefits paid by all Plans during a Claim Determination Period are not more than one hundred percent (100%) of the total of all Allowable Expenses.

The difference between the amount that this Cigna option would have paid if this Cigna option had been the Primary Group Health Plan, and the benefit payments that this Cigna option had actually paid as the Secondary Group Health Plan, will be recorded as a benefit reserve for you. Cigna will use this benefit reserve to pay any Allowable Expense not otherwise paid during the Claim Determination Period.

As each claim is submitted, Cigna will determine the following:

• Cigna obligation to provide services and supplies under this Cigna Option,
• Whether a benefit reserve has been recorded for you, and
• Whether there are any unpaid Allowable Expenses during the Claims Determination Period.

If there is a benefit reserve, Cigna will use the benefit reserve recorded for you to pay up to one hundred percent (100%) of the total of all Allowable Expenses. At the end of the Claim Determination Period, your benefit reserve will return to zero (0) and a new benefit reserve shall be calculated for each new Claim Determination Period.

Recovery of excess benefits

If Cigna pays charges for benefits that should have been paid by the Primary Group Health Plan, or if Cigna pays charges in excess of those for which we are obligated to provide under the Plan, Cigna will have the right to recover the actual payment made or the Reasonable Cash Value of any services.

Cigna will have sole discretion to seek such recovery from any person to, or for whom, or with respect to whom, such services were provided or such payments made by any insurance company, healthcare plan or other organization. If we request, you shall execute and deliver to us such instruments and documents as we determine are necessary to secure the right of recovery.

Right to receive and release information

Cigna, without consent or notice to you, may obtain information from and release information to any other Group Health Plan with respect to you in order to coordinate your benefits pursuant to this section. You must provide us with any information we request in order to coordinate your benefits pursuant to this section. This request may occur in connection with a submitted claim; if so, you will be advised that the other coverage information, (including an Explanation of Benefits paid under the Primary Group Health Plan) is required before the claim will be processed for payment. If no response is received within 90 days of the request, the claim will be denied. If the requested information is subsequently received, the claim will be processed.

Right of reimbursement

The Cigna option does not cover:

• Expenses for which another party may be responsible as a result of liability for causing or contributing to the injury or illness of you or your Family Member(s).
• Expenses to the extent they are covered under the terms of any automobile medical, automobile no fault, uninsured or underinsured motorist, workers' compensation, government insurance, other than Medicaid, or similar type of insurance or coverage when insurance coverage provides benefits on behalf of you or your Family Member(s).

If you or a Family Member incurs health care Expenses as described above, Cigna shall automatically have a lien upon the proceeds of any recovery by you or your Family Member(s) from such party to the extent of any benefits provided to you or your Family Member(s) by the Plan. You or your Family Member(s) or their representative shall execute such documents as may be required to secure Cigna’s rights. Cigna shall be reimbursed the lesser of:

• The amount actually paid by Cigna under the Plan, or
• An amount actually received from the third party,
• At the time that the third party's liability is determined and satisfied; whether by settlement, judgment, arbitration or otherwise.

Payment of benefits

To whom payable

At the option of Cigna and with the consent of the Employer, all or any part of medical benefits may be paid directly to the person or institution on whose charge claim is based. Otherwise, medical benefits are payable to you.

If any person to whom benefits are payable is a minor or, in the opinion of Cigna, is not able to give a valid receipt for any payment due him, such payment will be made to his legal guardian. If no request for payment has been made by his legal guardian, Cigna may, at its option, make payment to the person or institution appearing to have assumed his custody and support.

If you die while any of these benefits remain unpaid, Cigna may choose to make direct payment to any of your following living relatives: spouse, mother, father, child or children, brothers or sisters, or to the executors or administrators of your estate.

Payment as described above will release Cigna from all liability to the extent of any payment made.

Time of payment

Benefits will be paid by Cigna when it receives due proof of loss.

Recovery of overpayment

When an overpayment has been made by Cigna, Cigna will have the right at any time to: (a) recover that overpayment from the person to whom or on whose behalf it was made; or (b) offset the amount of that overpayment from a future claim payment.

Continuation coverage

Continuation coverage on the Retiree Medical Plan - Cigna OAPIN 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 Retiree 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. 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

Claim determination procedures

Claim determination procedures for the Retiree Medical Plan - Cigna option

Procedures regarding medical necessity determinations

In general, health services and benefits must be medically necessary to be covered under the Plan. The procedures for determining medical necessity vary, according to the type of service or benefit requested, and the type of health plan. Medical necessity determinations are made on either a pre-service, concurrent, or post-service basis, as described below.

Certain services require prior authorization in order to be covered. This prior authorization is called a pre-service medical necessity determination. This booklet describes who is responsible for obtaining this review. You or your authorized representative (typically, your health care provider) must request medical necessity determinations according to the procedures described below, and in your provider's network participation documents as applicable. When services or benefits are determined to be not medically necessary, you or your representative will receive a written description of the adverse determination, and may appeal the determination. Appeal procedures are described below, in your provider's network participation documents, and in the determination notices.

