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POS II A and POS II B Options

Summary plan description of the Retiree Medical Plan - POS II A and POS II B options as of January 2021

About the Retiree Medical Plan

This summary plan description (SPD) summarizes the ExxonMobil Retiree Medical Plan (the Plan) POS II A and B options. It does not contain all Plan details. In determining your specific benefits, the full provisions of the formal plan documents, as they exist now or as they may exist in the future, always govern. You may obtain copies of these documents by making a written request to the Administrator-Benefits. ExxonMobil reserves the right to change benefits in any way or terminate the Plan at any time.  These options are governed by federal laws, not by state insurance laws.

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

Tips for New Plan Participants

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

Information sources

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

For claims administration:

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

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

For benefits information:

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

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

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

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

Phone numbers and addresses:

Aetna Member Services 
800-255-2386
210-366-2416 (if international, call collect)
Monday – Friday 8:00 a.m. to 6:00 p.m. 
(U.S. Central Time), except certain holidays
Automated Voice Response - 24 hours a day, 7 days a week

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

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

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

Magellan Healthcare
14100 Magellan Plaza Drive
Maryland Heights, MO 63043

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

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

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

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

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

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

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

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

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

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

Introduction

The ExxonMobil Retiree Medical Plan (EMRMP) consists of the Retiree Medical Plan (RMP) POS II A, POS II B, Aetna Select, and Cigna OAPIN options for Pre-Medicare eligible participants, and the Medicare Primary Option (MPO) for Medicare-eligible participants.  The Medicare Supplement Plan (MSP) option is closed to new participants as the MPO is being implemented.  This SPD is a summary of benefits under the POS II options only. It does not contain all the details about the POS II options nor does it contain any information about other EMRMP options. If you enroll in any option other than the POS II options, you may access an SPD for that option.

The Retiree Medical POS II options have a network of physicians, hospitals, and other health care providers whose credentials have been reviewed by the network manager and who have agreed to provide their services at negotiated rates. The POS II A and B options are different plan designs utilizing the same network.

The network for medical care covered under the POS II options – referred to as the Retiree Medical POS II in this SPD – is offered by Aetna. Aetna Life Insurance Company (Aetna) is the network manager and claims administrator for the Retiree Medical POS II.

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 Retiree Medical POS II (Aetna Choice® POS II), 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 PPO for mental health and substance abuse care covered under the Retiree Medical POS II options – referred to as the Mental Health PPO (MHPPO) in this SPD – is managed by Magellan.

The Retiree Medical POS II options offer you the ability to use physicians and other health care providers that are part of a network. You can generally reduce your out-of-pocket expenses by using network providers.

If you elect the Retiree Medical POS II A and B option and you live outside one of the network areas, you are provided benefits on an out-of-network area basis. However, if you live within the network area and choose to use a non-network provider, specific limitations apply to the benefits you are provided.

These tools can help you find specific information quickly and easily:

  • Plan at a glance, a user's guide highlighting plan basics.
  • Charts and tables throughout this SPD provide information, examples and highlights of plan provisions, including Benefit Summary charts.
  • References to places where you can get more information.
  • A list of Key terms containing definitions of some words and terms used in this SPD. Terms are underlined and linked for easy identification.

A careful reading of this SPD will help you understand how the Retiree Medical POS II options work so you can make the best use of the Plan provisions. You may obtain additional information through the sources shown in the About the Retiree Medical Plan section.

Plan at a glance

Enrolling

You may enroll yourself and your eligible family members within 60 days of your retirement. If you do not enroll at this time, you will have limited opportunities to enroll at a later date. See the Eligibility and enrollment section for more information.

Basic plan features

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

The prescription drug program

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

Mental health and substance abuse care 

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

Covered and excluded expenses 

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

Payments

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

Claims 

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

Health Management Programs

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

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

Consolidated Omnibus Budget Reconciliation Act 1985 (COBRA) 

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

Administrative and ERISA information

This Plan is subject to rules of the federal government, including the Employee Retirement Income Security Act of 1974, as amended (ERISA), not state insurance laws. See Administrative and ERISA information Section.

Key terms

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

Benefit summaries

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

Eligibility and enrollment

Eligibility and enrollment for the Retiree Medical Plan - POS II A and B Options

Q. What are the Medical Plan's eligibility requirements? 


A. Most U.S. retirees and eligible family members of Exxon Mobil Corporation and participating affiliates are eligible for the POS II Options.

Generally, you are eligible if:

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

You are not eligible for the Retiree Medical Plan if:

  • You participate in any other employer medical plan to which ExxonMobil contributes.
  • You are eligible for coverage under the ExxonMobil Medical Plan.
  • You fail to make any required contribution toward the cost of the Plan.
  • You fail to comply with general administrative requirements including but not limited to enrollment requirements.
  • You lost eligibility as described under the Loss of eligibility section.
  • You are eligible for Medicare as your primary plan.

Eligible family members

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

  • Your spouse. When you enroll your spouse for coverage, you may be required to provide proof that you are legally married.
  • Your child(ren) under age 26, even if medicare eligible. Coverage ends at the end of the month in which they reach age 26. If your situation involves a family member other than your biological or legally adopted child, call the Benefits Service Center.
  • Your totally and continuously disabled child(ren)who is over age 26 and  who is incapable of self-sustaining employment by reason of mental or physical disability, that occurred prior to otherwise losing eligibility and meets the Internal Revenue Service's definition of a dependent, and is not eligible to be enrolled in Medicare as their primary medical plan.
  • A child or spouse of a Medicare-eligible retiree or survivor enrolled in the Medicare Primary Option (MPO), as long as that spouse or child over age 26 are not eligible to be enrolled in Medicare.

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). 

Refer to Key Terms for definitions of eligible family members, child, suspended retiree, and spouse.

Suspended retiree

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

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

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

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

Special eligibility rules

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

Classes of coverage

You can choose coverage as an:

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

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

Each class of coverage described in this section has its own contribution rate. Retirees and survivors receiving monthly benefit checks from ExxonMobil pay by deductions from these checks on an after-tax basis. Other retirees or survivors and participants with continuation coverage pay by check or by monthly draft on their bank account.  You must complete the forms required for payment of contributions within 60 days of enrollment in the Plan.  If you fail to do so, coverage will be retroactively suspended and you will be prevented from enrolling at a future date until you pay past contributions.

Double coverage

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

How to enroll

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

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

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

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

All enrollments must be completed within 60 days of the enrollment event. Coverage is effective the first of the month following receipt of your election by the ExxonMobil Benefits Service Center (EMBSC), except in the case of a birth or adoption of a child when changes will be effective on the date of the birth or adoption.

You can enroll either online or by phone. To enroll online go to www.exxonmobil.com/benefits. To enroll by phone, call the Benefits Service Center at 800-682-2847.

You may be requested to provide documents at some future date to prove that the family members you enrolled were eligible (e.g. marriage certificate, birth certificate). If you fail to provide such requested documents within the required time period, coverage for the family members will be cancelled the first of the following month. If you enroll family members who are not eligible for the Plan, for instance, by covering children who do not meet the eligibility requirements, you may lose eligibility for yourself and your family under all ExxonMobil health plans.

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

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

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

Post-Retirement changes in status

If this event occurs... You may...
Marriage Add your spouse and any new eligible family members.
Divorce – Retiree and spouse enrolled in ExxonMobil health plans You are required to remove coverage for your former spouse and any stepchild(ren).
Divorce – Retiree loses coverage under spouse’s health plans Enroll yourself and add other eligible family members who might have lost eligibility for spouse’s plan.
Gain a family member through birth, adoption or placement for adoption, sole court appointed legal guardian, or sole managing conservator Add new eligible family members.
Death of a spouse You must remove coverage for any stepchild(ren) unless you are their court appointed legal guardian or sole managing conservator.
You or a family member loses eligibility under another employer's group health plan Enroll yourself and add eligible family members.
You lose eligibility because of a change in your employment status, e.g., retiree to rehired employee. Your Retiree Medical Plan participation will automatically be suspended at the date of rehire and you will be covered under the ExxonMobil Medical Plan.
You gain eligibility because of a change in your employment status, e.g., employee to retiree. Enroll yourself and add eligible family members.
You change your residence affecting your eligibility to participate in your elected Retiree Medical Plan option Change your Retiree Medical Plan option.
You or your spouse become entitled to enroll in Medicare as your primary plan You or your spouse lose eligibility under the Retiree Medical Plan options but may enroll in the Medicare Primary Option.
Your disabled child over age 26 becomes entitled to enroll in Medicare as their primary plan (even if your child is not enrolled yet in Medicare) You must remove coverage for your child.
Judgment, decree, or other court order requiring you to cover a family member.
(e.g. begin a QMCSO)
Add new eligible family members.

