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Medicare Supplement Plan Option

Summary plan description of the Medicare Supplement Plan option as of January 2021

About the Medicare Supplement Plan option

This summary plan description (SPD) is a summary of the Medicare Supplement Plan option (MSP, the Plan) of the ExxonMobil Retiree Medical Plan (EMRMP). It does not contain all Plan details. In determining your specific benefits, the full provisions of the formal plan documents, as they exist now or as they may exist in the future, always govern. Copies of these documents are available for your review.

The Medicare numbers used in this SPD are current for 2020 but are subject to change. The dollar amounts in the examples are for explanation purposes only and may not reflect what a specific service might cost or how much Medicare and the Plan would pay toward that service.

Information sources

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

Please read carefully:

For claims administration:

Contact Aetna for medical/surgical, behavioral health and substance abuse claims forms, claims payment and other claims inquiries.

Contact Express Scripts for pharmacy claims forms, claims payment and other claims inquiries.

Prescription drug program -Express Scripts is the claims processor for outpatient prescription drugs provided through home delivery and Smart90 retail pharmacies (Express Scripts, Walgreens, CVS) for long-term prescriptions or a local retail pharmacy for short-term prescriptions.

In addition, Express Scripts can provide pharmacy benefits information, including clinical guidelines, benefits pre-determinations, and providers participating in the Express Scripts pharmacy network. Express Scripts also provides prior-authorization review for certain pharmacy services, medications, and equipment. Ask to speak to a Therapeutic Resource Center (TRC) pharmacist for specialized support services.

Phone Numbers: Address:
Express Scripts Pharmacy:

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

Home Delivery Pharmacy:
Express Scripts

P.O. Box 66577
St. Louis, MO 63166-65777

For questions regarding Retail Prescriptions:
Express Scripts
800-695-4116
800-497-4641 (international, use appropriate country access code depending on the country from which you are calling)*
Direct Reimbursement Claim Form:
Express Scripts
ATTN: Commercial Claims
P.O. Box 14711
Lexington, KY 40512-4711
Direct Reimbursement Claim Forms may also be faxed to: 608-741-5475 

*To be able to reach this international access line for Express Scripts, please use the appropriate access number (e.g., AT&T Direct Service) for the country you are calling from.

Another way to locate retail network pharmacies and order refills is via the Express Scripts website at www.express-scripts.com.

All other medical - Aetna, the claims administrator, provides claim forms, claims payment information and advanced approval for in-home skilled-nursing care. Aetna is also the claims processor for all medical expenses except outpatient prescriptions.

Phone Numbers:

Aetna Member Services 
800-222-3992 
210-366-2416 (international, call collect)
Monday - Friday 8:00 a.m. to 6:00 p.m. (U.S. Central Time), 
except certain holidays
Automated Voice Response Hours: 24 hours a day, 7 days a week

Address:

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

Benefits Administration - Retirees and survivors can enroll/change coverage on the ExxonMobil Benefits Service Center website at www.exxonmobil.com/benefits. If you are unable to access the Internet or need additional information, you may contact:

Phone Numbers:

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

Address:

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

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

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

Introduction

The Medicare Supplement Plan option, referred to as the Plan in this SPD, is a medical plan for retirees, survivors and their eligible family members who are also eligible for Medicare. It is designed to work with Medicare Parts A and B to give you medical coverage similar to that available to employees and retirees not eligible for Medicare.

The Medicare Supplement Plan option also covers care and supplies such as outpatient prescription drugs, in-home skilled-nursing care and medical care received outside the United States, which are not covered by Medicare Parts A and B; however, if you enroll in a Medicare Advantage (Part C) plan, which provides a Medicare prescription drug benefit or Medicare Part D (coverage for prescription drugs), the Plan will not cover any outpatient prescription drugs even if they are not covered under Medicare Part C or D.

While the Plan is designed to work with Medicare Parts A and B, it is not intended to pay all amounts that Medicare does not cover. Benefits payable under the Plan are considered together with the benefits received from Medicare.

The Plan does not involve an insurance policy. All claims are funded by contributions from ExxonMobil, other participating employers and participants. Aetna Life Insurance Company (Aetna) and Express Scripts are paid fees to provide services such as processing claims, answering questions, and managing the pharmacy network and home delivery pharmacy service. Neither Aetna nor Express Scripts has any responsibility for funding benefits under the Plan.

Aetna does not render medical services or treatments. Neither the Plan nor Aetna is responsible for the health care that is delivered by providers participating in the Medicare Supplement Plan option, and those providers are solely responsible for the health care they deliver. Providers are not the agents or employees of the Plan or Aetna.

The Plan is described in detail in this SPD. These tools help you find specific information quickly and easily:

  • Plan at a glance, a quick user's guide highlighting Plan basics.
  • Charts and tables to provide information, examples, highlights of Plan provisions, including a Benefit summary chart.
  • References to places where you can find more information.
  • A list of Key terms containing definitions of some words and terms used in this SPD.

A careful reading of this SPD will help you understand how the Plan works so you can make the best use of the Plan provisions. You may obtain additional information from the sources listed in the Information Sources section of this SPD.

Plan at a glance

Eligibility

Retirees and their eligible family members who are also eligible for Medicare as their primary plan may participate. Survivors of retirees or deceased employees may also be eligible once they become eligible for Medicare as their primary plan. See Eligibility and enrollment

The prescription drug program

The Plan offers cost-saving ways to buy outpatient prescription drugs if you are not participating in a Medicare Advantage (Part C) plan which provides a Medicare prescription drug benefit or Medicare Part D — at local participating network pharmacies, Smart90 pharmacies (Walgreens, CVS), and through home delivery. See Prescription drug program.

Other plan provisions

If you meet your annual out-of-pocket limit of $3,000, the Plan's reimbursement level — when combined with Medicare Parts A and B — is 100% of the Medicare approved amount for most covered expenses for the rest of that calendar year. You must satisfy an annual deductible of $300 before the Plan starts paying. The Plan covers some items Medicare may not, such as transition benefits from pre-65 medical plans sponsored by ExxonMobil, in-home skilled-nursing care and medical care received outside the United States. See Other Plan Provisions.

Accepting assignment

If your doctor or other health care providers accept assignment, they accept the amount Medicare approves as payment in full for each service or supply. You must still pay any coinsurance amount. See Accepting assignment. 

Covered and excluded expenses

The Plan provides benefits for many, but not all, types of treatment, care and services. See Covered expenses and Exclusions for more information.

Coordination of benefits

The Plan treats Medicare coverage as another group plan for purposes of coordinating benefits. See Coordination of benefits.

Claims

All claims should be submitted to Medicare first. If you participate in Medicare Direct, your Medicare Part B claims are automatically forwarded from Medicare to Aetna. If you do not participate in Medicare Direct, you submit the claim along with the Explanation of Medicare Benefits forms to Aetna. See Claims

COBRA

Your family members who lose eligibility may continue medical coverage for a limited time in certain circumstances. See Continuation coverage. 

Administrative and ERISA information

The 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. 

Key terms

This is an alphabetized list of words and phrases, with their definitions, used in this SPD. See Key terms. 

Benefit summary

Key features of the Plan and Medicare are highlighted. See Benefit summary.

Eligibility and enrollment

Eligibility and enrollment details for the Medicare Supplement Plan Option

Q. Who is a covered person in the Plan?

A) Prior to January 1, 2021 "Covered person" means a person who:

  • is eligible for Medicare,
  • is an eligible retireeeligible family member, or a survivor, 
  • complies with any administrative requirements of this Plan,
  • makes any required contribution toward the cost of this Plan; and
  • who either:
    • (a) enrolls in the Plan within sixty (60) days immediately following the loss of coverage under an employer-sponsored group medical plan (see Loss of Coverage under employer-sponsored group medical plan); or
    • (b) in the case of an individual who becomes an eligible family member by virtue of the marriage of that person or that person's parent to a retiree is enrolled in the Plan within 30 days of marriage.
  • Exception: A person who becomes the spouse of an eligible retiree after becoming entitled to be enrolled in Medicare may be added to the MSP option within 60 days of becoming eligible without demonstrating loss of coverage under another employer-sponsored medical plan.

Loss of coverage under employer-sponsored group medical plan:

You should have been covered by an employer-sponsored group medical plan immediately before Plan eligibility. You will have to show loss of coverage under an employer sponsored group medical plan (any group medical plan sponsored by either the Corporation or another employer) to enroll any time after your Medicare eligibility. You have 60 days from the date of loss of coverage under an employer sponsored group medical plan to provide documentation of loss of this coverage and enroll in the Medicare Supplement Plan option. If you do not enroll within 60 days from your loss of coverage you will not have another opportunity to enroll.

B) On or after January 1, 2021 through December 31, 2021 "Covered person" means a person who:

  • is eligible for Medicare;
  • is a retiree, an eligible family member or a survivor;
  • complies with any administrative requirements of this Plan;
  • makes any required contribution toward the cost of this Plan; and
  • is not eligible to be enrolled in the Medicare Primary Option or is enrolled in other Medicare Advantage (Part C) coverage.

C) On or after January 1, 2022 through June 30, 2022 "Covered person" means a person(s) who prior to January 1, 2022 was identified as being part of a closed group of existing MSP participants who:

  • is not eligible to be enrolled in the Medicare Primary Option (MPO) as the result of being eligible for Medicare but not enrolled in Medicare Parts A and/or B; or
  • is not eligible to be enrolled in the MPO as the result of not having a U.S. residential street address. 
  • This transition population will be required to meet all eligibility requirements to enroll in MPO or lose coverage under the EMRMP effective July 1, 2022.

Note: A covered person is not eligible for the pharmacy benefits under this Plan if they are enrolled in a Medicare Part D prescription drug plan

Eligible retiree

For purposes of the Plan, you are an eligible retiree if you attained retiree status from:

  • ExxonMobil,
  • Exxon,
  • Mobil, or
  • Superior Oil Company.
  • Former expatriate employees assigned to the U.S. who retired on or after July 1, 2020, had a company-sponsored Permanent Resident Visa (PRV), elected to maintain their PRV, and continue to reside in the U.S
  • Retirees of Station Operators, Inc. doing business as ExxonMobil Company Operated Retail Stores (CORS) are not eligible for coverage under this plan.