Pre-service medical necessity determinations

When you or your representative request a required medical necessity determination prior to care, Cigna will notify you or your representative of the determination within 15 days after receiving the request. However, if more time is needed due to matters beyond Cigna's control, Cigna will notify you or your representative within 15 days after receiving your request. This notice will include the date a determination can be expected, which will be no more than 30 days after receipt of the request. If more time is needed because necessary information is missing from the request, the notice will also specify what information is needed, and you or your representative must provide the specified information to Cigna within 45 days after receiving the notice. The determination period will be suspended on the date Cigna sends such a notice of missing information, and the determination period will resume on the date you or your representative responds to the notice.

If the determination periods above would (a) seriously jeopardize your life or health, your ability to regain maximum function, or (b) in the opinion of a Physician with knowledge of your health condition, cause you severe pain which cannot be managed without the requested services, Cigna will make the pre-service determination on an expedited basis. Cigna's Physician reviewer, in consultation with the treating Physician, will decide if an expedited appeal is necessary. Cigna will notify you or your representative of an expedited determination within 72 hours after receiving the request. However, if necessary information is missing from the request, Cigna will notify you or your representative within 24 hours after receiving the request to specify what information is needed. You or your representative must provide the specified information to Cigna within 48 hours after receiving the notice. Cigna will notify you or your representative of the expedited benefit determination within 48 hours after you or your representative responds to the notice. Expedited determinations may be provided orally, followed within 3 days by written or electronic notification.

If you or your representative fails to follow Cigna's procedures for requesting a required pre-service medical necessity determination, Cigna will notify you or your representative of the failure and describe the proper procedures for filing within five days (or 24 hours, if an expedited determination is required, as described above) after receiving the request. This notice may be provided orally, unless you or your representative requests written notification.

Concurrent medical necessity determinations

When an ongoing course of treatment has been approved for you and you wish to extend the approval, you or your representative must request a required concurrent medical necessity determination at least 24 hours prior to the expiration of the approved period of time or number of treatments. When you or your representative requests such a determination, Cigna will notify you or your representative of the determination within 24 hours after receiving the request.

Post-service medical necessity determinations

When you or your representative requests a medical necessity determination after services have been rendered, Cigna will notify you or your representative of the determination within 30 days after receiving the request. However, if more time is needed to make a determination due to matters beyond Cigna's control Cigna will notify you or your representative within 30 days after receiving the request. This notice will include the date a determination can be expected, which will be no more than 45 days after receipt of the request.

If more time is needed because necessary information is missing from the request, the notice will also specify what information is needed, and you or your representative must provide the specified information to Cigna within 45 days after receiving the notice. The determination period will be suspended on the date Cigna sends such a notice of missing information, and the determination period will resume on the date you or your representative responds to the notice.

Notice of adverse determination

Every notice of an adverse benefit determination will be provided in writing or electronically, and will include all of the following that pertain to the determination: (1) the specific reason or reasons for the adverse determination; (2) reference to the specific plan provisions on which the determination is based; (3) a description of any additional material or information necessary to perfect the claim and an explanation of why such material, or information is necessary; (4) a description of the Plan's review procedures and the time limits applicable, including a statement of a claimant's rights to bring a civil action under section 502(a) of ERISA following an adverse benefit determination on appeal; (5) upon request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the adverse determination regarding your claim, and an explanation of the scientific or clinical judgment for a determination that is based on a medical necessity, experimental treatment or other similar exclusion or limit; (6) in the case of a claim involving urgent care, a description of the expedited review process applicable to such claim.

When you have a complaint or an appeal

What to do when you have a complaint or an appeal on the Retiree Medical Plan - Cigna option

For the purposes of this section, any reference to you or your also refers to a representative or provider designated by you to act on your behalf; unless otherwise noted.

We want you to be completely satisfied with the care you receive. That is why we have established a process for addressing your concerns and solving your problems.

Start with customer service

We are here to listen and help. If you have a concern regarding a person, a service, the quality of care, contractual benefits, or a rescission of coverage, you may call the toll-free number on your ID card, explanation of benefits, or claim form and explain your concern to one of our Customer Service representatives. You may also express that concern in writing.

We will do our best to resolve the matter on your initial contact. If we need more time to review or investigate your concern, we will get back to you as soon as possible, but in any case within 30 days. If you are not satisfied with the results of a coverage decision, you may start the appeals procedure.

Internal appeals procedure

To initiate an appeal, you must submit a request for an appeal in writing to Cigna within 180 days of receipt of a denial notice. You should state the reason why you feel your appeal should be approved and include any information supporting your appeal. If you are unable or choose not to write, you may ask Cigna to register your appeal by telephone. Call or write us at the toll-free number on your ID card, explanation of benefits, or claim form.

Your appeal will be reviewed and the decision made by someone not involved in the initial decision. Appeals involving Medical Necessity or clinical appropriateness will be considered by a health care professional.