 

Changes at retirement

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

If you are not covered by a medical plan to which ExxonMobil contributes and would like to enroll in the ExxonMobil Retiree Medical Plan, or if you would like to change your Retiree Medical Plan option, you must do so within 60 days of your retirement date. Coverage is effective the first of the month following receipt of your election by the Benefits Service Center.

Annual enrollment

Each year, during the fall, ExxonMobil offers an annual enrollment period. During this time, you can switch from your current Retiree Medical Plan option to another available option. Changes elected during annual enrollment take effect the first of the following year.

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

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

If you do not want to make any changes, you don’t have to do anything during annual enrollment to continue with your current plan selection for the following year. 

Other situations that may affect your coverage

Change in coverage costs or significant curtailment

If the cost for coverage charged to you significantly increases or decreases during a plan year, you may be able to make a corresponding prospective change in your election, including the cancellation of your election. If you choose to cancel your elected coverage option, you may be able to elect coverage under another Retiree Medical Plan option.

This provision also applies to a significant increase in plan option deductible or copayment.

If the cost for coverage under your spouse's medical plan significantly increases or there is a significant curtailment of coverage that permits revocation of coverage during a plan year and you drop that coverage, you will be able to sign up for retiree medical coverage for yourself and your eligible family members.

Addition or improvement of plan options

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

Loss of option

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

If a covered family member lives away from home

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

If you or your covered spouse become eligible for Medicare

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

If you die

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

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

If you become a suspended retiree

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

Coverage continues for 12 months from the date coverage would otherwise end if you received transition benefits under the ExxonMobil Disability Plan. However, if you did not receive transition benefits under the ExxonMobil Disability Plan, coverage continues for 18 months from the date coverage would otherwise end. The cost of this continued coverage is 102% of the combined participant and company contributions. 

When coverage ends

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

The last day of the month in which:

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

OR

The date:

  • You do not make any required contribution,
  • You are rehired by ExxonMobil after retirement as an employee or non-regular employee,
  • The Retiree Medical Plan ends,
  • You enrolled an ineligible family member and in the opinion of the Administrator-Benefits, the enrollment was a result of fraud or a misrepresentation of a material fact.

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

Loss of eligibility

Fraud against the Plan

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

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

Basic Plan features

Basic Plan features for the Retiree Medical Plan - POS II A and B options

Q. What are the basic features of the RMP POS II options? 

A. The basic features of the RMP POS II options are:

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

Both RMP POS II options include the features listed below.

Medically necessary

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

When determining medical necessity, the Administrator-Benefits may consider the Clinical Policy Bulletins (CPBs) published by Aetna, the claims administrator. CPBs are based on established, nationally accepted governmental and/or professional society recommendations, as well as other recognized sources. These CPBs may be found on the Aetna website at www.aetna.com.

Precertification

Precertification or preauthorization is a mandatory review of inpatient admissions and select ambulatory procedures and/or services in advance of treatment, to confirm medical necessity based on clinical criteria and benefits eligible under the Plan. If you are using a network provider, the provider will perform the precertification process on your behalf. If you are using a non-network provider, you must initiate the precertification process yourself. Failure to obtain a required precertification for non-network hospitalization services will result in a $500 penalty, even if the services are medically necessary and otherwise covered under the Plan. For more information on precertification for medical/surgical procedures and services, see the National Precertification List on the Aetna member website. To find a list of mental health treatments requiring precertification, including inpatient and intensive outpatient services, visit the Magellan website.

The following outlines a few examples of services that need to be precertified (including mental health and substance abuse). If you are unsure if the service you are seeking requires precertification, call Aetna Member Services, or Magellan for mental health treatments.

For non-emergency medical care (including for mental health and substance abuse):

  • Hospitalization
  • If you are using POS II network provider, or a mental health PPO network provider, your provider will handle the precertification process for you.
  • Before you are admitted to a hospital that does not participate in the Aetna POS II or the Magellan mental health PPO network, you must call Aetna for a medical preadmission review or Magellan for a mental health preadmission review. This is required for most inpatient admissions, including extended-care facilities.

You are not required to call to precertify:

  • Hospitalization outside the United States, for both medical and mental health or substance abuse    
  • Extended care facility    
  • Skilled nursing facility
  • Private duty nursing
  • Defibrillators and pacemakers not a result of emergency treatment
  • Heart catheterizations             
  • Cardiac rhythm implantable devices
  • Spinal fusion surgery and other spinal procedures

Enhanced clinical review

The Plan also includes a utilization management program, known as Enhanced Clinical Review (ERC), of some diagnostic services (e.g., MRIs, CT Scans, Cardiac Imaging, sleep studies, hip/knee replacement procedures, etc.).

An enhanced clinical review is a mandatory review of select covered services that have equivalent, lower-cost alternatives, to ensure the higher cost service is medically necessary in advance of treatment. If the review is not completed and the treatment is not approved, it will not be covered under the Plan.

Please contact Aetna Member Services to determine if the service your physician has recommended requires enhanced clinical review.

The ECR precertification process applies to Aetna participating providers and facilities. Out of network providers and facilities are subject to retrospective claim reviews to determine if the services meet Aetna medical necessity guidelines.

For emergency inpatient admissions:

Certification must be made within 48 hours following an emergency inpatient admission. If the admission is on a weekend or holiday, notification must be made within 72 hours.

  • If you are using POS II network provider, your provider will obtain certification for you.
  • You or someone acting on your behalf must call to certify care if you are in a non-network or out-of-network area hospital.

For mental health or substance abuse care:

Call Magellan for precertification of any mental health or substance abuse care, including inpatient stays, residential treatment, and intensive outpatient therapy.

If you require mental health or substance abuse care in conjunction with a medical emergency, notify Magellan.

For certain prescription drugs: 

Your physician 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 precertified 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.

Predetermination

A predetermination is an estimate of covered services and benefits payable in advance of treatment. It is not a guarantee of benefits eligible or payment amount. You may request a predetermination for any covered service. In most cases, you may receive an answer over the phone. In other cases, information from your provider may be needed. You or your doctor can also request a predetermination of benefits, in writing, before the service is performed.

Predetermination is recommended for all outpatient surgical procedures. This predetermination may require review by one or more doctors. Be sure to allow time for this review between the predetermination request and the proposed date of the service. By obtaining the written response, you will have more detailed information about the level of reimbursement.

For more information on requesting a predetermination, see the Information sources section at the front of this SPD.

When you call for a benefit predetermination, be ready to provide the following information:

  • Primary participant's name and member ID, which can be found on your Aetna ID card,
  • Patient's name,
  • Complete description of medical services or surgical procedures. If possible, include the diagnosis code(s) and the five-digit Current Procedural Terminology (CPT) codes or the Healthcare Common Procedure Coding System (HCPCS) alpha-numeric codes, which you can get from the provider,
  • Provider's complete information including name, address, phone number, and zip code, and
  • Provider's proposed fee for each service.

About pregnancy

Federal law mandates that benefit programs such as the Retiree Medical Plan cover eligible participants for a minimum length of stay for delivery and newborn hospitalizations. Those minimums are 48 hours following a vaginal delivery and 96 hours following a Cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable).

The Plan does not provide breastfeeding support, counseling and equipment for the duration of breastfeeding.

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

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

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

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

Network locations

POS II networks are located throughout the United States. As explained in the Introduction, the Retiree Medical POS II is part of the Aetna Choice® POS II network.

You are a network participant if you live in a POS II area. These are some of the Retiree Medical POS II areas:

  • Beaumont, Texas
  • Baton Rouge, Louisiana
  • Dallas, Texas
  • Houston, Texas 

Benefits based on the network status of the provider

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

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

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

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

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

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

Is your doctor a network provider?