Eligible family members

For purposes of the Medicare Supplement Plan option, eligible family members who are also eligible to be enrolled in Medicare as their primary medical plan include:

  • The spouse of an eligible retiree.
  • The surviving spouse, who has not remarried, of a deceased eligible retiree or deceased employee.
  • The child of an eligible retiree, deceased eligible retiree, or deceased employee who was enrolled in the MSP on December 31, 2018 and continues to be enrolled in the MSP.


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).
 
Family members who are not entitled to be enrolled in Medicare as their primary medical plan may be eligible for coverage under one of the Retiree Medical Plan options of the ExxonMobil Retiree Medical Plan. See the SPD for the Retiree Medical Plan option of your choice for more information.

Eligibility for Medicare

In general, you are eligible for Medicare if you are at least 65 years of age or have received Social Security disability benefits for 24 consecutive months. Anyone, including children, can be eligible for Medicare by virtue of a disability as described in the Key terms section of this SPD.

No one becomes eligible for Medicare as the dependent of someone who is eligible for Medicare. For example:

  • If you are 65 years of age and your spouse is 61 and not disabled, you are eligible for Medicare but your spouse is not, or
  • If you are under age 65 and not disabled and have a spouse either over 65 or eligible due to disability, your spouse is eligible for Medicare but you are not.

Enrolling in Medicare

If you are receiving Social Security benefits, your Social Security office should contact you with information about Medicare before your 65th birthday. If you are not receiving Social Security benefits or if you have not been contacted by Social Security and are nearing your 65th birthday, contact your local Social Security office. To receive maximum benefits from the Plan and Medicare, you must enroll in both:

  • Part A covers hospital care and care in a skilled-nursing facility. There is no premium for most Part A participants.
  • Part B covers physician bills and some out-of-hospital expenses. A premium for Part B is deducted from your Social Security check. Contact Medicare for current premium information.

If your spouse worked in a job not covered by Social Security or did not work long enough to qualify for free Part A coverage, the Plan pays full benefits with or without Part A coverage. The spouse must, however, sign up for Part B to receive maximum benefits.

Enrolling in Medicare Advantage (Part C) or Medicare Part D

Participants who choose to enroll in a Medicare Advantage (Part C) plan which provides a Medicare prescription drug benefit or Medicare Part D Prescription Drug Plan will no longer be eligible for outpatient prescription drug coverage under the Plan. If you enroll in a Medicare Part C plan which provides a Medicare prescription drug benefit or Part D program and continue your plan participation, your required contributions remain the same, but you will not be eligible for outpatient prescription drug benefits under the Plan.

Questions about Medicare?

Contact Social Security Administration:

Enrolling in the plan

The ExxonMobil Benefits Service Center (EMBSC) contacts retirees and their spouses and surviving spouses shortly before their 65th birthdays. If you have not been contacted by the time you become eligible for Medicare, contact the EMBSC. This is particularly important if you become eligible for Medicare by virtue of disability rather than age. You should also contact the EMBSC when your child or spouse becomes eligible for Medicare.

Important notice about becoming Medicare-eligible

Retirees or survivors or covered family members of a retiree or survivor who become eligible to be enrolled in Medicare either due to age or Social Security disability status, are no longer eligible to participate in the Retiree Medical Plan (POS II options, Aetna Select, or Cigna OAPIN Network Only options).

NOTE: Effective January 1, 2019, a dependent child 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, including the MSP option, or any other ExxonMobil health plan.

Participants who are eligible for Medicare as their primary plan must change their Company-provided coverage from the Retiree Medical Plan to the Medicare Primary Option and enroll in Medicare Parts A and B. Even if you are enrolled in the Medicare Supplement Plan option, but choose not to enroll in Medicare Parts A and B, you will receive no reimbursement from the Medicare Supplement Plan option for claim expenses that would have been paid by Medicare had you been enrolled. Neither the ExxonMobil Retiree Medical Plan nor the ExxonMobil Medical Plan are available to retirees and survivors who are Medicare-eligible.  

If you have applied for Medicare Part B, but are not yet enrolled, then Part B claims will be reimbursed at 80% of Reasonable and Customary until Part B becomes effective but no later than the next possible Part B effective date. For example, applying during an upcoming January - March Medicare enrollment period for a July 1 effective date. As such, you will be responsible for the 20% coinsurance and amounts that are over Reasonable and Customary limits during this transition period. However, if you decline Medicare Part B, or do not enroll in Medicare Part B at the first available opportunity, then you will be responsible for the portion of your claims that Part B would have covered from that point forward until you enroll in Medicare Part B.

Don't be without coverage!

Notify the ExxonMobil Benefits Service Center as soon as you or your family members receive notice of eligibility for Medicare Parts A and B due to either age or disability. 

When plan eligibility ends

Eligibility for the Plan ends:

  • When a participant fails to make the required contributions.
  • When you cancel your coverage in writing.
  • For a spouse following a divorce.
  • For a surviving spouse and stepchildren upon remarriage.
  • For children upon the marriage of the surviving parent.
  • For the surviving spouse and children of an employee who died with less than 15 years of ExxonMobil benefit service after a period from the date of death equal to twice the deceased employee's length of ExxonMobil benefit service.
  • If, at some future date, the Plan is terminated or replaced.

If you cancel your coverage, you will not be allowed to re-enroll in the future. Also, if you are not covered under this or another medical plan to which ExxonMobil contributes, your otherwise eligible family members cannot continue coverage under any ExxonMobil medical plans.

The prescription drug program

Prescription drug program information for the Medicare Supplement Plan Option 

Q. Does the Plan cover outpatient prescription drugs

A. Yes, but only if you are not enrolled in Medicare Part D or a Medicare Part C plan that provides a Medicare prescription drug benefit. The Plan's prescription drug benefits offer cost-saving ways to buy outpatient prescription drugs: 

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

No deductible is required.

Note: Prescription medications, including injections, billed by and provided in a hospital or a doctor's office are typically not covered under the prescription drug program but may be covered medical expenses under the Medicare Supplement Plan option. Medications billed to you by a pharmacy vendor are not covered under the Medicare Supplement Plan option.

For certain prescription drugs:

You must call Express Scripts for precertification of certain prescription drugs. This applies whether you are inside or outside the United States.

In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the plan will cover another (usually more expensive) drug.

Additionally, as part of Express Scripts’ Advanced Utilization Management (AUM) program, certain targeted drugs will not be covered unless pre-certified by Express Scripts, based on medical evidence submitted by your physician.

Non-targeted drugs are covered without precertification or prior authorization. Refer to the Prescription drug program section for more details.

You must identify yourself as a member of the Express Scripts retail pharmacy program to receive Plan savings.

Call Express Scripts at 800-695-4116 or check the Express Scripts web site at www.express-scripts.com to locate a participating retail pharmacy near you. 

Short-term prescriptions

A short-term prescription is written for a drug taken for a limited period of time, such as an antibiotic for a specific illness or if your doctor wants you to try the prescription before having a long-term prescription filled. The Plan provides benefits for up to a 34-day supply. See Covered prescriptions for limitations.

You have the choice of filling your prescriptions at:

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

To receive the discounted price:

  • Present your prescription and either your prescription drug identification card or the primary participant's identification number at a participating network pharmacy.
  • The pharmacist enters the prescription and the primary participant's identification number into the pharmacy's computer system to confirm:
  • That you are a participant or family member covered by this option.
  • That it is a covered prescription.
  • Your share of the prescription's cost.
  • You do not file a claim.

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

Refills too soon?

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

Copayments

For short-term prescription drugs purchased at a participating retail pharmacy, you pay a percentage of the discounted cost of the drugs.

Type of Short-Term Drug Retail Pharmacy Percentage
Copayment
Generic drugs 30%
Preferred brand name drugs 30%
Non-preferred brand name drugs 50%

Examples:

Generic short-term drug purchased at a retail network pharmacy — discounted cost of medication is $24.

You pay 30% copayment ($24 x .30) = $7.20

Preferred brand name short-term drug purchased at a retail network pharmacy (if no generic is available) — cost of medication is $42.

You pay 30% copayment ($42 x .30) = $12.60

Non-preferred brand name short-term drug purchased at a retail network pharmacy (if no generic is available) — cost of medication is $64.

You pay 50% copayment ($64 x .50) = $32

Short-term retail refill limitation for maintenance medications

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

Using a non-participating pharmacy or not identifying yourself as an Express Scripts participant

You are not eligible for a discounted price if you:

  • Have your prescription filled at a non-participating pharmacy, or
  • Do not identify yourself as an Express Scripts participant at a network pharmacy.

In either case:

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

This example shows how you would save money when you use a network pharmacy and show your prescription ID card. In this case, you would save $10.

  Without Express Scripts Discount With Express Script Discount
Full retail cost of preferred brand name prescription (non-discounted)
Discounted cost
Ineligible cost

$ 50.00

- $ 40.00
$ 10.00

N/A

$ 40.00
0.00

Ineligible cost
30% copayment ($40 x .30)
$ 10.00
$ 12.00
$ 0.00
$ 12.00
Your cost $ 22.00 $ 12.00

Long-term prescriptions

A long-term or maintenance drug is one you take for an extended period of time, such as for ongoing treatment of diabetes, arthritis, heart condition or high blood pressure. The Plan generally provides benefits for up to a 90-day supply through a participating Smart90 retail pharmacy (Walgreens, CVS) or Express Scripts home delivery pharmacy. See Covered prescriptions for limitations.

If you need maintenance medication immediately, ask your doctor for two prescriptions — one for an immediate supply to be filled at a local pharmacy and a second for an extended supply to be ordered by mail or at a Smart90 retail pharmacy. 

After the third short-term fill of a maintenance medication at a participating or non-participating retail pharmacy, subsequent refills must be purchased as a 90-day supply at a Smart90 retail pharmacy (Walgreens, CVS) or Express Scripts home delivery pharmacy. If you continue to purchase short-term fills of a long-term or maintenance medication after the third fill, you will be responsible for 100% of the cost.