We will respond in writing with a decision within 30 calendar days after we receive an appeal for a required preservice or concurrent care coverage determination or a post-service Medical Necessity determination. We will respond within 60 calendar days after we receive an appeal for any other post-service coverage determination. If more time or information is needed to make the determination, we will notify you in writing to request an extension of up to 15 calendar days and to specify any additional information needed to complete the review.

In the event any new or additional information (evidence) is considered, relied upon or generated by Cigna in connection with the appeal, Cigna will provide this information to you as soon as possible and sufficiently in advance of the decision, so that you will have an opportunity to respond. Also, if any new or additional rationale is considered by Cigna, Cigna will provide the rationale to you as soon as possible and sufficiently in advance of the decision so that you will have an opportunity to respond.

You may request that the appeal process be expedited if, (a) the time frames under this process would seriously jeopardize your life, health or ability to regain maximum functionality or in the opinion of your Physician would cause you severe pain which cannot be managed without the requested services, or (b) your appeal involves nonauthorization of an admission or continuing inpatient Hospital stay.

If you request that your appeal be expedited based on (a) above, you may also ask for an expedited external review at the same time, if the time to complete an expedited review would be detrimental to your medical condition.

When an appeal is expedited, Cigna will respond orally with a decision within 72 hours, followed up in writing.

External review procedure

If you are not fully satisfied with the decision of Cigna's internal appeal review and the appeal involves medical judgment or a rescission of coverage, you may request that your appeal be referred to an Independent Review Organization (IRO). The IRO is composed of persons who are not employed by Cigna, or any of its affiliates. A decision to request an external review to an IRO will not affect the claimant's rights to any other benefits under the Plan.

There is no charge for you to initiate an external review. Cigna and your benefit plan will abide by the decision of the IRO.

To request a review, you must notify the Appeals Coordinator within 4 months of your receipt of Cigna's appeal review denial. Cigna will then forward the file to a randomly selected IRO. The IRO will render an opinion within 45 days.

When requested, and if a delay would be detrimental to your medical condition, as determined by Cigna's Physician Reviewer, or if your appeal concerns an admission, availability of care, continued stay, or health care item or service for which you received emergency services, but you have not yet been discharged from a facility, the external review shall be completed within 72 hours.

Notice of benefit determination on appeal

Every notice of a determination on appeal will be provided in writing or electronically and, if an adverse determination, will include: information sufficient to identify the claim; the specific reason or reasons for the adverse determination; reference to the specific plan provisions on which the determination is based; a statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other Relevant Information as defined below; a statement describing any voluntary appeal procedures offered by the Plan and the claimant's right to bring an action under ERISA section 502(a), if applicable; upon request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the adverse determination regarding your appeal, and an explanation of the scientific or clinical judgment for a determination that is based on a Medical Necessity, experimental treatment or other similar exclusion or limit, and information about any office of health insurance consumer assistance or ombudsman available to assist you in the appeal process. A final notice of an adverse determination will include a discussion of the decision.

You also have the right to bring a civil action under section 502(a) of ERISA if you are not satisfied with the decision on review. You or your plan may have other voluntary alternative dispute resolution options such as Mediation. One way to find out what may be available is to contact your local U.S. Department of Labor office or the Plan Administrator.

Relevant information

Relevant Information is any document, record or other information which: was relied upon in making the benefit determination; was submitted, considered or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; demonstrates compliance with the administrative processes and safeguards required by federal law in making the benefit determination, or constitutes a statement of policy or guidance with respect to the Plan concerning the denied treatment option or benefit for the claimant's diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.

Legal action

If your plan is governed by ERISA, you have the right to bring a civil action under section 502(a) of ERISA if you are not satisfied with the outcome of the Appeals Procedure. In most instances, you may not initiate a legal action against Cigna until you have completed the appeal processes. However, no action will be brought at all unless brought within three years after proof of claim is required under the Plan. However, no action will be brought at all unless brought within three years after a claim is submitted for In-Network Services or within three years after proof of claim is required under the Plan for Out-of-Network service

Federal Notices

Notice of federal requirements related to the Retiree Medical Plan - Cigna 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.

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 Cigna Customer Service.

Coverage for maternity hospital stay

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

Administrative and ERISA information

Administrative and ERISA information for the Retiree Medical Plan - Cigna option

Basic Medical 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 Plan. 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 administrator and discretionary authority

The Plan Administrator of the ExxonMobil Retiree Medical Plan is the Administrator-Benefits who is the Manager-Global Benefits Design, Exxon Mobil Corporation. 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.  Various aspects of the Cigna option are administered by Cigna.

The Administrator-Benefits has delegated to Cigna the full and final discretionary authority to interpret and apply plan terms and to make factual determinations in connection with its review of claims under the Cigna Open Access Plus-In Network option. Such discretionary authority is intended to include, but not limited to, the determination of the eligibility of persons desiring to enroll in or claim benefits under the Cigna option, the determination of whether a person is entitled to benefits under the Cigna option, and the computation of any and all benefit payments. The Administrator-Benefits also delegates to Cigna the full and final discretionary authority to perform a full and fair review, as required by ERISA, of each claim denial which has been appealed by the claimant or his duly authorized representative.