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

Show your ID card

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

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

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

When you use non-network providers:

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

If you cannot find a Network Provider (network deficiency)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Emergency care

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

If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. Aetna has adopted the following definition of an emergency medical condition:
 
An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson (including the parent of a minor child or the guardian of a disabled individual), who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

  • Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
  • Serious impairment to bodily function, or
  • Serious dysfunction of any bodily organ or part.

Some examples of emergencies are:

  • Heart attack or suspected heart attack
  • Uncontrolled or severe bleeding
  • Suspected overdose of medication
  • Severe burns
  • High fever (especially in infants)
  • Loss of consciousness

Some common examples of non-emergencies are:

  • Routine exams and immunizations
  • Ear Infections
  • Colds and Flu

Reimbursement for Emergency Services

Reimbursement for emergency services from non-network providers are limited to reasonable and customary amounts, including services for professional fees for radiologists, anesthesiologists, pathologists, hospitalists, neonatologists, intensivists, ambulance or emergency room physician services. In most instances, the provider will accept this reimbursement; however, in the event you are billed for any balance, you may submit the balance to Aetna for additional processing.

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

Reimbursement for non-emergency services

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

Urgent care

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

Telemedicine

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

Care while traveling

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

If a covered family member lives away from home

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

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

  • If your family member receives care from a network provider, benefits will be paid at the network level.
  • If your family member lives in a POS II network area but uses non-network providers, benefits are paid at the non-network level.
  • If your family member lives in an area where the POS II network is not available and receives care from a non-network provider, benefits are paid at the out-of-network area level — regardless of whether you live in a network or out-of-network area — if you have notified Aetna of your family member's address.

Upon request, Aetna Member Services will provide an identification card for your family member.

Preventive care

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

 
  • Breastfeeding durable medical equipment
  • Lactation support and counseling
  • Contraceptives
  • Obesity prevention counseling
  • Tobacco prevention counseling
  • Drug and alcohol counseling
  • Routine Immunizations including immunizations received at a pharmacy
  • Prostate-Specific Antigen Test (PSA)
  • Digital Rectal Examination (DRE)
  • Routine Adult Physical
  • Routine Mammography
  • Routine GYN Exam
  • Routine Well Baby Exam (includes hearing exam if under age 7)
  • Routine Well Child Exam (includes hearing exam if under age 7)
  • Colorectal Cancer Screening
  • Double Barium Enema
  • Fecal Occult
  • Sigmoidoscopies
  • Colonoscopy

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

Prescription drug program

Prescription drug program information for the Retiree Medical Plan -  POS II 'A' and 'B' Options

Q. Does the Plan cover prescription drugs? 

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

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

Short-term prescriptions

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

You have the choice of filling your prescriptions at:

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

The participating retail network pharmacy

You may call Express Scripts, check the Express Scripts website (www.express-scripts.com), or use the Express Scripts mobile app to locate a participating retail pharmacy near you. When you fill a prescription, you must identify yourself as a member of Express Scripts’ retail pharmacy program to maximize your savings.

Percentage copayment

Percentage copaymentFor prescription drugs purchased at a participating retail pharmacy, you pay a percentage of the discounted cost of the drugs:

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


Examples: Generic drug purchased at a retail network pharmacy
— Discounted cost of medication is $20

You pay a 30% copayment ($20 x .30) = $6

Preferred brand name drug purchased at a retail network pharmacy (if no generic is available) — Cost of medication is $40

You pay a 30% copayment ($40 x .30) = $12

Non-preferred brand name drug purchased at a retail network pharmacy — Cost of medication is $60 

You pay a 50% copayment ($60 x .50) = $30

Retail refill limitation

For the third and subsequent refills of a long-term or maintenance drug, which is a drug you take for an extended period of time, such as for ongoing treatment of diabetes, arthritis, a heart condition or blood pressure, you will pay an additional 25% copayment. The additional 25% copayment does not apply to your annual prescription drug out-of-pocket maximum.

How to obtain your prescription or a refill

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

The term Primary Participant refers to the participant whose identification number is used. The primary participant is the retiree or 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.

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

Using a Non-Participating Pharmacy or Not Showing Your Express Scripts or Medco ID Card

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

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

Long-term prescriptions

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

How to get started with Express Scripts Pharmacy

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

Home delivery pharmacy prescriptions

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

Type of  Drug 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.

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 generally used 75% of the previous prescription based on the prescribed dosage.

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

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

POS II A

Type of Drug

Retail Per Prescription Out-of-Pocket Maximum

Mail Per Prescription Out-of-Pocket Maximum

Generic

$60.00

$120.00

Preferred brand name drugs

$130.00

$260.00

Non-preferred brand name drugs

$200.00

$400.00

 

Comparing retail pharmacy with Express Scripts Pharmacy

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

At a Participating Retail Pharmacy   Through Express Scripts, or Smart90 retail pharmacy
$108.00 Cost of formulary preferred brand name drug (30-day supply)   $324.00 Cost of formulary preferred brand name drug (90-day supply)
x 30% Percentage copayment x 25% Percentage copayment
$32.40 Your copayment $81.00 Your copayment
You pay $32.40, or $97.20 for 3 purchases. You pay $81.00

By purchasing a 90-day supply of this prescription through home delivery, you would save $16.20. That is $64.80 a year for one prescription. Note: This example does not include in the calculation the additional 25% copayment for the third and any subsequent refills from a participating retail pharmacy. Actual savings may be greater..

Covered prescriptions

The prescription drug program 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 dispense only generics that receive FDA approval and only if authorized by your doctor.

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

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

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

  Generic Brand
Prescription cost $ 50.00 $ 200.00
Copayment (30% of the cost of generic drug) $ 15.00 $ 15.00
Difference in cost with available generic* $ 0.00 $ 150.00
Total cost $ 15.00 $ 165.00

If you purchase the brand name drug:

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

Available alternatives

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

The network formulary program

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

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

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

Drug monitoring service

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

The pharmacist will contact your doctor about the potential problem or otherwise resolve the issue before dispensing the prescription.

Your doctor makes the final decision about any change in your prescription or course of treatment.

Special provisions

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

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

Specialty medications

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

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

Advanced Utilization Management

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 precertified by Express Scripts, based on medical evidence submitted by your physician. In addition, some therapies will be monitored for appropriate pharmacogenomic parameters, and oral oncology medications will be limited to ensure appropriate use. Please visit www.express-scripts.com to more information about your medications and if they require a coverage review.  If you have a question regarding a drug on the AUM program list, contact Express Scripts at the number listed in the Information Sources section of this SPD.

Preferred drug step therapy rules

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

Prior authorization rules

Prior authorization rules apply to certain therapeutic classes of drugs; therapies in this section will be monitored for appropriate use, including pharmacogenomics parameters in some cases.  These classes include miscellaneous immunological agents, central nervous system/miscellaneous neurological therapy, biotechnology/adjunctive cancer therapy, central nervous system/headache therapy, central nervous system/analgesics, neurology/miscellaneous psychotherapeutic agents, and miscellaneous pulmonary agents. In addition, anabolic steroids, high cost antibiotics, anti-emetics, antivirals, narcotics, acne dermatologicals and topical pain medications may trigger a prior authorization.  Oral oncology medications will also be limited to ensure appropriate use. Certain drugs within each 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.

When a prescription drug becomes available over the counter

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

Coordinating benefits for prescriptions

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

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

Mental health and substance abuse care

Mental health and substance abuse care for the Retiree Medical Plan - POS II A and B Options

Q. Do the POS II A and B options cover mental health and substance abuse treatment?

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

The POS II options include a number of provisions specific to mental health and substance abuse treatment.

When determining whether a service or supply is medically necessary, Magellan's utilizes written medical necessity criteria. Those criteria are available upon request, consistent with applicable law. You and your providers may contact Magellan at 800-442-4123 to request the medical necessity criteria applicable to your treatment or visit their website at Magellan Ascend.ed.

Precertification

All inpatient and intensive outpatient mental health and substance abuse care must be precertified by Magellan. The health care provider is responsible for obtaining precertification for network care. The participant is responsible for obtaining required precertifications for non-network and out-of-network care; if precertification for inpatient care is not obtained, a $500 penalty will be assessed for failure to precertify inpatient non-network and out-of-network care.