Express scripts pharmacy — home delivery pharmacy

With Express Scripts Pharmacy, the home delivery pharmacy, you save money and have the convenience of home delivery. Ask the doctor to write a prescription for up to a 90-day supply with appropriate refills. Enclose your original prescription(s) and payment of your percentage copayment in an envelope. If you are paying via check or money order, you may obtain a calculation of your percentage copayment from the Express Scripts web site or by calling Express Scripts directly. If you are paying via credit card, Express Scripts will deduct the appropriate percentage copayment and you will receive notification of the deduction with your medication.

For each prescription filled, you pay:

Type of Drug Express Scripts Pharmacy Percentage Copayment
Generic drugs 25%
Preferred brand name drugs 25%
Non-preferred brand name drugs 45%

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

Refills

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

You can also fill or refill a long-term prescription at a participating Smart90 (Walgreens, CVS) retail pharmacy.

Comparing retail pharmacy with Express Scripts Pharmacy

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

Assume you purchase a 90-day supply of a preferred brand name drug:

At a Participating Retail Pharmacy: Through Express Scripts, or Smart90 Pharmacy:
$ 108.00 Cost of preferred brand name drug
(30-day supply)
$ 324.00

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

x 30% Percentage copayment x 25% Percentage copayment
$ 32.40 Your copayment for a 30-day supply or $97.20 for a 90-day supply $ 81.00 Your copayment
You pay $97.20 for a 90-day supply You pay $81.00 for a 90-day supply

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

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

  • Your payments and copayments under the outpatient prescription drug benefits do not apply toward your deductible for other benefits under the Plan.
  • Your prescription drug payments and copayments do not apply toward your annual medical out-of-pocket limit.
  • Your prescription drug annual out-of-pocket maximum is $2,500 for each individual in your family, or $5,000 for your entire family.
  • The additional cost for purchasing brand-name prescription drugs when a generic is available, as well as the full cost for purchasing subsequent refills of maintenance medications after the third fill obtained at retail pharmacies that are not part of the Smart90 network (Walgreens, CVS), will not count toward your annual out-of-pocket maximum. 
  Short-Term Per Prescription Out-of-Pocket Maximum (30-day or less supply) Long-Term Per Prescription Out-of-Pocket Maximum (Generally 90-day or less supply)
Generic $50.00 $100.00
Preferred brand name drugs $125.00 $250.00
Non-preferred brand name drugs $200.00 $400.00

Covered prescriptions

The Plan covers drugs, medicines and supplies that are:

Generic drugs

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

Note: If both generic and brand name drugs are available to treat your condition, your percentage copayment amount will depend on which medication you select. If you purchase the brand name drug, you are responsible for paying the generic drug percentage copayment PLUS the full difference in cost between the generic drug and the brand name drug. This difference in cost will not count toward your annual prescription drug out-of-pocket maximum.

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

Cost Difference between Brand and Generic   Percentage Copayment
$100.00 Cost of preferred brand-name drug (30-day supply)   $50.00 Cost of generic drug
(30-day supply)
$50.00 Cost of generic drug
(30-day supply)
x 30% Percentage copayment
$50.00 Cost difference $15.00 Your copayment if you purchase the generic
You pay $32.40, or $97.20 for 3 purchases. You pay $81.00
*If you purchase the brand name drug:
Your copayment will be $15.00 + $50.00 (cost difference) = $65.00
The additional $50 does not count toward your annual prescription drug out-of-pocket maximum.

Available alternatives

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

The network formulary program

A formulary is a list of commonly prescribed medications within particular therapeutic categories. The drugs on the list have been selected based on their effectiveness and cost. To be included in the formulary list, a drug must meet rigorous standards of approval by the Express Scripts Pharmacy and Therapeutic Committee - a group of nationally recognized medical professionals.

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

Drug monitoring service

All prescriptions, both home delivery and retail, are screened by the network's computerized drug monitoring service.

This service analyzes all of your prescriptions in the system for potential problems such as adverse drug interactions, drug duplications and unusually high or low dosages. This service will also detect if a refill is requested too soon. If a potential problem is detected, the drug monitoring service transmits a message to the pharmacist. The pharmacist will contact your doctor about the potential problem or otherwise resolve the issue before dispensing the prescription. Of course, your doctor makes the final decision about any change in your prescription or course of treatment.

Limitations

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

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

When a prescription drug becomes available over the counter

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

Special rules for coordinating benefits for prescriptions

If you or your family members are covered under any other group medical plan, the Plan coordinates benefits with that plan, as described in the Coordination of benefits section of this SPD. In addition, information about the other coverage is provided to the outpatient prescription drug network.

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

Medicare Advantage (Part C) Plans, Medicare Part D, and the Prescription Drug Program

Participants who choose to enroll in a Medicare Advantage (Part C) plan which provides a Medicare prescription drug benefit or Medicare Part D Prescription Drug Plan will no longer be eligible for outpatient prescription drug coverage under the Plan. If you enroll in a Medicare Part C plan which provides a Medicare prescription drug benefit or Part D program and continue your Plan participation, your required contributions remain the same, but you will not be eligible for outpatient prescription drug benefits under the Plan.

Specialty medications

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

Specialty medications administered by Express Scripts are filled through their specialty pharmacy, Accredo, and can be delivered to hospitals, clinics, doctor’s offices, or to a home health care provider. Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits. However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program. If the specialty medication being purchased qualifies for copay assistance, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program. If you choose not to enroll in the program, you will be responsible for the higher copayment.

Advanced utilization management program

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

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

Precertification: preferred drug step therapy rules

You must call Express Scripts for precertification of certain prescription drugs described below:

Preferred drug step therapy rules are used for certain therapeutic chapters of drugs, to encourage the use of effective, lower-cost drugs by excluding some targeted medications from coverage. In the therapeutic chapters including: proton pump inhibitors, sleep agents, depression, osteoporosis, respiratory, cardiovascular, triptans, growth hormone, stimulants for Attention Deficit Hyperactivity Disorder, prostate therapy drugs, topical steroids, and stroke prevention, there will be targeted drugs determined by Express Scripts which will not be covered unless pre-certified by Express Scripts. Non-targeted drugs will be covered without such authorization and will continue to be dispensed with no further action by either you or the prescribing physician. If you have a question regarding a drug in any of these therapeutic chapters, contact Express Scripts to determine whether your drug is covered. You will be notified directly by Express Scripts if you are affected by these rules.

Prior authorization rules 

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

Therapeutic Resource Centers

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

Split-fill program

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

Other Plan provisions

Other Plan provisions for the Medicare Supplement Plan Option

Q. How does the Plan work?

A. In addition to outpatient prescription drugs, the Plan covers certain other expenses. You and the Plan share costs for covered treatment and services. You must satisfy an annual deductible before the Plan considers expenses for payment. Once the annual deductible is met, the Plan's reimbursement level - when combined with Medicare - is 80% for the following expenses: covered charges that are paid by Medicare at less than 80%, claims from outside the U.S., and in-home skilled nursing care. The Plan also includes an annual out-of-pocket limit that includes your deductible. If you should meet your annual out-of-pocket limit, the Plan's reimbursement level — when combined with Medicare — is 100% of the Medicare approved amount for most covered charges for the rest of that calendar year. For examples, please see chart in the Benefit summary.

Deductibles

Each year you must meet the deductible before any expenses, other than outpatient prescription drugs, are eligible for reimbursement by the Plan.

You may become eligible for the Plan during a year in which you have met part or all of the deductibles under another medical plan to which ExxonMobil contributes. Those amounts apply to your deductible for the Plan, but do not apply to Medicare deductibles.

Annual out-of-pocket limit

The Plan protects you against most extremely high medical expenses. It does so by limiting your annual out-of-pocket payments for most covered expenses to $3,000 per person. Once you have spent $3,000 for covered expenses (including your deductibles), the Plan's reimbursement level when combined with Medicare is 100% of the Medicare approved amount for most covered charges during the remainder of that year.

For the year in which you become eligible for the Plan, this limit includes your out-of-pocket amounts for covered expenses while participating in any medical plan to which ExxonMobil contributes.

Certain expenses do not count toward this out-of-pocket limit, including:

  • Your share of the costs of outpatient prescription drugs.
  • Your share of the cost of in-home skilled nursing care.
  • Charges above the Plan's reasonable and customary limits or the Medicare limiting charge
  • Charges not covered by the Plan, such as the difference in cost between a private and semiprivate hospital room.

To receive credit for medical deductibles and out-of-pocket expenses paid under another ExxonMobil plan, attach an explanation of benefits from that plan showing up-to-date information about your expenses when filing your first claim.  

No lifetime limit

There is no lifetime maximum for the Plan.

Mental health treatment

Like other types of covered medical expenses where the Plan may provide a benefit even though Medicare does not, the Plan will reimburse 80% of reasonable and customary charges for eligible covered mental health treatment.

Medicare only pays for outpatient mental health care and professional services when they are provided by a health care professional who can be paid by Medicare. You should ask your provider if they accept Medicare payment before you schedule treatment. If Medicare does not cover mental health treatment, because it is rendered outside of the U.S., the Plan will reimburse 80% of reasonable and customary charges for eligible covered services. For example, mental health treatment rendered outside the U.S. is not covered by Medicare; however, it is covered under the Plan.

In order for the Plan to consider charges for treatment of a mental health or chemical abuse condition the facility/provider must meet the Medicare definition of a covered facility/provider. For further clarification call Aetna to confirm benefits.

Transition benefits

A transition benefit will be provided under the Plan when medically appropriate as determined by Aetna. A transition benefit will be provided:

  • If such medical expenses were covered under a medical plan that was sponsored by ExxonMobil, and
  • the covered person was participating in a medical plan sponsored by ExxonMobil that covered such care immediately prior to the covered person becoming Medicare eligible and moving into the Plan, and
  • expenses for such care are excluded from coverage by Medicare, and
  • a transition benefit request form is submitted to Aetna by the covered person's treating physician.

Examples

Example 1 — Care in a skilled-nursing facility and the annual out-of-pocket limit:

This example assumes you have met all Medicare and Plan deductibles when, following a period of hospitalization, you enter a Medicare-approved skilled-nursing facility. You remain there 100 days. The facility charges and Medicare approves $300 a day. The total bill is $30,000. It also assumes you have covered out-of-pocket expenses of $900 before you entered the skilled-nursing facility.