You may contact the Administrator-Benefits at the following address. Legal process may be served upon the Administrator-Benefits c/o Exxon Mobil Corporation by serving the Corporation’s Registered Agent for Service of Process, Corporation Service Company (CSC).

For appeals of eligibility or enrollment issues:
Administrator-Benefits
Address: P.O. Box 18025

Norfolk, VA 23501-1867

For service of legal process:
Corporation Service Company
211 East 7th Street, Suite 620
Austin, TX 78701-3218

Cigna

For appeals on benefits issues:

Cigna may be contacted for appeals of benefits issues at an address provided by calling Cigna Customer Service or as reflected on your Explanation of Benefits.

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 Cigna 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's fiscal year ends on December 31.

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 is: 

The Northern Trust Company
50 S. LaSalle
Chicago, IL 60675

Claims processor

Cigna is the claims processor and claims fiduciary.

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 ExxonMobil Retiree Medical Plan and any of their 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 Cigna option, is terminated, you will have the right to elect continuation coverage, as described in the COBRA section of this booklet, in any other health plan option maintained by ExxonMobil 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 Plan, including a copy of the latest annual report (Form 5500 Series) filed by the 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 Plan, including collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Description. 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 may 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 ExxonMobil Retiree Medical 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 denied or ignored, in whole or in part, you may file suit in a 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 ExxonMobil Retiree Medical 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

List of key terms in the Retiree Medical Plan - Cigna option

Allowable expense

A necessary, reasonable and customary service or expense, including deductibles, coinsurance or copayments, that is covered in full or in part by any Group Health Plan covering you. When a Group Health Plan provides benefits in the form of services, the Reasonable Cash Value of each service is the Allowable Expense and is a paid benefit.

Bed and board

The term Bed and Board includes all charges made by a Hospital on its own behalf for room and meals and for all general services and activities needed for the care of registered bed patients.

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, as a special-agreement person, in a service station, car wash, or car care center operations, or
• When you are covered by a contract that requires the company to contribute to a different benefit program, unless a special authorization credits the service.

Benefits Administration

The following sets out the contact numbers based on your status under the ExxonMobil Retiree Medical Plan. It is your responsibility to contact the Benefits Service Center with any required notices and address changes. If your status is not listed, call the Benefits Service Center.

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

PO Box 18025

Norfolk, VA 23501-1867

Benefits Administration / ExxonMobil sponsored sites

Access to medical 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.

Charges

The term "charges" means the actual billed charges; except when the provider has contracted directly or indirectly with Cigna for a different amount.

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 regular retiree.

Child does not include a foster child.

Claim determination period

A calendar year, but does not include any part of a year during which you are not covered under this Cigna Option or any date before this section or any similar provision takes effect.

Copayments

Your share of medical (including out-patient prescription drugs) and mental health and substance use disorder expenses. For some services, such as hospital stays, your share of expenses will be a percentage of the cost of the service, called coinsurance. For other services, such as routine office visits your share of expenses will be a fixed amount, called a copay.

Custodial care

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

Durable medical equipment

Durable Medical Equipment is defined as items which are designed for and able to withstand repeated use by more than one person, customarily serve a medical purpose, generally are not useful in the absence of Injury or Sickness, are appropriate for use in the home, and are not disposable. Such equipment includes, but is not limited to, crutches, hospital beds, wheel chairs, and dialysis machines.

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
2. is aged 26 or over and is totally and continuously disabled and incapable of self-sustaining employment by reason of mental or physical disability, provided the child:
   • 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
3. is not eligible to be enrolled in Medicare as their primary medical plan, or  the child 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 two (2) above, ceases to be an eligible family member 60 days following the date on which the applicable requirement is not met.

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

Emergency services

Emergency services means, with respect to an emergency medical condition, a medical screening examination that is within the capability of the emergency department of a Hospital, including ancillary services routinely available to the emergency department to evaluate the emergency medical condition; and such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the Hospital, to stabilize the patient.

Out-of-Network Emergency Services Charges

1. Emergency Services are covered at the In-Network cost-sharing level if services are received from a non-participating (Out-of-Network) provider.
2. The allowable amount used to determine the Plan's benefit payment for covered Emergency Services rendered in an Out-of-Network Hospital, or by an Out-of-Network provider in an In-Network Hospital, is the amount agreed to by the Out-of-Network provider and Cigna, or if no amount is agreed to, the greatest of the following, not to exceed the provider’s billed charges: (i) the median amount negotiated with In-Network providers for the Emergency Service, excluding any In-Network copay or coinsurance; or (ii) the amount payable under the Medicare program.

The member is responsible for applicable In-Network cost-sharing amounts (any deductible, copay or coinsurance). The member is also responsible for all charges that may be made in excess of the allowable amount. If the Out-of-Network provider bills you for an amount higher than the amount you owe as indicated on the Explanation of Benefits (EOB), contact Cigna Customer Service at the phone number on your ID card.