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

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

Emergency treatment

If emergency mental health or substance abuse care is needed:

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

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

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

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

Mental Health PPO

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

If you use mental health network providers

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

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

If you do not use mental health network providers

You should contact Magellan for precertification of non-network care. Remember, if you are referred, even in an emergency, by a POS II network provider to a mental health provider, you still must precertify with Magellan.

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

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

  Certified Network Care Certified Non-Network Care Non-Certified Non-Network Care
Total Charges: $15,000.00 $19,000.00 $19,000.00
Total Covered Charges: $15,000.00 $15,000.00 $15,000.00
You Pay: $200.00 (inpatient deductible)
$300.00
(annual deductible)
$600.00 (annual deductible) $600.00 (annual deductible)
Certified Network Care – 20% of covered charges after the deductible, up to the remaining out-of-pocket limit of $3,000 ($15,000 - $500) = $14,500 X 20%) = $2,890 $2,890.00    
Certified Non-network Care – 40% of covered charges after the deductible ($15,000-$600 = $14,400 x 40%):   $5,760.00  
Non-certified, Non-network Care – 40% of covered charges after the deductible ($15,000-$600 = $14,400 x 40% + $500 penalty for no precertification = $6,260)     $6,260.00
  • Expenses exceeding covered charges:
  $4,000.00 $4,000.00
Your Total Payment: $3,390.00 $10,360.00 $10,860.00
Your Plan Pays: $11,610.00 $8,640.00 $8,140.00

 

Mental health care outside the United States

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

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

Covered expenses

Covered expenses for the Retiree Medical Plan - POS II 'A' and POS II 'B' Options

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

A. The Plan covers a wide range of health care services, tests, treatments, and supplies. For plan purposes, all covered expenses must be medically necessary and not excluded. Generally Aetna's Clinical Policy Bulletins (CPBs) are relied upon to ensure consistent determination of coverage under the Medical Plan. Aetna's CPB's may be viewed online at www.aetna.com.

Covered expenses (POS II A and B)

Some of the services covered by the Plan are listed below. Services not listed as a covered expense are excluded.  If you do not see your procedure or treatment listed below, please contact Aetna Member Services listed in the Information sources section of this SPD to confirm coverage for the expense.

  • Acupuncture if performed by a physician.
  • Ambulatory surgical center, care, or services. An ambulatory surgical center:
  • Is established, equipped and operated in accordance with applicable local laws primarily for the purpose of performing surgical procedures,
  • Is operated under the full-time supervision of a licensed doctor of medicine or doctor of osteopathy,
  • Permits a surgical procedure to be performed only by a duly qualified physician who, at the time the procedure is performed, has admitting privileges in at least one hospital to perform such a procedure,
  • Has at least two operating rooms and at least one post-anesthesia recovery room, is equipped to perform x-ray and laboratory examinations, and has available trained personnel and necessary equipment, including a defibrillator, a tracheotomy set, and a blood supply, to handle foreseeable emergencies,
  • Provides the full-time services of one or more registered graduate nurses for patient care in operating rooms and in the post-anesthesia recovery room,
  • Maintains a written agreement with at least one hospital in the area for immediate acceptance of patients who develop complications or require post-operative confinement, and
  • Maintains appropriate medical records for each patient.
  • Braces, crutches and prostheses required because of an injury or disease. Coverage is generally limited to the purchase price.
  • Chiropractic services, performed by a licensed doctor of chiropractic who is acting within the scope of his or her license, up to $1,000 per person per year (benefits paid for acupuncture and supplies billed by a doctor of chiropractic are not included in the $1,000 annual maximum).
  • Dental work required by an accidental injury to sound, natural teeth or the mouth. Also, certain cutting procedures in the mouth. (See Dental treatment in Specific Coverage).
  • Diagnosis and treatment of the underlying medical cause of infertility, but Comprehensive Infertility Services, fertility prescriptions, and Advanced Reproductive Technologies (ART) are not covered.
  • Doctor visits at home, a hospital or an office, including emergency room care.
  • Drugs and medicines obtainable only with a physician's prescription and approved by the U.S. Food and Drug Administration for the specific diagnosis.
  • Durable medical equipment (DME) when medically necessary, prescribed by a physician for the treatment of an illness or injury. Some DME may require preauthorization from Aetna. For more information on precertification, see the National Precertification List on the Aetna member website. Replacement, repair and maintenance are only covered for purchased DME if:    
    • It cannot be repaired,                
    • Repairs would be more expensive than purchasing or renting replacement equipment, or                         
    • The attending physician recommends replacement because of a change in the patient’s physical condition.
  • Expert Medical Opinion services provided through the designated service provider (2ndMD), including evaluation of medical records and consultation either online or by phone to confirm diagnosis and recommend a treatment plan for complex healthcare needs. To register for services, call 866-410-8649 or www.2ndMD.com/Aetna.
  • Extended Care Facility when precertified. (See Extended-care facility in the Specific Coverage section.) 
  • Gender reassignment surgery consistent with Aetna's Clinical Policy Bulletins.
  • Hearing aids. (See Hearing aid in the Specific Coverage section for more details).
  • Home health aides to provide individualized, non-custodial home care.
  • Hospice care.
  • Hospital emergency room care, including surgical care and other related charges.
  • Hospital semi-private room and board, x-ray and pharmacy, tests and other medical supplies and services received in a hospital.
  • Immunizations/vaccinations obtained outside of a physician's office or hospital. Some immunizations can also be obtained or administered at participating retail pharmacies, using the Aetna ID card at an Aetna network pharmacy, or the Express Scripts ID card at an Express Scripts network pharmacy.
  • Inpatient services performed by surgeons, anesthesiologists, and other physicians.
  • Insulin and diabetic supplies received in a doctor's office or an outpatient setting are covered medical expenses. Insulin and diabetic supplies obtained in a retail setting, such as a pharmacy or those obtained by home delivery, are covered by Express Scripts, or are provided through the Livongo Pharmacy Diabetes Management program.
  • Morbid obesity (generally 100% or more over ideal body weight) treatments including physician expenses for the initial office visit and laboratory costs. Contact Aetna Member Services for guidelines regarding eligibility and approved programs for this coverage.
  • Network mental health and substance abuse treatment (both inpatient and outpatient) and non-network mental health and substance abuse treatment (both inpatient and outpatient).
  • Nutritional counseling performed by a licensed nutritionist for anorexia nervosa, bulimia nervosa and after bariatric surgery consistent with Aetna's internal Clinical Policy Bulletins.
  • Oral-motor therapy ordered by a physician for treatment of dysphagia or hypotonia.
  • Outpatient medical tests and surgery.
  • Physical therapy or occupational therapy for treatment of illness, injury or disease, which is performed by a licensed physical or occupational therapist who is acting within the scope of his or her license. If you or your provider anticipates that your current course of therapy may exceed 25 visits, have your physician or therapist submit medical records with each physical therapy claim. Claims for therapy services beyond the 25th visit are subject to medical review. Additional information will be required. Claims will not be paid if the service is found to not be medically necessary.
  • Prescription smoking deterrent medications.
  • Preventive care services. (See POS II Network in the Basic Plan Features section for details).
  • Private-duty nursing care rendered by a nurse when furnished outside of a hospital if such care requires a nurse's services and it is determined that such services are neither primarily custodial in nature nor could be provided by a person other than a nurse.
  • Professional emergency transportation services. The Plan pays for medically necessary trips to or from the nearest facility capable of handling the situation. In addition, the Plan pays for transportation to the nearest POS II network facility once the patient is stabilized in a non-network facility.
  • Reconstructive surgery including, but not limited to, surgery required because of a mastectomy. The Plan pays benefits for:
  • Reconstructive surgery of the breast on which the surgery was performed,
  • Reconstructive surgery of the other breast in order to produce symmetry, and
  • Prostheses for physical complications of mastectomy.
  • Services related to the pregnancy of a covered child, but not those related to the child born to the family member.
  • Medically necessary procedures to evaluate or diagnose learning, intellectual or developmental disability; excluding, Applied Behavioral Analysis and other training, educational, or behavioral modification for learning, intellectual or developmental disability.
  • Skilled-nursing care. (See Skilled-nursing care in Specific Coverage in the Covered Expenses section for details).
  • Speech therapy, on an outpatient basis, to:
  • Restore speech after a demonstrated previous ability to speak is lost or impaired,
  • Improve or develop speech after surgery to correct a birth defect which impaired or would have impaired the ability to speak, or
  • Improve or develop speech lost or impaired by an irreversible and permanent profound hearing loss resulting from a birth defect. (See Speech Therapy under Exclusions. Submission of a proposed treatment plan for a benefit predetermination is strongly recommended.)
  • Sterilization procedures.
  • Treatment of temporomandibular disorders, sometimes referred to as TMJ/TMD, including splints and orthotics, when preauthorized by Aetna. This includes diagnosis and surgical treatment of the jaw and cranio-mandibular joint resulting from an accident, trauma, congenital or developmental defect, or pathology.
  • Telemedicine services through the designated service provider (Teladoc) for non-emergency medical and behavioral health conditions such as cold/flu symptoms, stomach aches, common childhood illnesses, depression, stress, and anxiety.
  • Vision examinations and eyeglasses or contact lenses needed because of injury or disease.
  • Vision therapy by a physician for amblyopia and strabismus up to a maximum of 32 vision therapy visits or sessions.
  •  Abortion if the life of the mother is in danger or complications from pregnancy arise or other specific circumstances.
  • Habilitative therapy - Aetna standardly covers rehabilitation and habilitation services, as long as the services aren’t considered experimental and investigational and aren’t specifically excluded under a plan: 
                                     o Rehabilitation is defined as services to restore body function following an accident, injury or because of a medical condition  
                                     o Habilitation is defined as services that help a person keep, learn or improve skills for daily living—generally due to a behavioral or developmental deficit  