How the benefit is calculated

Medicare pays:
  • All of the first 20 days x $300
    per day
  • All but $170.50 per day for days
    21-100 ($300 - $170.50) x 80 days

$6,000.00

+ $10,360.00

Total $16,360.00
IMPORTANT NOTE: Because the Medicare deductibles and daily coinsurance rates change each year please call Medicare or Aetna member services for current Medicare coinsurance amounts.

The ExxonMobil Plan pays 80% of covered charges minus the amount paid by Medicare:

$ 300 per day x 100 days =

$ 30,000

$ 30,000 x .80 = $ 24,000
$ 24,000 - $ 16,360 = $ 7,640
The Preliminary Results
Medicare pays $ 16,360
The ExxonMobil Plan pays $ 7,640
You would pay + $ 6,000
Total $ 30,000

The Actual Results - Applying Your Annual Out-of-Pocket Limit

Because the Plan limits your annual out-of-pocket expenses to $3,000, and you had already incurred $900 in out-of-pocket expenses, the $30,000 bill is paid as follows:

Medicare pays $ 16,360.00
The ExxonMobil Plan pays $ 11,50.00
You would pay $ 2,100.00
Total $ 30,000.00

For skilled-nursing facility services to be considered for payment by the Plan, certain requirements must be met, see Covered expenses

Example 2 — Major surgery:

This example assumes a seven-day hospital stay for major surgery. In addition to hospital charges, there are fees for a surgeon and an anesthesiologist. It also assumes you have not met the Part A deductible but that you have met the Part B and the Plan deductibles and that all providers accept Medicare assignment. Here is what such a procedure might cost:

Hospital Charges for Major Surgery with Medicare
Medicare-approved amount* $ 22,000.00
Medicare-approved amount* for surgeon and anesthesiologist + $ 1,875.00
Total $ 23,875.00
* Approved Amount is the amount on which Medicare bases its
payments for a particular service.

How the benefit is calculated

Medicare pays:

  • All of the Medicare-approved hospital charges except the Part A deductible $22,000 - $1,260 (Part A deductible) = $20,740
  • 80% of surgeon's and anesthesiologist's Medicare-approved amount $1,875 x .80 = $1,500

The Plan starts with the total Medicare-approved amount

  • 80% of Medicare-approved hospital charges minus Medicare payment $22,000 x .80 =

$17,600

$17,600 - $20,740 = $0

  • 80% of surgeon's and anesthesiologist's bills minus Medicare payment $1,875 x .80 =

$1,500

$1,500 - $1,500 = $0

You Pay

  • Medicare Part A deductible $1,260
  • 20% of surgeon's and anesthesiologist's bills $1875 x .20 = $375
  • Total = $1,635

The results

In this example, the $23,875 in expenses is paid as follows:

The result
Medicare pays $ 22,240.00
The plan pays $ 0.00
You pay $ 1,635.00
Total $ 23,875.00

Of the total charges, Medicare paid 93%, and you paid the remaining 7%. Because Medicare paid more than 80%, the Plan pays $0.

Example 3 — Traveling or living outside the United States:

Medicare does not generally cover medical care received while traveling or living outside the United States. The Plan pays for certain covered expenses at 80% after your annual medical deductible has been met. (See Expenses incurred outside the United States, for more information). 

In this example, you incur $22,000 in covered medical expenses while vacationing in Europe.

How the benefit is calculated

Medicare does not cover these expenses.

The Plan pays 80% of covered charges after you pay the annual $300 deductible

How the Benefit is Calculated
Total medical expenses $ 20,000.00
$22,000 - $300 = $21,700.00
$21,700 x .80 = $17,360.00

You Pay

  • Plan deductible $300
  • 20% of $21,700 = $4,340
  • Total = $4,640
The Preliminary Results
Medicare pays $ 0.00
The Plan pays $ 17,360.00
You would pay + $ 4,640.00
Total $ 22,000.00

The actual results - applying your annual out-of-pocket limit

Because the Plan limits your annual out-of-pocket expenses to $3,000, the bill is paid as follows:

Medicare pays $ 0.00
The Plan pays $ 19,000.00
You would pay + $ 3,000.00
Total $ 22,000.00

See the Claims section for information about filing a claim and the Coordination of Benefits section to learn how the Plan coordinates benefits.

In-home skilled-nursing care

With few exceptions, Medicare does not cover skilled-nursing care at home. If you need nursing care at home, there are two types of care — one is covered by the Plan and the other is not:

  • Skilled-nursing care is care that only licensed medical professionals can provide. Feeding someone intravenously is an example of skilled-nursing care. This type of care is covered by the Plan but generally not by Medicare. However, Medicare does cover some intermittent short-term service if a homebound patient needs occasional skilled-nursing care but only in limited situations.
  • Custodial care is care which primarily helps people meet personal needs and daily living activities — care which does not require the services of a licensed medical professional. Helping someone eat, walk, bathe and dress — even if ordered by a physician, and even if performed by a licensed professional — are examples of custodial care. Custodial care is not covered by either Medicare or the Plan. 

A hospital, nursing home or other facility that mainly provides nursing or rehabilitation services cannot be considered your home.

If you think you need in-home private-duty-nursing care, contact Aetna immediately. Aetna must pre-approve this care.

When considering whether nursing care is a covered expense, the critical question is: Does the care require the presence of licensed medical personnel to perform, observe, evaluate or teach?

If the answer is no, the Plan does not cover such care. The severity of a patient's condition is not a factor. A patient with an ongoing and steadily deteriorating condition may require constant attention, but may rarely require the services of a licensed medical professional. Only services requiring such a professional are covered.

If the answer is yes, the Plan covers in-home skilled-nursing care if you meet these conditions:

  • Care has been approved in advance by Aetna. (See Information sources at the front of this SPD.)
  • A physician must certify the care is medically necessary. The care given must actually be skilled-nursing care as described in this section below.
  • A registered nurse, a licensed practical nurse or a licensed vocational nurse must provide the care.

After you meet the Plan's annual deductible, the Plan pays 80% of the reasonable and customary cost of in-home skilled-nursing care with these limits: 

  • The Plan covers as much as 24-hour-a-day care for up to 30 days in any calendar year.
  • The Plan covers up to 16 hours a day for as long as the care is needed.

None of the money you spend on in-home skilled-nursing care counts toward your annual out-of-pocket limit.

Example 1 — In-home skilled-nursing care:

In this example, you have satisfied plan requirements for in-home skilled-nursing care, and you have met the annual deductible. You have not had any other charges for in-home skilled-nursing care during this calendar year. You need such care for four hours a day for 42 days. Assuming this care costs $40 an hour, the daily cost is $160 a day. The cost for 42 days is $6,720.

How the benefit is calculated

Medicare does not pay for this type of service.

The Plan pays 80% of covered charges

$ 160 a day x 42 days = $ 6,720.00
$ 6,720.00 x .80 = $ 5,376.00
You pay 20% of covered for four hours of care a day:
$ 6,720.00 x .20 = $ 1,344.00

The results

The $6,720 bill is paid as follows:

Medicare pays 0.00
The Plan pays $ 5,376.00
Your share $ 1,344.00
Total bill paid $ 6,720.00

None of your share of the cost of in-home skilled-nursing care applies to your annual out-of-pocket limit. The Plan will never pay 100% of in-home skilled-nursing care expenses.

Accepting assignment

Accepting assignment details for the Medicare Supplement Plan Option

Q. What does it mean if a doctor accepts assignment?

A. There are basically three Medicare contractual options for physicians. Physicians may sign a participating agreement and accept Medicare's allowed charge as payment in full for all of their Medicare patients. They may elect to be a non-participating physician, which permits them to make assignment decisions on a case-by-case basis and to bill patients for more than the Medicare allowance for unassigned claims. Or they may become a private contracting physician, agreeing to bill patients directly and forego any payments from Medicare to their patients or themselves. If your doctor or other health care providers accept assignment, they accept the amount Medicare approves as payment in full for that service or supply. You must still pay the difference between the Medicare-approved amount and the amount Medicare and the Plan pay (percentage copayment). 

If a doctor does not accept assignment, you may be required to pay the full amount of the bill when you receive the service. Medicare will then reimburse you for its share of the bill.

All doctors and medical suppliers must accept assignment in some situations, for example, for clinical laboratory services covered by Medicare.

Limiting charge

Medicare sets a limiting charge which is 15% of 95% of Medicare's approved payment amount. As a general rule, doctors and other health care providers who do not accept assignment for a particular service may not require you to pay more than 9.25% over the 100% Medicare-approved amount for that service. Under provisions of the Social Security Act Amendments of 1994, you are not liable for and do not owe amounts billed in these cases which are in excess of Medicare's limiting charge (109.25% of the Medicare-approved amount). In cases where a physician is a non-participating Medicare provider, the plan benefit amount will be calculated using the Medicare limiting charge (see example 2 below).

Medicare Opt-Out Providers

Exceptions to the above limits are services you get from doctors with whom you have a private contract, or for certain items and services, such as vaccinations, ambulance services and durable medical equipment. A private contract is an agreement between you and your doctor who has decided not to give services through the Medicare program. These physicians are referred to as opt out physicians because they have opted out of the Medicare system. Private contracts must meet the following specific requirements:

  • THE PHYSICIAN MUST SIGN AND FILE AN AFFIDAVIT AGREEING TO FOREGO RECEIVING ANY PAYMENT FROM MEDICARE FOR ITEMS OR SERVICES PROVIDED TO ANY MEDICARE BENEFICIARY FOR THE FOLLOWING 2-YEAR PERIOD (either directly, on a capitated basis, or from an organization that received Medicare reimbursement directly or on a capitated basis),
  • Medicare does not pay for the services provided or contracted for,
  • the contract must be in writing and must be signed by you before any item or service is provided,
  • the contract cannot be entered into at a time when you are facing an emergency, or an urgent health situation.