Employer

The term Employer means Exxon Mobil Corporation and participating affiliated companies, who are self-funding the benefits described in this SPD, on whose behalf Cigna is providing claim administration services.

Expense incurred

An expense is incurred when the service or the supply for which it is incurred is provided.

ExxonMobil Medical Plan (Medical Plan)

The Plan sponsored by ExxonMobil, which provides medical benefits for eligible employees and their family members and includes as one option the Cigna option.

ExxonMobil Retiree Medical Plan (EMRMP)

The Plan sponsored by ExxonMobil, which provides medical benefits for eligible retirees, survivors and their family members and includes as one option the Cigna option.

Formulary

Listing of approved drugs and medications approved in accordance with parameters established by the Pharmacy and Therapeutics Committee.  This list is subject to periodic review and updates.

Free-standing surgical facility

The term Free-Standing Surgical Facility means an institution which generally meets  the following requirements:

• It has a medical staff of Physicians, Nurses and licensed anesthesiologists,
• It maintains at least two operating rooms and one recovery room,
• It maintains diagnostic laboratory and x-ray facilities,
• It has equipment for emergency care,
• It has a blood supply,
• It maintains medical records,
• It has agreements with Hospitals for immediate acceptance of patients who need Hospital admittance on an inpatient basis, and
• It is licensed in accordance with the laws of the appropriate legally authorized agency.

Group health plan

Any of the following that provides benefits or services for medical, dental, or vision care or treatment:

• Group insurance and/or group-type coverage, whether insured or uninsured. This includes prepayment, group practice or individual practice coverage.
• Coverage under Medicare and other governmental benefits as permitted by law accepting Medicaid and Medicare policies. It does not include any plan when benefits are in excess to those of any private insurance program or other non-governmental program.
• Medical benefits coverage of group, group-type, and individual no-fault and traditional automobile fault contracts.

Each Group Health Plan or part of a Group Health Plan which has the right to coordinate benefits will be considered a separate Group Health Plan.

Home health aide

The term Home Health Aide means a person who: (a) provides care of a medical or therapeutic nature, and (b) reports to and is under the direct supervision of a Home Health Care Agency.

Home health care agency

The term Home Health Care Agency means a Hospital or a non-profit or public home health care agency which:

• Primarily provides skilled nursing service and other therapeutic service under the supervision of a Physician or a Registered Graduate Nurse,
• Is run according to rules established by a group of professional persons,
• Maintains clinical records on all patients, and
• Does not primarily provide custodial care or care and treatment of the mentally ill; but only if, in those jurisdictions where licensure by statute exists, that Home Health Care Agency is licensed and run according to the laws that pertain to agencies which provide home health care.

Home Health Care Plan

The term Home Health Care Plan means a plan for care and treatment of a person in his/her home. To qualify, the Plan must be established and approved in writing by a Physician who certifies that the person would require admission to a Hospital or Skilled Nursing Facility if he/she did not have the care and treatment specified in the Plan.

Hospice Care Program

The term Hospice Care Program means:

• A coordinated, interdisciplinary program to meet the physical, psychological, spiritual and social needs of dying persons and their families;
• A program that provides palliative and supportive medical, nursing and other health services through home or inpatient care during the illness;
• A program for persons who have a Terminal Illness and for the families of those persons.

Hospice care services

The term Hospice Care Services means any services provided by: (a) a Hospital, (b) a Skilled Nursing Facility or a similar institution, (c) a Home Health Care Agency, (d) a Hospice Facility, or (e) any other licensed facility or agency under a Hospice Care Program, and is a Medicare approved Hospice Care Program.

Hospice facility

The term Hospice Facility means an institution or part of it which:

• Primarily provides care for Terminally Ill patients,
• Is accredited by the National Hospice Organization,
• Meets standards established by Cigna, and
• Fulfills any licensing requirements of the state or locality in which it operates.

Hospital

The term Hospital means:

• An institution licensed as a hospital, which: (a) maintains, on the premises, all facilities necessary for medical and surgical treatment, (b) provides such treatment on an inpatient basis, for compensation, under the supervision of Physicians, and (c) provides 24-hour service by Registered Graduate Nurses,
• An institution which qualifies as a hospital, a psychiatric hospital or a tuberculosis hospital, and a provider of services under Medicare, if such institution is accredited as a hospital by the Joint Commission on the Accreditation of Hospitals, or
• An institution which: (a) specializes in treatment of mental illness, alcohol or drug abuse or other related illness, (b) provides residential treatment programs, and (c) is licensed in accordance with the laws of the appropriate legally authorized agency.

The term Hospital will not include an institution, which is primarily a place for rest, a place for the aged, or a nursing home.

Injury

The term Injury means an accidental bodily injury.

Medicaid

The term Medicaid means a state program of medical aid for needy persons established under Title XIX of the Social Security Act of 1965 as amended.

Medicare

The term Medicare means the program of medical care benefits provided under Title XVIII of the Social Security Act of 1965 as amended.