Specific coverage 

Dental treatment

Certain dental expenses are covered under the POS II A and B options. Covered services include the following when provided by a physician, dentist and hospital:

  • • Cutting out:
    - Cysts, tumors, or other diseased tissues
     
  • • Cutting into gums and tissues of the mouth. 
    ‒ Only when not associated with the removal, replacement or repair of teeth

 
Oral surgery and related procedures covered under the POS II options are reimbursed at 75% for the POS II 'A' and 80% for the POS II 'B', regardless of the provider’s network participation.

Extended-care facilities

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

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

Skilled-nursing care

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

Skilled care

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

Hearing aids

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

You may be able to maximize your benefit through the Amplifon Hearing Health Care (formerly HearPo) or the Hearing Care Solutions Discount Program. These programs are available to Aetna participants and offer discounts on hearing exams, services and hearing aids. If you go to a participating hearing discount center, your out-of-pocket expenses could be lower. To find a participating hearing discount center location, visit www.aetna.com and select “Hearing Discount Locations”. To compare costs, please call Amplifon Hearing Health Care at 1-888-HEARING (1-888-432-7464) or Hearing Care Solutions at 1-866-344-7756 and identify yourself as an Aetna member.

Organ, tissue and bone marrow transplants

Aetna's National Medical Excellence® Program (NME Program) coordinates all aspects of organ, tissue, and bone marrow transplants and other complex specialized care. Providers in this program are recognized as centers of excellence with demonstrated improved outcomes in their area of expertise. In addition, if travel over 100 miles is required, transportation and lodging for the patient and a family member will be covered. The NME Program is separate and distinct from the Centers of Excellence described in the Health Management Programs section of this SPD.

The NME Program is available on a voluntary basis. Contact Aetna Member Services for information.

Case management alternative treatment program 

If as a result of a catastrophic or chronic illness, injury, mental health, or in conjunction with certain organ transplant procedures, a participant proposes an alternative course of treatment, the Administrator-Benefits may waive any exclusion or limitation under the Plan which would otherwise apply to covered medical expenses, the reimbursable portions of covered medical expenses or out-of-pocket limits if such waiver would result in overall cost savings to the Plan. The review will include factors such as the efficacy of the proposed treatment, the patient's condition, availability and efficacy of other treatments that are approved for the patient's diagnosis, and the prior use of appropriate treatments for the condition. Such approval must be prior to the participant commencing the alternative course of treatment.

Exclusions

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

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 of them. Exclusions shall be interpreted and applied consistently with Clinical Policy Bulletins published by Aetna. These bulletins can be accessed on the Aetna website at www.aetna.com. See Basic Plan features for more information.

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

  • Any claim submitted past the claim-filing deadline.
  • Any expense incurred before you or your family members became covered under this option (except children less than 31 days old).
  • Any expense not recommended and approved by a physician acting within the scope of his or her license.
  • Any expenses that exceed reasonable and customary limits.
  • Bariatric surgery expenses for the treatment of morbid obesity in excess of the $25,000 lifetime maximum.
  • Chelation therapy.
  • Chiropractic services for therapeutic purposes in excess of $1,000 per person per year and any maintenance chiropractic care.
  • Concierge or annual fees.  Any portion not related to medical care (such as a private waiting room, same-day appointments, extended time with physician) is excluded.
  • Confinement in a facility that is primarily a school, place of rest, or nursing home.
  • Cosmetic surgical procedures, treatments or hospital confinements, except for those that are primarily for the purpose of restoring a bodily function or surgery, which is medically necessary.
  • Custodial care or maintenance care, even if ordered by a physician.
  • Dental charges except as specifically provided for in Specific coverage in the Covered expenses section.
  • Drugs or vitamins that are available over the counter, even if prescribed by a physician (referred to as legend vitamins, except prenatal vitamins, Rocaltrol).
  • Services primarily of an educational nature or in an educational setting, including but not limited to services for developmental reading disorders, developmental arithmetic disorders, developmental language disorders or developmental articulation disorders.
  • Elective abortions
  • Experimental or investigational drugs or treatments for a particular diagnosis.
  • Foot orthotics and other supportive devices for feet with the exception of some types of foot braces, even if prescribed by a physician.
  • In-hospital expenses for non-medical items, such as a telephone or television set.
  • Fertility services, treatments, and prescriptions.
  • Maintenance, replacement, or repair for continuously rented DME, frequently serviced DME, or oxygen equipment are not covered as a separate expense under the Plan.
  • Laser-assisted in situ keratomileusis (LASIK), photorefractive keratectomy (PRK), and other similar or related procedures to improve visual acuity. Revision or repeated treatment of surgery is not covered.
  • Nutritional programs, weight programs, and related food supplements, except for physician expenses and lab costs for treatment of morbid obesity, and for nutritional counseling performed by a licensed nutritionist or dietician, consistent with Aetna's Clinical Policy Bulletins.
  • Nutritional supplements, even if prescribed by a physician, except for treatment of phenylketonuria (PKU).Outpatient physical or occupational treatment necessary due to delayed development.
  • Outpatient prescription drugs in excess of the allowed supply (34 days for retail and 90 days for home delivery) per fill or refill.
  • Outpatient speech therapy treatment necessary due to delayed speech development or treatment that is educational rather than restorative in nature.
  • Periodic physical examinations paid for by the company.
  • Some prescription medications including injections, billed by and provided in an outpatient hospital or Doctor's office, are not covered under Aetna, but may be covered under the prescription drug program administered through Express Scripts.
  • Private-duty nursing, except as defined in the Covered expenses section.
  • Private room rate above the hospital's most common semiprivate room rate, except when medically necessary.
  • Any program or service performed in a nonconventional setting, even if the services are performed by a licensed provider, including: spas/resorts, outdoor learning or leadership programs; wilderness, camp, or ranch programs; academic, vocational, or recreational settings.
  • Routine eye examinations, eyeglasses, contact lenses, and orthoptics.
  • Self-treatment.
  • Treatment not specifically covered or meeting the Plan's requirements for medical necessity for the care or treatment of a particular disease, injury, or pregnancy, . even when medical provider has recommended/prescribed the services.
  • Treatment of injuries received or illnesses contracted while on military assignment and covered by a government medical plan.
  • Treatment of occupational illnesses or injuries sustained in situations covered by workers' compensation or a similar law.
  • Transportation or travel expenses other than emergency transportation service by professional ambulance, transportation costs to travel to a COE/IOE, if the distance is over 100 miles, and for Organ, Tissue and Bone Marrow Transplants.
  • Voluntary sterilization reversal procedures (including any services for infertility related to voluntary sterilization and its reversal).
  • Wigs or hairpieces for androgenic alopecia (male pattern baldness).
  • Charges for missed appointments, and/or completion of claim forms are excluded by the Plan. 