In addition, the contract must state unambiguously that by signing the private contract, you:

  • give up all Medicare payment for services furnished by the opt out physician,
  • agree not to bill Medicare or ask the physician to bill Medicare,
  • are liable for all of the physician's charges, without any Medicare balance billing limits,
  • acknowledge that Medigap or any other supplemental insurance will not pay toward the services, and
  • acknowledge that you have the right to receive services from physicians for whom Medicare coverage and payment would be available.

If you enter into such a private contract, Medicare will pay nothing toward the cost of care and the Plan may pay up to 80% of reasonable and customary charges for eligible covered expenses upon receipt of an itemized bill and a copy of the letter from Medicare to the physician approving the physician’s Medicare opt-out status.

Examples

Example 1 — A Medicare participating (MED-PAR) physician:

MED-PAR physicians are required to take assignment on all Medicare claims. In this example, the MED-PAR physician must accept the Medicare-approved amount. The physician's regular fee for this service is $120. The Medicare-approved amount for this service is $100. You have met all the deductibles for the year.

How the benefit is calculated

Medicare pays 80% of its approved amount directly to the physician.

$100 x .80 = $80

Aetna takes the Medicare-approved amount, calculates the Plan's 80% benefit, and subtracts the amount Medicare pays. The Plan's benefit is calculated as follows:

$100 x .80 = $80

$80 - $80 = $ 0

The results

Payment of the physician's fee is as follows:

Medicare pays $ 80.00
The Plan pays 0
You pay ($100 x .2) + $ 20.00
Total $ 100.00

The payments total $100. Because the physician is a MED-PAR physician who must accept assignment he or she, in effect, reduces the original fee by $20.

Example 2 — A Medicare non-participating (Non-Med-Par) physician

We changed the preceding example in two important ways: The physician is a non-MED-PAR physician who determines whether to accept Medicare assignment on a case by case basis. In this situation, the non-MED-Par physician does not accept assignment and submits a fee of $120. The Medicare-approved amount for this service for a non-MED-PAR physician (whether or not assignment is accepted) is 95% of $100 or $95. Medicare's limiting charge for non-MED-PAR physicians is 115% of the Medicare-approved amount ($95) or $109.25.

How the benefit is calculated

Medicare pays 80% of its approved amount. Medicare pays:

$ 95 x .80 = $ 76.00
The Plan calculated benefit is 80% of Medicare’s limiting charge
($ 109.25). The Plan’s benefit is calculated as follows:
$ 109.25 x .80 = $ 87.40
This amount is reduced by Medicare’s payment. The Plan then pays:
$ 87.40 - $ 76.00 = $ 11.40

The results

You will pay the physician's fee of $109.25 (the full limiting charge) at the point of service and either you or the physician's office will need to file the claim with Medicare. Payment of the physician's fee is as follows:

Medicare reimburses you $ 76.00
The Plan pays $ 11.40
You pay your physician ($109.25 less $87.40) + $ 21.85
Total $ 109.25

Example 3 — A physician with whom you have a private contract (opt-out physician)

We changed the preceding example in one important way: You have signed a private contract with the physician who submits a fee of $120. Since the Medicare-approved amount is not available, the Plan bases payment on reasonable and customary charges. The reasonable and customary amount for this service is $110. The Plan pays 80% of reasonable and customary charges or in this case $88.

The results

Payment of the physician's fee is as follows:

Medicare pays $ 0.00
The Plan pays $ 110.00 x .80 $ 88.00
You pay your physician + $ 32.00
Total $ 120.00

Covered expenses

Covered expenses for the Medicare Supplement Plan Option

Q. What types of medical services are covered by the Plan?

A.The Plan covers a wide range of medically necessary health care services, tests, treatments and supplies. Certain expenses must be approved by Medicare, must be a covered expense under the Plan (listed below), and are subject to certain Plan limitations.

In addition, the Plan may pay benefits for the following covered expenses that are not eligible for reimbursement under Medicare Parts A and B: outpatient prescription drugs (so long as the person is not enrolled in Medicare Part D or a Medicare Part C plan that provides a Medicare prescription drug benefit) and care received while traveling outside the U.S.

The Plan may also pay limited additional benefits for covered expenses beyond reimbursements by Medicare: in-home skilled-nursing care, approved transition benefits and skilled-nursing facilities.

Note: Although Medicare pays for an expense, the Plan may not provide benefits.

All covered expenses must be medically necessary as defined by the Plan. See Key terms

Expenses covered by the Plan are:

  • Acupuncture treatment performed by a recognized physician.
  • Anesthesia
  • Chiropractic services, performed by a licensed doctor of chiropractic who is acting within the scope of his or her license.
  • Colonoscopies that are not for the purpose of routine screening, but are related to the diagnosis and treatment of an injury or illness.
  • Emergency transportation provided by professional ambulance or air ambulance for the first trip to or from the nearest hospital that can provide the necessary care for each illness or injury or non-emergency transportation if approved by Medicare.
  • Home-health care, if approved by Medicare.
  • Hospice care, if approved by Medicare.
  • Hospital charges for a semiprivate room, meals and general-duty nursing care (as opposed to the services of a private-duty nurse).
  • Laboratory tests, analyses or X-rays made for diagnostic or treatment purposes.
  • Outpatient prescription drugs unless you are enrolled in Medicare Part D.
  • Physical therapy prescribed in writing by a physician and performed by a licensed physical therapist.
  • Radiation therapy including X-ray, radon, radium and radioactive isotope treatments.
  • Routine pap smears and mammograms, if approved by Medicare.
  • Prescription smoking deterrent medications.
  • Prostate cancer screening, if approved by Medicare.
  • Second surgical opinion, and third surgical opinion, if first and second opinions contradict.
  • Skilled-nursing care— in-home —prescribed in writing by a physician, essential to medical care and approved in advance by Aetna. Remember, you must need skilled-nursing care on a daily basis. Neither Medicare nor the Plan will cover your expenses if you need skilled-nursing care only occasionally, such as once or twice a week.
  • Skilled-nursing services and skilled-rehabilitation services provided in a skilled-nursing facility, if approved by Medicare. When your stay in a skilled-nursing facility is covered by Medicare, the Plan helps pay for your care during Medicare's 100 days of coverage. If you need skilled-nursing care for more than 100 days, the Plan will continue to help pay for your care for as long as all of the following conditions are met: 
  • You are confined to the Medicare-approved skilled-nursing facility primarily because you need skilled care.
  • Your condition requires daily skilled-nursing or skilled-rehabilitation services which, as a practical matter, can only be provided in a skilled-nursing facility.
  • Your need for skilled care continues for a consecutive number of days without interruption beyond Medicare's 100 days.
  • A physician certifies that you need, and you receive, skilled-nursing or skilled-rehabilitation services on a daily basis.
  • The care rendered in the Medicare-approved skilled-nursing facility is primarily non-custodial care as determined by Aetna reasonably applying Medicare standards.
  • Surgery or other medical care and treatment by physicians.
  • Treatment of fractures and dislocations of the jaw and for certain cutting procedures in the mouth (other than care of the teeth and gums for extractions and repairs).
  • Treatment of temporomandibular joint (TMJ) dysfunction, if approved by Medicare.
  • Vaccinations for flu, pneumonia and preventive shots, if approved by Medicare and billed by your physician. Medically necessary shingles vaccine and its administration when received in a physician’s office or other medical clinic. Coverage for the shingles vaccination at a retail pharmacy may be covered under your pharmacy benefits plan.

Equipment and supplies

  • Appliances to replace lost physical organs or body parts or to help them function if impaired.
  • Bandages and surgical dressings.
  • Blood (if not replaced) or other fluids injected into the circulatory system.
  • Drugs and medications available only with a physician's written prescription and not otherwise excluded, and which are approved by the U.S. Food and Drug Administration for the specific diagnosis.
  • Durable medical equipment rental for temporary therapeutic use such as:
  • Hospital-type beds,
  • Rental of a mechanical ventilator or other mechanical equipment for treating respiratory paralysis,
  • Oxygen and the equipment to administer it, and
  • Wheelchairs.

The Plan may approve the purchase of these items, if the net cost would be lower than renting.

  • Lenses — either first pair of contact lenses, or eyeglass lenses, or intraocular lenses — if required in conjunction with cataract surgery.
  • A wig or hairpiece (synthetic, human hair or blends) ordered by a physician for hair loss due to injury, illness, or treatment of an illness, or ordered in connection with chemotherapy treatment.

Exclusions

Exclusions for the Medicare Supplement Plan Option 

Q. Are there expenses not covered by the Plan?

A. Although the Plan covers many types of treatments and services, it does not cover all. In addition, if you are enrolled in Medicare Part D there are no benefits for outpatient prescription drugs under the Plan.

No benefits are payable under the Plan for any charge incurred for:

Services

  • Care not related to and for diagnosis or treatment of injury or sickness.
  • Care received in a government hospital, if the patient would not have to pay if not covered by the Plan.
  • Cosmetic surgery, except necessary expenses in connection with treatment of an accidental injury.
  • Custodial care which primarily helps people meet personal needs and daily living activities, whether given in or out of a hospital, skilled-nursing facility, nursing home or similar facility.
  • Dental treatments, except as noted under Covered expenses
  • Experimental or investigational procedures or other procedures not proven by long-term clinical studies (see Key terms). 
  • Home-health care not approved by Medicare.
  • Hospice care not approved by Medicare.
  • In-home private duty nursing care not approved in advance by Aetna.
  • Mental health condition that does not constitute the definition of a mental health condition (see Key terms).
  • Nurse's aides.
  • Private-duty nursing care in a hospital or extended-care facility.
  • Routine screening colonoscopies.
  • Routine eye examinations.
  • Routine hearing examinations.
  • Routine physical examinations and related diagnostic lab and radiology.
  • Self-Treatment
  • Skilled-nursing services and skilled rehabilitation services provided in a skilled-nursing facility not approved by Medicare.
  • Treatment for temporomandibular joint dysfunction (TMJ) not approved by Medicare.
  • Treatment for which a covered person is not legally required to pay.
  • Treatment of conditions for which benefits are provided by worker's compensation or similar laws.
  • Treatment of corns, calluses or toenails unless the procedure involves removing a nail root or treating a metabolic or peripheral-vascular disease.
  • Treatment of weak, strained or flat feet or any metatarsalgia or bunion unless the charges involve a cutting procedure.
  • Vaccinations, inoculations or preventive shots or any charges for examination for checkup purposes, other than those specifically noted under Covered expenses or covered by Medicare Part B.