Mental illness

The term mental illness means any disorder, other than a disorder induced by alcohol or drug abuse, which impairs the behavior, emotional reaction or thought process of a person, regardless of medical origin. In determining benefits payable, charges made for the treatment of any physiological symptoms related to a mental illness will not be considered to be charges made for treatment of a mental illness.

Necessary services and supplies

The term Necessary Services and Supplies includes any charges, except charges for Bed and Board, made by a Hospital on its own behalf for medical services and supplies actually used during admission to a Hospital.

The term Necessary Services and Supplies will not include any charges for special nursing fees, dental fees or medical fees.

Network

Providers and facilities that participate in a health maintenance organization available under this Cigna Option.

Nurse

The term Nurse means a Registered Graduate Nurse, a Licensed Practical Nurse or a Licensed Vocational Nurse who has the right to use the abbreviation R.N., L.P.N. or L.V.N.

Outpatient mental illness services

Outpatient Mental Illness Services are services of providers who are qualified to treat mental illness when treatment is provided on an outpatient basis, while you or your eligible/covered Family Member is not admitted in a Hospital, in an individual, group or structured group therapy program. Covered Services include, but are not limited to, outpatient treatment of conditions such as: anxiety or depression which interferes with daily functioning, emotional adjustment or concerns related to chronic conditions, such as psychosis or depression; emotional reactions associated with marital problems or divorce, child/adolescent problems of conduct or poor impulse control; affective disorders, suicidal or homicidal threats or acts; eating disorders, or acute exacerbation of chronic mental illness conditions (crisis intervention and relapse prevention) and outpatient testing and assessment.

Participating pharmacy

The term Participating Pharmacy means a retail pharmacy or mail-order pharmacy with which Cigna has contracted, either directly or indirectly, to provide prescription services to its plan participants.

Participating provider

The term Participating Provider means:

• An institution, facility, agency or healthcare professional which has contracted directly or indirectly with Cigna.

The providers qualifying as Participating Providers may change from time to time. A list of the current

Participating Providers will be provided with this booklet.

Pharmacy & Therapeutics (P&T) Committee

A committee of Provider Organization members comprised of Medical providers, Pharmacists, Medical Directors and Pharmacy Directors, which reviews medications for safety, efficacy, cost effectiveness and value. The P & T Committee evaluates medications for addition to or deletion from the Formulary and may also set dispensing limits on medications. Related Services are also reviewed & evaluated.

Physician

The term Physician means a licensed medical practitioner who is practicing within the scope of his license and who is licensed to prescribe and administer drugs or to perform surgery. It will also include any other licensed medical practitioner whose services are required to be covered by law in the locality where the services are received if he is:

• Operating within the scope of his license, and
• Performing a service for which benefits are provided under this Cigna Option when performed by a Physician.

Prescription drug

Prescription Drug means; (a) a drug which has been approved by the Food and Drug Administration for safety and efficacy, or (b) certain drugs approved under the Drug Efficacy Study Implementation review, or (c) drugs marketed prior to 1938 and not subject to review, and which can, under federal or state law, be dispensed only pursuant to a prescription order, or (d) injectable insulin.

Primary Care Physician

The term Primary Care Physician means a Physician: (a) who qualifies as a Participating Provider in general practice, internal medicine, family practice or pediatrics, and (b) who has been selected by you, as authorized by the Provider Organization, to provide or arrange for medical care for you or any of your covered Family Members.

Primary group health plan

The Group Health Plan that determines and provides or pays benefits without taking into consideration the existence of any other Group Health Plan.

Provider organization

The term Provider Organization refers to a network of Participating Providers.

Psychologist

The term Psychologist means a person who is licensed or certified as a clinical psychologist. Where no licensure or certification exists, the term Psychologist means a person who is considered qualified as a clinical psychologist by a recognized psychological association. It will also include: (1) any other licensed counseling practitioner whose services are required to be covered by law in the locality where the services are received if he is: (a) operating within the scope of his license, and (b) performing a service for which benefits are provided under this plan when performed by a Psychologist, and (2) any psychotherapist while he is providing care authorized by the Provider Organization if he is: (a) state licensed or nationally certified by his professional discipline, and (b) performing a service for which benefits are provided under this plan when performed by a Psychologist.

Reasonable cash value

An amount which a duly licensed provider of health care services usually charges patients and which is within the range of fees usually charged for the same service by other health care providers located within the immediate geographic area where the health care service is rendered under similar or comparable circumstances.

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 as a regular employee 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 non-regular or 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, and includes the Cigna option.

Secondary group health plan

A Group Health Plan that determines, and may reduce its benefits after taking into consideration, the benefits provided or paid by the Primary Group Health Plan. A Secondary Group Health Plan may also recover from the Primary Group Health Plan the Reasonable Cash Value of any services it provided to you.

Self-funded plan

A self-funded plan option, under the ExxonMobil Retiree Medical Plan, is an option set up by ExxonMobil to set aside funds to pay participants’ health claims. Because ExxonMobil has hired insurance companies to administer these self-funded options, they may look just like fully-funded plans. For example, the Cigna option under the  Plan is a self-funded plan.