Payments

Payments for the Retiree Medical Plan - POS II A and B options

Q. How do the Plan and I share the cost of my health care? 

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

Coinsurance

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

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

Deductible

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

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

The network deductible for medical, mental health and substance abuse expenses is currently $300 per year for an individual or $600 per year for a family for the EMMP POS II B. The non-network deductible is currently $600 per year for an individual or $1,200 per family for the EMMP POS II B. For the EMMP POS II A, the network deductible is $500 per year for an individual or $1,000 per year for a family, and the non-network deductible is $700 per year for an individual or $1,400 per year for a family.

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

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

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

Charges that Do Not Count Toward the Deductible

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

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

Adjustments to billed charges

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

Reasonable and customary limits

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

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

Example: 

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

Incidental charges 

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

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

Example:

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

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

Multiple surgeries (including bilateral procedures)

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

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

Example:

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

A B C D E
Multiple Surgery Charges Submitted Multi-Surgery % Allowed Amount
(A X B)
Plan pays at 80%
(C X 80%)
You Pay
(C - D)
$80.00 100% $80.00 $64.00 $16.00
$60.00 50% $30.00 $24.00 $6.00
$40.00 25% $10.00 $8.00 $2.00
$180.00   $120.00 $96.00 $24.00

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

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

A B C D E
Multiple Surgery Charges Submitted Multi-Surgery % Allowed Amount
(A X B)
Plan pays at 60%
(C X 60%)
You Pay
(A - D)
$80.00 100% $80.00 $48.00 $32.00
$60.00 50% $30.00 $18.00 $42.00
$40.00 25% $10.00 $6.00 $34.00
$180.00   $120.00 $72.00 $108.00

Surgical assistants/assistant surgeons

If your physician uses a non-physician during a procedure, any charges submitted for the non-physician's services will not be allowed unless a non-physician meets the definition of physician. For the medical treatment or surgical procedures to be considered covered medical expenses, a physician must perform the procedure. See definition of physician under Key Terms.

If your physician is assisted during the procedure by another physician (assistant surgeon), billed charges will be reduced to 25% of the R&C allowance or 25% of the participating fee if in-network for each surgical procedure, according to the allowance for assistant surgeon fees.

Multiple imaging diagnostic tests

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

No volitional control

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

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

Reimbursement to non-network providers will be limited to a reasonable and customary amount, rather than billed charges.  In the event you are billed for any balance at a network facility or in an emergency situation at a non-network facility, by a non-network physician you may submit the balance to Aetna for additional processing. Only amounts that are above the reasonable and customary fee schedule will be considered for additional reimbursement. Charges for services not covered by the Plan will not be reprocessed.

Out-of-Pocket limits

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

EMMP POS II A option - Annual Out-of-Pocket Limits
  Fixed
copayment:
Percentage coinsurance*: Until you reach your annual out-of-pocket limit of:
If you live in a Medical POS II area and:
Use network providers for medical services $40 (PCP) or $55 (Specialist) 25% $4,500 per person
$9,000 per family unit
Do not use network providers for medical services N/A 45%** $18,000 per person
$36,000 per family unit
If you do not live in a Medical POS II area and:
Use network providers for medical services $40 (PCP) or $55 (Specialist) 25% $4,500 per person
$9,000 per family unit
Do not use network providers for medical services N/A 25%** $4,500 per person
$9,000 per family unit
If for precertified*** mental health care, you:
Use mental health network providers $40 25% $4,500 per person
$9,000 per family unit
Do not use network providers. Magellan's network, not Aetna's, is used for mental health and substance abuse care. N/A 45%** *** $18,000 per person
$36,000 per family unit

* After the annual deductible and, if applicable, the inpatient hospital deductible is met.
** All non-network out-of-pocket expenses are subject to reasonable and customary limits.
*** Call Magellan for precertification. See Precertification in the Mental Health and Substance Abuse Care section for details.

EMMP POS II B option - Annual Out-of-Pocket Limits
  Fixed
copayment:
Percentage coinsurance*: Until you reach your annual out-of-pocket limit of:
If you live in a Medical POS II area and:
Use network providers for medical services $25 (PCP) or $40 (Specialist) 20% $3,000 per person
$6,000 per family unit
Do not use network providers for medical services N/A 40%** $15,000 per person
$30,000 per family unit
If you do not live in a Medical POS II area and:
Use network providers for medical services $25 (PCP) or $35 (Specialist) 20% $3,000 per person
$6,000 per family unit
Do not use network providers for medical services N/A 20%** $3,000 per person
$6,000 per family unit
If for pre-certified*** mental health care, you:
Use mental health network providers $25 20% $3,000 per person
$6,000 per family unit
Do not use network providers. Magellan's network, not Aetna's, is used for mental health and substance abuse care. N/A 40%** *** $15,000 per person
$30,000 per family unit

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

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

Using both network and non-network providers

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

  • Network and non-network out-of-pocket maximums must be met separately, unless you are eligible for Out of network area benefits. 
  • Once your annual out-of-pocket total from a network provider reaches $3,000 for an individual (or $6,000 for a family) for the POS II B and $4,500 for an individual (or $9,000 for a family) for the POS II A, the Plan pays 100% of covered expenses when you use network providers. However, at this point, the Plan would still pay only 60% of covered expenses for non-network medical providers for the POS II B and 55% of covered expenses for non-network medical providers for the POS II A.
  • Once your out-of-pocket total from a non-network provider reaches $15,000 for an individual (or $30,000 for a family) for the POS II B and $8,000 for an individual (or $36,000 for a family) for the POS II A, the Plan pays 100% of covered medical expenses when you use a non-network provider.

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

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

No lifetime maximum

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

Coordination of benefits

If you are covered by more than one group medical plan (e.g., your spouse's employer's medical plan), you are entitled to coverage from all plans in which you participate, but not to the extent that you collect more than 100% of the amount of the charges.

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

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

For example, if you, as a retiree in this option, incur covered expenses, this Plan is primary and your spouse's plan is secondary. However, if your spouse incurs the expenses, his or her plan is primary and this Plan is secondary. This Plan is primary for retirees who are not working, regardless of other coverage under a spouse's plan.

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

Refer to Special provisions for coordination of benefits for the Prescription Drug Program.

Coverage of a child

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

Medical Plan will consider the plan that has covered the child longer as primary.

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

Retirees covered by two plans

If a retiree covered by the Retiree Medical Plan obtains a full-time job in which the retiree is covered by the new employer's medical plan, that plan becomes the primary plan and the Retiree Medical Plan is secondary.

When the retiree leaves the last employer, the plan in which the retiree was covered for the longer period becomes the primary plan and the other plan is secondary.

Medicare as primary

If you or your family member become entitled to Medicare, to the extent legally permitted, Medicare is the primary plan.

Payments

If payment for covered medical expenses should have been made under this Plan, but has been made under any other plan, any insurance company or other organization may be reimbursed an amount the Administrator-Benefits determines will satisfy the intent of coordination of benefits provisions.

That amount will be considered to be benefits paid under this Plan and shall fully discharge any obligation to make such payments.

Incorrect computation of benefits

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

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

Recovery of overpayment

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

Claims

Filing claims for the Retiree Medical Plan - POS II 'A' and POS II 'B' Options

Q. When must claims be filed? 

A. For an expense to be eligible for reimbursement, the claim must be filed within two years from the date the expense was incurred. An expense is incurred when the services are rendered and not when you are billed.

How to file claims

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

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

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

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

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

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

If you need to file a claim:

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

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

Claim denial and reconsideration

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

Right of reimbursement and subrogation

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

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

Claims outside the United States

If you receive medical care when traveling or working outside the United States, generally you must pay the medical bills first. For reimbursement, submit an itemized bill along with a claim form. If the original bills are in a foreign language, you should obtain an English translation, if possible, of the services rendered.  Please note, a dose or doses of prescription medication or injections given at the time of treatment in a doctor’s office is covered under the Retiree Medical POS II as a part of the medical service rendered.  Self-administered or take home use prescription medication may be covered under your prescription drug benefit and you must submit claims separately to Express Scripts for reimbursement.