Supplies

  • Dental prosthetic appliances or the fitting of such appliances, except as required on account of accidental bodily injury to physical organs.
  • Eyeglasses.
  • Hearing aids. Even though this Plan does not provide coverage for hearing aids, if you are considering the purchase of hearing aids, you may be able to lower your out-of-pocket expenses through Ampifon Hearing Health Care or the Hearing Care Solutions Discount Program. These programs are available to Aetna participants and offer discounts on hearing exams, services and hearing aids. If you go to a participating hearing discount center, your out-of-pocket expenses could be lower. To find a participating hearing discount center location, you can visit www.aetna.com and search Find a Doctor, Facility or Pharmacy and then select Hearing Discount Locations. To compare costs, please call Ampifon at 1-888-HEARING (1-888-432-7464) or Hearing Care Solutions at 1-866-344-7756 and identify yourself as an Aetna member.
  • Nutritional supplements, even if prescribed by a physician, except for the treatment of phenylketonuria (PKU).
  • Non-prescription drugs, vitamins, or medicines that can be purchased over the counter even if prescribed by a physician (referred to as legend vitamins, except prenatal vitamins, Rocaltrol).
  • Orthopedic shoes, foot orthotics and other supportive devices for the feet not approved by Medicare.
  • Outpatient prescription drugs purchased in excess of the allowed supply (34-day supply for retail pharmacies and 90-day supply for home delivery) per prescription or refill.

Federal notices

Federal notices related to the Medicare Supplement Plan option

A note regarding the ExxonMobil Retiree Medical Plan

The Medicare Supplement Plan option is a retiree only plan. A retiree only health plan is exempt from most provisions of the PPACA. As a retiree only plan the Plan will not include the consumer protections of PPACA that apply to the other plans.

Women's Health and Cancer Rights Act of 1998

If you have a mastectomy, at any time, and decide to have breast reconstruction, based on consultation with your attending physician, the following benefits will be subject to the same percentage 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, and
  • Prostheses, and
  • physical complications in all stages of mastectomy, including lymphedema.

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

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

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.

Coordination of benefits

Coordination of benefits for the Medicare Supplement Plan Option

Q. How does the Plan coordinate benefits with Medicare?

A. The Plan treats Medicare coverage as another group plan for purposes of coordinating benefits. Medicare is the primary plan under which benefits are first payable. Plan benefits are secondary to Medicare.

The Plan will pay benefits on eligible charges up to the Plan's reimbursement level when combined with the benefits payable under Medicare. This means that benefits payable under Medicare are subtracted from the Plan's calculated benefit amount, and if eligible, any remaining Medicare approved amount is paid by the Plan. Plan benefits are determined assuming that you (and any Medicare-eligible family members) are enrolled in both Parts A and B of Medicare even if you (or your family members) have not actually enrolled.

The Plan coordinates benefits with other group plans. As used here, group does not include such organizations as the American Association of Retired Persons (AARP) or professional societies that offer their members insurance coverage. Nor does it apply to personal insurance you may purchase as an individual (sometimes called Medigap plans). 

Medicare advantage plans

If you are enrolled in a Medicare Advantage Plan, including a group prepayment plan (HMO) or a Medicare PPO that replaces your Medicare coverage, you are eligible to receive benefits from the Plan for outpatient prescription drugs only if your Medicare Advantage Plan does not provide a Medicare Prescription Drug benefit. You will continue to be eligible for approved transition benefits from pre-65 medical plans sponsored by ExxonMobil, in-home skilled-nursing care, and certain services received outside of the U.S. 

Some people are eligible for reimbursement from more than one group medical plan in addition to Medicare. Other group plans that are coordinated with the Plan include any group plan that is sponsored by or contributed to by another employer or labor union.

If you are covered by another group plan as defined above, you may be reimbursed by Medicare, the Plan and other group plans. The Plan's benefits can bring you up to — but not more than — 100% of your cost for covered expenses.

If a group medical plan covers either you or your spouse as an active employee, Medicare requires that plan (that is, the active employee plan) to process claims incurred by the employee and family members covered by that plan first. Only after that can Medicare and the Plan process the claims.

For those providers that are unaffiliated with or have been deactivated by Medicare, the Medicare Supplement Plan option will assume Medicare benefits.

If neither you nor your spouse is covered by a group medical plan as an active employee, but both are covered by a plan for retirees, Medicare is primary and pays benefits first. After Medicare pays, one of the retiree plans is considered the secondary plan and the other is third. The secondary plan pays benefits next, without considering benefits payable by the third plan. The third plan will apply its benefit formula, up to the total allowable expenses covered by that plan. If the Plan is third, it will pay remaining amounts under its rules but reimbursement from the Plan will not make total benefits more than 100% of the covered expense.

If the retiree has a claim, Medicare is primary, the Plan is secondary and your spouse's plan is third. If another plan covers the spouse and they have a claim, the other plan is secondary and the Plan is third. However, no one may be covered twice by the Plan, or by the Plan and any other plan to which ExxonMobil contributes. For example, if you and your spouse both worked for the ExxonMobil, neither you nor your children may be covered by both you and your spouse under any medical plan or combination of plans to which ExxonMobil contributes.

Special rules apply to coordinating benefits for prescription drugs. See Covered prescriptions for details. 

Claims

Filling claims for the Medicare Supplement Plan option

Q. When must claims be filed?

A. You must file claims no later than two years after the date you incur the expense.

In most cases, you do not have to file claims if you follow procedures set out for purchasing outpatient prescription drugs (listed in the Prescription drug program section of this SPD) and enroll in the Medicare Direct program. In the event you do need to file a claim, be sure to follow the instructions described in this section.

Outpatient prescription drug claims

You do not have to file a claim for outpatient prescription drugs if you:

  • Use a participating network retail pharmacy and identify yourself as an Express Scripts participant, or
  • Purchase drugs through Express Scripts Pharmacy, the home delivery pharmacy.

Otherwise, you must submit a completed Direct Reimbursement Claim Form to Express Scripts. You may obtain a claim form by calling Express Scripts at the number shown in the front of this SPD.

Note: If you enroll in a Medicare Advantage (Part C) plan which provides a Medicare prescription drug benefit or a Part D Prescription Drug Plan, you are not eligible to submit claims for outpatient prescription drug benefits under the Plan.

Other medical claims

The Plan has contracted with Aetna to process claims for expenses other than outpatient prescription drugs. If you need to file a claim:

  • Submit a completed claim form which can be found at www.exxonmobilfamily.com.
  • Include copies of what Medicare has paid (explanation of benefits, EOB).
  • If expenses submitted are not covered by Medicare, submit itemized bills and Medicare's denial EOB.
  • Keep a copy of a submitted claim.
  • Keep your explanation of benefits.

You may obtain claim forms by contacting Aetna. See Information sources at the front of this SPD. 

Medicare Part A claims

On admission, a hospital generally asks if you have any coverage other than Medicare. Show your Plan identification card.

The hospital usually bills Medicare first, the Plan second, and then bills you for the balance.

Medicare Part B claims

You or your provider or physician should submit your bills first to Medicare. If your provider or physician submits the itemized bill to Medicare, be sure to get a copy. Medicare processes the claim and sends you an explanation of benefits. Send the explanation of benefits to Aetna along with a copy of the itemized bill. Be sure to include the primary participant's Aetna Member Identification number. Aetna processes the claim and sends you an EOB.

Medicare Direct

Medicare Direct, also known as Medicare Crossover, is a program providing you an easier way to handle Medicare Part A and Medicare Part B bills for services received such as office visits, outpatient hospital treatment and medical supplies.

With this program, Medicare forwards information about claims directly to Aetna. This allows faster claims processing as well as less cost and paperwork for you. Plan benefits are paid directly to the provider if you have assigned Medicare benefits to the provider.

To enroll in Medicare Direct, contact Aetna Member Services. You may begin or stop using this program at any time. Changes in your enrollment may take from 45 to 60 days to implement. There is no additional cost for using Medicare Direct.

Bills for dental services

This Plan does not cover dental services.

Expenses incurred outside the United States

If you receive medical care or mental health treatment when traveling or living outside the United States, generally you must pay the medical or mental health treatment bills first. For reimbursement, submit an itemized bill along with a claim form. If the original bills are in a foreign language, you should obtain an English translation, if possible, of the services rendered. Services outside the United States do not require precertification or predetermination. Aetna can only determine coverage of the claim once they receive the itemized bill. 

Bills should be submitted in the appropriate foreign currency. The claims administrator will convert the bill to U.S. dollars using the website Oanda as of the date the medical services were rendered.

Claim denial and reconsideration

If all or part of a claim is denied, the claims administrator will provide you with a written explanation, including the Plan provisions supporting the denial and describing additional information, if any, that may improve the claim's likelihood of being approved. See Administrative and ERISA information.

Right of reimbursement and subrogation

If your claim results from an accident or other injury that may be the fault of another party, you must reimburse any amount paid by the Plan that you recover from the responsible party. The Plan does not require reimbursement from any personal medical insurance you may carry, such as medical coverage under your automobile insurance. The Plan's right to subrogation and reimbursement also constitute an equitable lien against any payments by such third party made or payable to you, your covered family members, or anyone acting on your behalf, now or in the future, regardless of how the payments are characterized. For example, injury, illness or disability related payments that you receive for expenses such as past medical expenses, future medical expenses, attorneys' fees and expenses, or other costs or compensation, up to the full amount of all benefits paid by the Plan, must first be used to repay the Plan before any money goes to you. By accepting benefits from the Plan you are agreeing to this arrangement. The Plan's right to do this is called its right to impose an equitable lien or constructive trust.

Continuation coverage

Continuation coverage for the Medicare Supplement Plan option

Q. Can coverage be continued after eligibility in the Plan ends?

A. No. The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) does not apply to the ExxonMobil Medicare Supplement Plan option.