Cigna is responsible for only administering the plans. (i.e., Cigna is the claims processor for the self-funded plan.) ExxonMobil is responsible for funding the plans to pay health claims. This does not impact the benefits provided under the Cigna Option under the Medical and Retiree Medical Plans. The U.S. Department of Labor regulates self-funded plans, not the state insurance department.

You may contact the Department of Labor at the address listed in the ERISA section: Assistance with Your Questions.

Service area

The geographic area designated by the Cigna option in which an individual must live in order to be an eligible member. This area is determined by the participant's home address zip code.

Sickness - for medical coverage

The term Sickness means a physical or mental illness. It also includes pregnancy. Covered Expenses incurred for routine Hospital and pediatric care of a newborn child prior to discharge from the Hospital nursery will be considered to be incurred as a result of Sickness.

Skilled nursing facility

The term Skilled Nursing Facility means a licensed institution (other than a Hospital) which specializes in:

• Physical rehabilitation on an inpatient basis, or
• Skilled nursing and medical care on an inpatient basis,

but only if that institution (a) maintains on the premises all facilities necessary for medical treatment,

(b) provides such treatment, for compensation, under the supervision of Physicians, and (c) provides Nurses' services.

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.

Survivor/ surviving spouse

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

Terminal illness

A Terminal Illness will be considered to exist if a person becomes terminally ill with a prognosis of six months or less to live, as diagnosed by a Physician.

Urgent care

Urgent Care is medical, surgical, Hospital or related health care services and testing which are determined by Cigna, in accordance with generally accepted medical standards, to have been necessary to treat a condition requiring prompt medical attention. This does not include care that could have been foreseen before leaving the immediate area where you ordinarily receive and/or were scheduled to receive services. Such care includes, but is not limited to, dialysis, scheduled medical treatments or therapy, or care received after a Physician's recommendation that the covered person should not travel due to any medical condition.

Benefit Summary

Information on the Benefit Summary for the Retiree Medical Plan - Cigna OAPIN option