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

Health Management programs

24-Hour nurse line

Trained, licensed nurses are available by telephone at 1-800-556-1555, 24 hours a day, 7 days a week to answer routine questions about your health, or questions about a specific medical situation, condition, or concern. However, these nurses cannot diagnose medical conditions/ailments, prescribe medication or give specific medical instruction. Topics discussed during your call may include services and expenses not covered under the Plan (see Exclusions). The nurse may refer you to a Health Advocate for a more detailed conversation if you face a health risk or serious medical condition.

Health Advocate Program

The Health Advocate Program provides direct support to you, your family, and your treating physician(s) in the management of specific health care needs. The Health Advocate staff consists of registered nurses, supported by a medical director. Once you begin working with a Health Advocate, the nurse will work personally with you as long as you need support.

Health Advocates will assist you to coordinate a wide array of health care-related support and educational services. As situations require, your Health Advocate will assist you with admission, counseling, inpatient advocacy, discharge planning and home counseling. The nurse will also act as your proactive partner, working directly with you to help you navigate the health care delivery system by assisting with the coordination and management of your health care needs and collaborating with others involved in your treatment. Your Health Advocate could refer you to a Condition Management nurse if you are identified as needing treatment for a condition that is included in the program.

If you or a family member is identified as having an illness or condition or if you have signs or symptoms that indicate that you are at risk for contracting a serious illness or condition and you have primary coverage under the Retiree Medical Plan, the Health Advocates may contact you to provide support, information, and guidance. In addition, you may contact Aetna Member Services to reach a Health Advocate if you have any questions.  

Condition Management Program

If you have certain chronic illnesses and meet eligibility criteria, you may be contacted by a licensed registered nurse through the Condition Management Program offered by Optum or you can contact Optum directly at 1-800-557-5519. These specially trained nurses focus on helping participants with conditions in which education, daily choices, and lifestyle decisions can have a significant effect on health and the progression of the condition. If you elect to work with a condition management nurse, you will receive educational materials, assistance in managing your condition, and personal support.

Condition management programs available through Optum include congestive heart failure, coronary artery disease, diabetes, chronic obstructive pulmonary disease (COPD), and orthopedic health support programs.

Cancer Care Program

If you are newly diagnosed with cancer, undergoing active treatment for cancer, or are experiencing a recurrence, you may be referred to a specifically trained Cancer Care nurse through your Health Advocate or Condition Management nurse. Referrals will be made to Optum for support to those undergoing treatment or you can call Optum directly at 1-800-557-5519.

Expert Medical Opinion Services

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

Pharmacy Diabetes Management

Livongo and Express Scripts offer a diabetes remote monitoring and acute assistance program at no additional cost to you. Key benefits of the program include unlimited test strips and lancets, availability of a glucose meter with automatic uploads and secure access to readings at any time, as well as personalized real-time tips to manage diabetes effectively. Program participants will also have access to Certified Diabetes Educators who can answer nutrition or lifestyle questions. Call Livongo at 800-945-4355 to enroll or find out more information.

Centers of Excellence and Institutes of Excellence

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

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

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

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

If you decide not to use a COE/IOE, you will not incur additional out-of-pocket costs for choosing another hospital in the Plan's network. However, you must obtain Comprehensive Infertility Services and Advanced Reproductive Technologies at an Aetna-designated Institute of Excellence in order for the services to be covered.

Continuation coverage

Continuation coverage for the Retiree Medical Plan - POS II 'A' and POS II 'B' Options

Q1. Can coverage be continued after eligibility in this Plan ends? 

A1. Yes. In certain circumstances, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) entitles you and your covered family members to extend medical benefits beyond the date your coverage would normally end.

Q2. What notification time limits must I comply with to begin COBRA for my spouse or my family member? 

A2. You are responsible for ending coverage with the Benefits Service Center when your spouse or family member is no longer eligible for coverage. This must be done as soon as possible. See What is Cobra coverage? for details. In order to be eligible for COBRA, you must notify and provide the appropriate forms to the Benefits Service Center within 60 days of the event which caused the person to lose eligibility.

Continuation coverage rights under COBRA

Introduction

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

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

Benefits Service Center entity to contact

Exxon, ExxonMobil, Mobil, XTO or Superior Oil Retirees, or their Survivors, or their covered family members contact ExxonMobil Benefits Service Center.

The contact information is as shown at the end of this Continuation coverage section.

What is COBRA coverage?

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

Who is entitled to elect COBRA?

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

  • The retiree dies, or
  • You become divorced from the retiree.  Also, if the retiree reduces or eliminates your group health coverage in anticipation of a divorce, and a divorce later occurs, then the divorce may be considered a qualifying event for you even though your coverage was reduced or eliminated before the divorce.

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

  • The retiree dies, or
  • The child stops being eligible for coverage under the Plan as a child.

When is COBRA coverage available?

When the qualifying event is the death of a retiree, the Plan will offer COBRA coverage to qualified beneficiaries.

You must give notice of some qualifying events

For the other qualifying events (divorce of the retiree and spouse or a child losing eligibility for coverage), a COBRA election will be available to you only if you notify and provide the appropriate forms to the Benefits Service Center entity within 60 days after the later of (1) the date of the qualifying event or (2) the date on which the qualified beneficiary loses (or would lose) coverage under the terms of the Plan as a result of the qualifying event. See the end of this section, Continuation coverage, for the listing of Benefits Service Center entities. Notices of these qualifying events from retirees and survivors must be made via the ExxonMobil Benefits Web or by calling the ExxonMobil Benefits Service Center. Notice is not effective until the properly completed form is received by the Benefits Service Center. If these procedures are not followed or if the wrong entity is notified during the 60-day notice period, THEN ALL QUALIFIED BENEFICIARIES WILL LOSE THEIR RIGHT TO ELECT COBRA.

Election of COBRA

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

How long does COBRA coverage last?

When the qualifying event is the death of the retiree, the covered retiree’s divorce or a child's losing eligibility as a child, COBRA coverage under the Plan can last for up to a total of 36 months.

Are there other coverage options besides COBRA continuation coverage?

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

More information about individuals who may be qualified beneficiaries during COBRA

A child born to, adopted by, or placed for adoption with a covered retiree during a period of COBRA coverage is considered to be a qualified beneficiary provided that, if the covered retiree is a qualified beneficiary, the covered retiree has elected COBRA coverage for himself or herself. The child's COBRA coverage begins when the child is enrolled in the Plan, whether through special enrollment or open enrollment, and it lasts for as long as COBRA coverage lasts for other family members of the retiree. To be enrolled in the Plan, the child must satisfy the otherwise-applicable Plan eligibility requirements (for example, regarding age).

Cost of COBRA coverage

A person who elects continuation coverage may be required to pay 102% of the cost to the Plan to maintain the coverage. A person who elects continuation coverage must pay the required contributions within 45 days from the date coverage is elected retroactively to the date benefits terminated under the Plan.

If you have questions

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

Keep your plan informed of address changes

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

Benefits Service Center

The following sets out the contact numbers based on your status under the Retiree Medical Plan.  Failure to notify the correct entity could result in your loss of COBRA rights.  If your status is not listed, call the ExxonMobil Benefits Service Center for assistance or contact them at 1-800-682-2847.

Retirees, their survivors and covered family members:

Phone Numbers:
ExxonMobil Benefits Service Center
Monday – Friday except certain holidays
8:00 a.m. to 6:00 p.m. (U.S. Eastern Time)
800-682-2847 (toll free)
800-TDD-TDD4 (833-8334) for the hearing impaired

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

 

Administrative and ERISA information

Administrative and ERISA information for the Retiree Medical Plan - POS II A and B options

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 formal name of the Plan is 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 Exxon Mobil Corporation by serving the Corporation's Registered Agent for Service of Process, Corporation Service Company (CSC).