Administrative and ERISA information

Administrative and ERISA information for the Medicare Supplement Plan option

Q. What other information do I need to know about the Plan?

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

The Medicare Supplement Plan option is a part of 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, TX 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.

Basic Plan information

Plan administrator

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

Administrator-Benefits 

Medicare Supplement Plan
P.O. Box 64111
Spring, TX 77387-4111  

For service of legal process:

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

Authority of administrator-benefits

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

Type of plan

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

Plan numbers

The ExxonMobil Retiree Medical Plan (of which the Medicare Supplement Plan option is a part) is identified with government agencies under two numbers: the Employer Identification Number, 13-5409005, and the Plan Number (PN), 540.

Plan year

The plan year is the calendar year.

Plan funding

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

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

Claims administrator

The claims administrator provides information about claims payment, and benefit pre-determinations. The claims administrator is Aetna for medical claims and advanced approval for in-home skilled-nursing care. Express Scripts is the claims administrator for prescription drugs claims.

Claims fiduciary and appeals

The claims fiduciary is the person to whom all appeals are filed. The claims fiduciary is Aetna for medical mandatory appeals, Express Scripts for prescription drug appeals and the Administrator-Benefits for all non-prescription drug voluntary appeals. You may contact the claims fiduciary as follows:

Medical Mandatory Appeals Prescription Drug Mandatory and Voluntary Appeals Medical Voluntary Appeals
Aetna
P.O. Box 14463
Lexington, KY 40512
Express Scripts
P.O. Box 66587
St. Louis, MO 63166-6587
ATTN: Administrative Appeals Dept.
Phone: 800-946-3979
Administrator-Benefits 
ExxonMobil Retiree Medical Plan
P.O. Box 64111
Spring, TX 77387-4111
 
NOTE: Effective January 1, 2019, no appeals of eligibility will be available regarding decisions that a  dependent child no longer meets the clinical definition of totally and continuously disabled. All decisions by Magellan or Aetna confirming a dependent no longer meets the clinical definition of totally and continuously disabled are final.

Benefit claims procedures

Filing a claim

If you have a problem with a Plan benefit, contact the claims administrator's Member Services. You must file a claim in writing to the appropriate claims administrator, either Aetna Member Services for medical claims or Express Scripts for prescription drug claims. Aetna is responsible for determining and informing you of your entitlement to a benefit and any amounts payable to you with regard to medical services or supplies. Express Scripts is responsible for determining and informing you of your entitlement to a benefit and any amount payable to you under the prescription drug program.

Claims for benefits where the Plan provisions do not require approval before medical care is obtained are the most common claims filed under the Plan. The claims administrator will review your claim and respond within a designated response time, usually 30 days after receiving your claim. If the claims fiduciary needs additional time (an extension) to decide on your claim because of special circumstances, you will be notified within the claim response period. An additional 15 days is all that is allowed. If an extension is necessary due to incomplete information, you must provide the additional information within 45 days from the date of receipt of the extension notice.

Denied claims

If your claim for benefits is denied completely or partially, you, your beneficiary, or designated representative will receive written notice of the decision. The notice will describe:

  • The specific reason(s) for the denial, and
  • The process for requesting an appeal.

You should be aware that the claims administrators have the right to request repayment if they overpay a claim for any reason.

Filing a mandatory appeal

If your claim is denied, you, your beneficiary, or your designated representative may appeal the decision to the appropriate claims fiduciary. If someone is filing a written appeal on your behalf, written authorization from you is required.  Please contact the appropriate claims fiduciary for information regarding the written authorization. Your written appeal should include the reasons why you believe the benefit should be paid and information that supports, or is relevant to, your claim (written comments, documents, records, etc.). Your written appeal may also include a request for reasonable access to, and copies of, all documents, records and other information relevant to your claim. In the case of an urgent care claim, you may request an expedited appeal orally or in writing. You must submit your written appeal within 180 calendar days from the date of the denial notice.

The review will take into account all comments, documents, records and other information submitted relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. You will receive a response to the appeal within a designated response time as follows:

Claim Type Response Time
Urgent care claims 72 hours
Pre-service claims 30 days
Post-service claims 60 days

If additional time is needed to decide on your claim because of special circumstances, you will be notified within the claim response period. However, if an extension is requested and granted, the law stipulates that no additional time must be allowed.

If your appeal is denied, you will receive written notice of the decision. The notice will set forth in plain language:

  • The specific reason(s) for the denial and the Plan provisions upon which the denial is based.
  • A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to the claim.
  • A statement of the voluntary appeal procedure and your right to obtain information about such procedure or a description of the voluntary appeal procedure.
  • A statement of your right to bring an action under section 502(a) of the Employee Retirement Income Security Act (ERISA).

Statute of limitations

After you have received the response of the mandatory appeal, you may bring an action under section 502(a) of ERISA without requesting a voluntary appeal. The statute of limitations or other defense based on timeliness is suspended during the time that a voluntary appeal is pending. Any such lawsuits must be brought within one year of the date on which the appeal was denied.

Filing a voluntary appeal

If your mandatory appeal is denied, you may then submit a voluntary appeal to the appropriate claims fiduciary. New information pertinent to the claim is required for the voluntary appeal to be considered. You must submit your voluntary appeal within 30 days of the denial of your mandatory appeal. The statute of limitations or other defense based on timeliness is suspended during the time that a voluntary appeal is pending.

If it is determined that there is no new information pertinent to your claim, your voluntary appeal will not be considered. If it is determined that there is new relevant information, a decision will be made within 60 days of the date the Administrator-Benefits receives your request for a voluntary appeal.

Future of the ExxonMobil Retiree Medical Plan

ExxonMobil has the right to change, suspend, withdraw, amend, modify or terminate the ExxonMobil Retiree Medical Plan or any of its provisions at any time and for any reason. A change also may be made to required contributions and future eligibility for coverage, and may apply to those who retired in the past, as well as those who retire in the future. If any material changes are made in the future, you will be notified. For health plans, certain rules apply regarding what happens when a plan is changed, terminated or merged.

Expenses incurred before the effective date of a Plan change or termination will not be affected. Expenses incurred after a Plan is terminated will not be covered. If a Plan cannot pay all of the incurred claims and plan expenses as of the date the Plan is changed or terminated, ExxonMobil will make sufficient contributions to the Plan to make up the difference.

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 as a Plan participant, you 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 Medical Plan, including collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Medical Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.
  • Obtain, upon written request to the Administrator-Benefits, copies of documents governing the operation of the Medical Plan, including collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated SPD. The administrator may require a reasonable charge for the copies.
  • Receive a summary of the Medical Plan's annual report. The Administrator-Benefits is required by law to furnish each participant with a copy of this summary annual report.

Prudent actions by medical plan fiduciaries

In addition to creating rights for Medicare Supplement Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate the Medicare Supplement Plan option, called fiduciaries of the Medicare Supplement Plan option, have a duty to do so prudently and in the interest of you and other Medicare Supplement Plan participants and beneficiaries. No one, including your employer, your union, or any other person, 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 Medicare Supplement Plan documents or the latest summary annual report from the Medicare Supplement Plan option 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 your Medicare Supplement Plan option, you should contact Aetna Member Services via the telephone number on your ID card, or call the Benefits Service Center. If you have any questions about this statement or 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.

Federal notices

A note regarding the ExxonMobil Retiree Medical Plan

The Medicare Supplement Plan option is a retiree only plan. A retiree only health plan is exempt from most provisions of the PPACA. As a retiree only plan the Plan will not include the consumer protections of PPACA that apply to the other plans.

Women's Health and Cancer Rights Act of 1998

If you have a mastectomy, at any time, and decide to have breast reconstruction, based on consultation with your attending physician, the following benefits will be subject to the same percentage 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, and
  • Prostheses, and
  • physical complications in all stages of mastectomy, including lymphedema.

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

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

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.

Key terms

List of key terms in the Medicare Supplement Plan option

Accepts assignment

A physician who accepts Medicare assignment agrees to accept no more than the Medicare-approved amount as total payment for a service.

Approved amount

The amount on which Medicare bases its payments for a particular service.

Benefit period

A period beginning when you enter a hospital and ending after you have remained out of the hospital (or a skilled-nursing facility) for 60 consecutive days.

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 or 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.

Clinical psychologist

A person specializing in clinical psychology who is licensed or certified by an appropriate governmental authority. If there is no licensing or certification in a particular area, he or she must be a member or fellow of the American Psychological Association.

Copayment and coinsurance

The portion of covered expenses you pay. For some services the coinsurance will be a percentage of the cost of the service once the deductible has been satisfied. For outpatient prescription drugs there is a percentage copayment.

Covered charges or covered expenses

Expenses that are eligible for reimbursement under the Plan. Some expenses must be Medicare-approved to be covered. All expenses must meet Plan requirements including medical necessity.

Custodial care

Care that helps meet personal needs and daily living activities such as walking, bathing, dressing, eating and giving medicine. Custodial care, even if prescribed by a treating physician and performed by a licensed medical professional, such as a nurse, is not covered by Medicare nor the Plan.

Deductibles

The amount of covered expenses you incur before a plan begins to pay. Medicare and the Plan have separate and different deductibles.

Disability

You may qualify for Social Security and Medicare by virtue of a disability, even if you are less than age 65.

Eligibility rule for participants of the Comprehensive Medical Expense Benefit Plan of Mobil Oil Corporation and the Superior Oil Medical Plan

If you or your family members were participating in the Comprehensive Medical Plan of Mobil Oil Corporation on March 31, 2004, and you were Medicare eligible, you are a participant in the Plan effective April 1, 2004. In addition, individuals who became your eligible family members (e.g., marriage) after March 31, 2004, are eligible.

Eligible family members

For purposes of the Medicare Supplement Plan option, eligible family members who are also eligible to be enrolled in Medicare as their primary medical plan include:

  • The spouse of an eligible retiree.
  • The surviving spouse, who has not remarried, of a deceased eligible retiree or deceased employee.
  • The child of an eligible retiree, deceased eligible retiree, or deceased employee who was enrolled in the MSP on December 31, 2018 and continues to be enrolled in the MSP.