2022 In-Network Benefit Summary

In-Network Benefits	How this Plan Works
Preventive Services
Preventive Care Office Visit	No charge
Routine Physicals & Immunizations	No charge
Well Woman Care (including Pap Smear Test)	No charge
Mammograms	No charge
Well Baby Care (including Immunizations)	No charge
Preventive Screenings (including Basic Lab Tests, Mammography, Colorectal/Prostate Cancer)	No charge
Physician Services
Telemedicine Consultation, using Cigna designated telemedicine providers	$25 copay
Primary Care Physician Office Visit	$25 copay
Hearing Screening (Adults over age 21) in PCP Office	$25 copay
Specialty Care Physician Office Visit	$40 copay
Surgery Performed in the Physician's Office	No charge after the $25 PCP or $40 Specialist copay
Allergy Treatment/Injections	No charge after either the office visit copay or the actual charge, whichever is less
Inpatient Hospital - FacilityServices
Semi Private Room and Board	90% coverage up to the out-of-pocket maximum
Private Room	90% of the Hospital's negotiated rate for a semi-private room, up to the out-of-pocket maximum, then 100% of the Hospital’s negotiated rate for semi-private room
Special Care Units (ICU/CCU)	90% coverage, up to the out-of-pocket maximum
Operating Room, Recovery Room, Oxygen Anesthesia and Respiratory/Inhalation Therapy	90% coverage, up to the out-of-pocket maximum
Inpatient Professional Services
Anesthesiologists	90% coverage, up to the out-of-pocket maximum
Radiologists, Pathologists	90% coverage, up to the out-of-pocket maximum
Surgeon	90% coverage, up to the out-of-pocket maximum
Assistant Surgeon or Co-Surgeon	90% coverage, up to the out-of-pocket maximum
Physician Visit	90% coverage, up to the out-of-pocket maximum
Nursing Care	90% coverage, up to the out-of-pocket maximum
Mastectomy and Breast Reconstruction	90% coverage, up to the out-of-pocket maximum
Diagnostic and Therapeutic Laboratory and X-ray	90% coverage, up to the out-of-pocket maximum
Hemodialysis	90% coverage, up to the out-of-pocket maximum
Radiation Therapy and Chemotherapy	90% coverage, up to the out-of-pocket maximum
Organ Transplant Services	90% coverage, up to the out-of-pocket maximum
Outpatient Facility Services
Operating Room, Recovery Room, Procedure Room, and Treatment	90% coverage, up to the out-of-pocket maximum
Outpatient Professional Services
Anesthesiologists and Respiratory/Inhalation Therapy	90% coverage, up to the out-of-pocket maximum
Radiologists, Pathologists	90% coverage, up to the out-of-pocket maximum
Surgeon	90% coverage, up to the out-of-pocket maximum
Assistant Surgeon or Co-Surgeon	90% coverage, up to the out-of-pocket maximum
Physician Visit/Charges for Outpatient Surgery	90% coverage, up to the out-of-pocket maximum
Hemodialysis	90% coverage, up to the out-of-pocket maximum
Mastectomy and Breast Reconstruction	90% coverage, up to the out-of-pocket maximum
Diagnostic and Therapeutic Laboratory and X-ray	90% coverage, up to the out-of-pocket maximum
Radiation Therapy and Chemotherapy	90% coverage, up to the out-of-pocket maximum
Emergency and Urgent Care Services
Telemedicine Consultation, using Cigna designated telemedicine providers	$25 copay
Urgent Care Facility	$60 copay
Free-Standing ER or Outpatient Facility	$150 copay
Hospital Emergency Room	$150 copay* *Waived if admitted
Ambulance	90% coverage, up to the out-of-pocket maximum
Independent Lab Services
Physician's Office	No Charge after office visit copay
Lab Facility	90% coverage, up to the out-of-pocket maximum
Hospital Outpatient	90% coverage, up to the out-of-pocket maximum
Skilled Nursing
Facility Services	90% coverage, up to the out-of-pocket maximum
Skilled Nursing Room and Board	90% coverage, up to the out-of-pocket maximum
Contract Year Maximum: 60 Days including Rehabilitation Hospitals and Sub-Acute Facilities
Home Health Care
Home Health Care Services	90% coverage, up to the out-of-pocket maximum
Hospice
Inpatient	90% coverage, up to the out-of-pocket maximum
Outpatient	90% coverage, up to the out-of-pocket maximum
Rehabilitative Therapy (including Speech, Occupational, Physical, Chiropractic, Pulmonary, Cardiac and Cognitive Therapy)
Inpatient	90% coverage, up to the out-of-pocket maximum
Maximum of 60 visits per contract year for any combination of Therapies	$40 copay
Maternity
Initial Visit to Confirm Pregnancy	$25 PCP or $40 Specialist copay
Subsequent Visits (Pre-Natal, Post-Natal, Physician’s Delivery Charges subject to global maternity fee)	90% coverage, up to the out-of-pocket maximum
Office Visits in addition to the global maternity fee when performed by an OB/GYN or Specialist	$25 PCP or $40 Specialist copay
Delivery (Inpatient Hospital, Birthing Center)	90% coverage, up to the out-of-pocket maximum
Family Planning
Office Visit (Tests)	$25 PCP or $40 Specialist copay
Surgical Treatment: Limited to Sterilization Procedures for Vasectomy/Tubal Ligation (excludes Reversals):	90% coverage, up to the out-of-pocket maximum
Inpatient Facility	90% coverage, up to the out-of-pocket maximum
Outpatient Facility	90% coverage, up to the out-of-pocket maximum
Physician's Services	90% coverage, up to the out-of-pocket maximum
Durable Medical Equipment
Contract Year Maximum: Unlimited	90% coverage, up to the out-of-pocket maximum
External Prosthetic Appliances	90% coverage, up to the out-of-pocket maximum
Diabetes Services
Diabetes Management Medical Equipment - including blood glucose monitors, monitors designed to be used by blind individuals; insulin pumps and associated appurtenances, insulin infusion devices, and podiatric appliances for the prevention of complications associated with diabetes.	90% coverage, up to the out-of-pocket maximum
Diabetes Supplies - including test strips for blood glucose monitors, visual reading and urine test strips, lancets and lancet devices, insulin and insulin analogs, injection aids, syringes, prescriptive, and non-prescriptive oral agents for controlling blood sugar levels, and glucagon emergency kits.	Same as Prescription Drug Copayment
Pharmacy Benefits
The designation of a prescription drug as Generic, Preferred Brand or Non-Preferred Brand is per generally accepted industry sources and adopted by Cigna.
Retail Prescription Drugs/30 day supply
Generic	20% coinsurance per prescription order or refill. The maximum copay is $105 per prescription.
Preferred Brand	30% coinsurance per prescription order or refill. The maximum copay is $125 per prescription.
Non-Preferred Brand	45% coinsurance per prescription order or refill. The maximum copay is $135 per prescription.
Participating Retail, or Cigna Home Delivery Prescription Drugs/90 day supply
Generic	20% coinsurance per prescription order or refill. The maximum copay is $155 per prescription.
Preferred Brand	30% coinsurance per prescription order or refill. The maximum copay is $175 per prescription.
Non-Preferred Brand	45% coinsurance per prescription order or refill. The maximum copay is $200 per prescription.
Mental Health and Substance Use Disorder Benefits
Telemedicine Behavioral Health Consultation using Cigna designated telemedicine provider	$25 copay
Individual, Family or Group Therapy Office Visit	$25 copay
Inpatient Treatment – includes Hospital, Residential Treatment Facilities, and Partial Hospitalization	90% coverage, up to the out-of-pocket maximum
Intensive Outpatient Treatment	90% coverage, up to the out-of-pocket maximum
Annual Out-of-Pocket Maximum
Individual Out-of-Pocket Maximum	$3,000
Family Out-of-Pocket Maximum	$6,000
If an employee 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%.