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). If your dependent, or your spouse become eligible for Medicare, you need to notify this event. 

Family members who are not eligible to be enrolled in Medicare as their primary medical plan may be eligible for coverage under one of the Retiree Medical Plan options of the ExxonMobil Retiree Medical Plan. See the SPD for the Retiree Medical Plan option of your choice for more information.

Eligible retiree

In the Plan, an eligible retiree is a person who:

  • Retired with retiree status from ExxonMobil,
  • Retired with retiree status from Exxon,
  • Retired with retiree status from Mobil or Superior Oil,
  • Is a former Exxon or ExxonMobil employee who retired with retiree status from Exxon or ExxonMobil and is not currently working for ExxonMobil as a regular or non-regular employee
  • Retirees of Station Operators, Inc. doing business as ExxonMobil Company Operated Retail Stores (CORS) are not eligible for coverage under this plan.

Experimental or investigational

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

Explanation of benefits

A statement summarizing charges and payments for medical services including the amount paid by Medicare or the Plan, and amounts remaining to be paid.

ExxonMobil Retiree Medical Plan (EMRMP)

The Plan sponsored by Exxon Mobil Corporation which provides medical benefits for eligible retirees, survivors and their family members, and includes the Retiree Medical Plan (RMP) and the Medicare Supplement Plan option (or MSP) as constituent parts.

Home-health care

Medically necessary care and equipment provided at home by a Medicare-certified agency on a part-time or intermittent basis by skilled nurses, home-health aides, occupational, physical or speech therapists and those providing medical social services.

Hospital

An institution which is engaged primarily in providing medical care and treatment of sick and injured persons on an inpatient basis at the patient's expense which is:

  • Accredited by the Joint Commission on Accreditation of Hospitals,
  • A hospital, psychiatric hospital or a tuberculosis hospital, as those terms are defined in Medicare (or as may be amended by Medicare in the future), which is qualified to participate and eligible to receive payments under and in accordance with the provisions of Medicare, or
  • An institution which:
  • maintains on its premises diagnostic and therapeutic facilities for surgical and medical diagnosis and treatment of sick and injured persons by or under the supervision of a staff of duly qualified physicians,
  • continuously provides on its premises twenty four hour a day nursing service by or under the supervision of registered graduate nurses, and
  • functions continuously with organized facilities for operative surgery on its premises.

Limiting charge

The maximum amount (currently 115% of 95%, or 109.25% of the Medicare-approved amount) a physician may require a Medicare beneficiary to pay for a covered service if the physician does not accept assignment.

Medically necessary or medical necessity

Services or supplies that are: legal; ordered by a physician or clinical psychologist; safe and effective in treating the condition for which ordered; part of a course of treatment generally accepted by the American medical community; of a proper quantity, frequency and duration for treating the condition for which ordered; not redundant when combined with other services and supplies used to treat the condition for which ordered; not experimental, meaning unproven by long-term clinical studies; and for the purpose of restoring health or extending life.

Mental health condition

Neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or behavioral disorder or disturbance with a diagnosis code from the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV), or its successor publication, and which is otherwise covered by Medicare. Such a condition will be considered a mental health condition, regardless of any organic or physical cause or contributing factor.

Non-custodial

See skilled-nursing care.

Nurse

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

Other services and supplies

Services and supplies provided by a hospital or skilled-nursing facility required to treat a patient. Excluded are fees for room and board and fees charged by physicians, private-duty or special nursing services.

Outpatient prescription drug

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

Part A

That part of Medicare which pays certain hospital and skilled-nursing facility bills.

Part B

That part of Medicare which pays certain physician and other medical bills.

Part C

That part of Medicare that provides Medicare Advantage plans.

Part D

That part of Medicare which pays certain outpatient prescription drug bills.

Physician

Physician means a person acting within the scope of his or her license and holding the degree of Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Dental Surgery (D.D.S.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (O.D.), or Doctor of Chiropractic (D.C.), or who is duly licensed as an orthoptist, a physician assistant or nurse practitioner.

Primary Care Physician means a Physician engaged in general practice, family practice, internal medicine, pediatrics or obstetrics/gynecology who provides basic health services to covered persons.

Primary participant

The participant whose Social Security number or Aetna Member Identification Number is used for identification purposes. The primary participant is the retiree, survivor or individual who elected COBRA coverage. Covered family members use the primary participant's Social Security number or Aetna Member Identification Number to access all benefits.

Private duty nursing

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

Reasonable and customary

An amount which is less than or equal to the most common charge for a particular medical service or supply in a particular geographic area. The Plan bases its payments on the lesser of the actual amount charged, the reasonable and customary amount, or the Medicare limiting charge, except when the provider accepts assignment under Medicare (then the Medicare-approved amount is used).

Reserve days

A Medicare term for available benefits after you use 90 days of hospital coverage in any benefit period. You have a lifetime maximum of 60 reserve days.

Retiree

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

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

Retiree Medical Plan (RMP)

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

Room and board

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

Skilled-nursing care

Care requiring services only licensed medical professionals can provide in the home or in a skilled-nursing facility. Both Medicare and the Plan cover such care when prescribed by a treating physician and determined to be medically necessary. These types of services are sometimes called non-custodial nursing care.

Skilled-nursing facility

A Medicare-approved institution meeting government-prescribed standards for skilled-nursing care or skilled-rehabilitation services. The Plan covers only Medicare-approved skilled-nursing facilities.

Skilled rehabilitation services

Services only licensed rehabilitation professionals can provide. Both Medicare and the Plan cover such care when prescribed by a physician and determined to be medically necessary.

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 of a deceased ExxonMobil regular employee or retiree.

Benefit summary

Benefits summary of the Medicare Supplement Plan option 

The following section provides a brief summary of the Medicare Supplement Plan amounts, and how payments are determined.

The Plan provides benefits up to the Plan's reimbursement level when combined with Medicare. This means that Medicare's payments are subtracted from the Plan's benefits and any difference is paid by the Plan. For more information, check the Medicare Web site at www.medicare.gov.

Annual Deductible Per covered individual $300
Out-of-Pocket Maximum Per covered individual $3,000
Medical Individual Lifetime Maximum Unlimited
Medical Services 80% of covered charges less any Medicare payment
Inpatient Hospital Services 80% of covered charges less any Medicare payment
Outpatient Hospital Services 80% of covered charges less any Medicare payment
Physician Services 80% of covered charges less any Medicare payment
Prescription drugs — Annual out-of-pocket maximums for prescription drugs--$2,500/individual and $5,000/family.

  Short Term Retail Pharmacy Co-Pay* ** *** **** Long Term Express Scripts, or Smart90 Pharmacy
  (up to 34-day supply) Maximum Per Prescription
3rd+ Retail Refill****
(up to 90-day supply) Maximum Per Prescription
Generic Drugs 30%
$50 25% $100
Formulary Brand Drugs 30% $125
25% $250
Non-Formulary Brand Drugs 50% $200
45% $400

*If using a non-network pharmacy, you pay 100% of the difference between the actual cost and the discounted network cost plus retail copays.

** If your doctor prescribes a brand name drug for which a generic equivalent is available, you will be responsible for paying the generic copay and the full difference in the cost between the brand name and the generic equivalent. The difference in the cost between the brand and the generic does not apply to the annual out-of-pocket maximum for prescription drugs.

*** You must present your Express Scripts Prescription Card or Social Security number of the primary participant or benefits will be paid at the non-network level.

**** Preferred means Express Scripts’ formulary of preferred prescription drugs. Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits. However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program. If the specialty medication being purchased qualifies for copay assistance, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program. If you choose not to enroll in the program, you will be responsible for the higher copayment.

Care Outside of the U.S. 80% of the covered charge
Home Health Care 80% of Medicare approved charges less any Medicare payment, must be approved in advance
Blood 80% of Medicare pre-approved covered charges less any Medicare payment
Skilled Nursing Facility Charges 80% of covered charges less any Medicare payment
Hospice Care 80% of covered charges less any Medicare payment
Mental Health Treatment 80% of reasonable and customary charges less any Medicare payment

Claims examples: 

  Claim 1 Claim 2 Claim 3 Claim 4 Claim 5 Total
Eligible Expenses Medicare Approved Amount $200.00 $300.00 $2,600.00 $15,100.00 $1,310.00 $19,510.00
Medicare Deductible $183.00 $0.00 $0.00 $0.00 $0.00 $183.00
Medicare Coinsurance $3.40 $60.00 $520.00 $3,020.00 $262.00 $ 3,865.40
Medicare Paid based on 80% benefit after Medicare Part B deductible ($166 applied) Please reference your Medicare Handbook for current deductible/coinsurance for the expenses incurred $13.60 ($200 ‐ $183 = $17 x 80%) $240 ($300 x 80%) $2,080 ($2,600 x 80%) $12,080 ($15,100 x 80%) $1048 ($1,310 x 80%) $15,461.60
Amount Applied to $300 MSP Annual Deductible $200.00 $100.00 $0.00 $0.00 $0.00 $300.00
True Out of Pocket Expense Applied to $3000 Annual Out of Pocket Maximum $186.40 $60.00 $520.00 $2,233.60 $0.00 $3,000.00
Amount Paid by MSP after Medicare’s Payment and Applicable Yearly Plan Deductible and Coinsurance is Applied $0.00 $0.00 $0.00 $786.40 $262.00 $1,048.40
Paid by Participant $186.40
$60.00 $520.00 $2,233.60 $0.00 $3,000.00
MSP Plan Benefit Calculation:
Medicare’s Approved
Amount Plan
Deductible Annual
Plan Coinsurance
Medicare Paid = Plan
benefit Payment
$200
applied to deductible
= $0 plan
paid
$300 $
100 applied deductible
= $200 x
80% = $160-$240 Medicare paid = $0
plan paid
$2,600 x 80% = $2,080
$2,080
Medicare paid = $0 plan paid
$15,100 x 80% = $12,080
$3,000 plan
out of pocket maximum met at
$12,866.40 $12,080 Medicare paid =
$786.40 plan paid
$1310 x 100% annual out of pocket met = $1310 - $1048 Medicare payment = $262 plan paid $1,048.40

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