Administrator-Benefits
ExxonMobil Retiree Medical 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 Retiree Medical Plan 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 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. The claims administrator is Aetna for medical claims and for mental health and substance abuse claims and Express Scripts for prescription drug 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, Magellan for mandatory and voluntary appeals for all mental health and substance abuse-related appeals, and Express Scripts for all prescription drug mandatory and voluntary appeals. The Administrator-Benefits is the claims fiduciary for medical voluntary appeals. You may contact the claims fiduciary as follows:

Medical Mandatory and Voluntary Appeals: Mandatory and Voluntary Mental Health and Substance Abuse Related Appeals: Prescription Drug Mandatory and Voluntary Appeals:
:

Aetna 
P.O. Box 14463
Lexington, KY 40512

Magellan Healthcare
P.O. Box 2128
Maryland Heights,
Missouri, 63043
Express Scripts
P.O. Box 66587
St. Louis, MO 63166-6587
Attn: Administrative Appeals Dept.
 
Note: For initial claims incurred before January 1, 2021, the Administrator-Benefits is the claims fiduciary for medical voluntary appeals.


Administrator-Benefits

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


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

Benefit claims procedures

Filing a claim

A claim occurs whenever a plan participant requests:


• An authorization or referral from a participating provider or Aetna, or

• Payment for items or services received.


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


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


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


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


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


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

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

 
Post-service claim: a claim for a benefit that is not a pre-service claim.
Type of Claim Response time

Urgent care claim: a claim for medical care or treatment where delay could:
• Seriously jeopardize your life or health, or your ability to regain maximum function, or
• Subject you to severe pain that cannot be adequately managed without the requested care or treatment

 
As soon as possible but not later than 72 hours.
Pre-service claim: a claim for a benefit that requires Aetna’s approval of the benefit in advance of obtaining medical care. 15 calendar days
Concurrent care claim extension: a request to extend a previously approved course of treatment
Concurrent care claim extension: a request to extend a previously approved course of treatment. Urgent care claim - as soon as possible, but not later than 24 hours, provided the request was received at least 24 hours prior to the expiration of the approved treatment. 

Other claims - 15 calendar days
 Concurrent care claim reduction or termination: a decision to reduce or terminate a course of treatment that was previously approved. With enough advance notice to allow the plan participant to appeal.  With enough advance notice to allow the plan participant to appeal.
 30 calendar days
 
Extensions of time frames
 
The time periods described in the chart may be extended.
 
For urgent care claims: If Aetna does not have sufficient information to decide the claim, you will be notified as soon as possible (but no more than 24 hours after Aetna receives the claim) that additional information is needed. You will then have at least 48 hours to provide the information. A decision on your claim will be made within 48 hours after the additional information is provided.

For non-urgent pre-service and post service claims: The time frames may be extended for up to 15 additional days for reasons beyond the Plan’s control. In this case, Aetna will notify you of the extension before the original notification time period has ended. If you fail to provide the information, your claim will be denied.
 
If an extension is necessary because Aetna needs more information to process your post service claim, Aetna will notify you and give you an additional period of at least 45 days after receiving the notice to provide the information. Aetna will then inform you of the claim decision within 15 days after the additional period has ended (or within 15 days after Aetna receives the information, if earlier). If you fail to provide the information, your claim will be denied.
 
Grievances and appeals
 
There are procedures for you to follow if you are dissatisfied with a decision that Aetna has made or with the operation of the Plan. The process depends on the type of complaint you have. There are two categories of complaints:

• Quality of care or operational issues, and

• Adverse benefit determinations.

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

Grievances 

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

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

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

Type of Claim

Level One Appeal

Level Two Appeal

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

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

36 hours

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

36 hours

Review provided by Appeals Committee.

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

15 calendar days

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

15 calendar days

Review provided by Appeals Committee.

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

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

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

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

30 calendar days

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

30 calendar days

Review provided by Appeals Committee.

 
 
 Effective January 1st, 2021, you may perform your appeal in writing or verbally. You may also choose to have another person (an authorized representative) make the appeal on your behalf by providing written consent to Aetna. However, in case of an urgent care claim or a pre-service claim, a physician familiar with the case may represent you in the appeal.
 
Depending on the type of appeal, you and/or an authorized representative may attend the Level 2 appeal hearing and question the representative of Aetna and any other witnesses, and present your case. The hearing will be informal. You may bring your physician or other experts to testify. Aetna also has the right to present witnesses.
 
If the Level One and Level Two appeals uphold the original adverse benefit determination, you may have the right to pursue an external review of your claim. See External review of Aetna’s final appeal determinations for more information.
 
External review of Aetna’s final appeal determinations
 
You may file a voluntary appeal for external review of any final appeal determination that qualifies.
You must complete the two levels of appeal described above before you can appeal for external review. Subject to verification procedures that may be established, your authorized representative may act on your behalf in filing and pursuing this voluntary appeal. You must request this voluntary level of review within 60 days after you receive the final denial notice.
 
If you file a voluntary appeal, any applicable statute of limitations will be tolled while the appeal is pending. The filing of a claim will have no effect on your rights to any other benefits under the Plan. However, the appeal is voluntary and you are not required to undertake it before pursuing legal action.

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

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

• You have received notice of the denial of a claim by Aetna, and

• Your claim was denied because Aetna determined that the care was not medically necessary or was experimental or investigational, and
 

The claim denial letter you receive from Aetna will describe the process to follow if you wish to pursue an external review, and will include a copy of the Request for External Review Form.
You must submit the Request for External Review Form to Aetna within 60 calendar days of the date you received the final claim denial letter. The form must be accompanied by a copy of the final claim denial letter and all other pertinent information that supports your request.

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

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

No assignment

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

Limited authorization of payments

To the extent allowed by the claims administrator, you may authorize your claims administrator to make payments directly to a health care provider for covered services. Further, even without such authorization, a claims administrator may make direct payments to a health care provider for covered services according to the claims administrator’s rules and procedures at the applicable time.
Authorization of payments to a health care provider or direct payments to a health care provider are not assignment of benefits. Even though you may authorize a health care provider to receive a payment or reimbursement of covered services and even though a claims administrator may pay a health care provider directly for payments or reimbursements of covered services, in no event will any such authorizations, payments or reimbursements to or on behalf of a health care provider cause the provider to become a plan participant or plan beneficiary (or assignee of a participant or beneficiary) under ERISA.

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

No assignment of rights and benefits

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

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

Health care provider agreements not binding on the plan

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

Recovery of Excess Payments

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

Future of the ExxonMobil Retiree Medical Plan

ExxonMobil has the right to change, suspend, withdraw, amend, modify or terminate the 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. If all claims and expenses are paid and there is still money in ExxonMobil's book reserve established for the purpose of making contributions toward the cost of retirees' health care coverage, ExxonMobil will determine what to do with the excess amount in view of the purposes of the plans.

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

Prudent actions by ExxonMobil Retiree Medical Plan fiduciaries

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

Enforce your rights

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

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

If you have a claim and an appeal for benefits, which are denied or ignored, in whole or in part, you may file suit in a Federal court. 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 retiree would be required to file. Any such lawsuits must be brought within one year of the date on which an appeal was denied. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

Assistance with your questions

If you have any questions about the ExxonMobil Retiree Medical Plan, you should contact 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 Retiree Medical Plan (RMP) is a retiree only plan. A retiree only health plan is exempt from all the insurance mandates of the PPACA and HIPAA portability. As a retiree only plan the RMP will not include the consumer protections of PPACA that apply to the other plans.

Women's Health and Cancer Rights Act 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,
  • Prostheses, and
  • Services for physical complications in all stages of mastectomy, including lymphedema.

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

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

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 Retiree Medical Plan - POS II A and B options

Benefit service

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

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

Benefit predetermination

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

Case management

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

Change in status

Life or work event that allows you to make changes to your elections during the plan year.

Child

A person under age 26 who is:

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

Child does not include a foster child.

Claims administrator / processor

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

Copayments and coinsurance

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

Covered medical expense

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

Covered person

Any person identified on the books of the employer as a retiree, eligible family member, or survivor who:

  • Complies with the established enrollment requirements and makes any required contributions,
  • In the case of a retiree, family member, or survivor, is not eligible for Medicare, and
  • Is not eligible for any other medical plan to which ExxonMobil contributes on their behalf.

Custodial care

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

Deductible

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

Eligible family members

Eligible family members are generally your:

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

A child who was disabled but who no longer meets the requirements of paragraph two above, ceases to be an eligible family member 60 days following the date on which the applicable requirement is not met.

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

Experimental or investigational

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

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

Explanation of benefits (EOB)

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

Extended-care facility

An institution that meets the following criteria:

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

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) ), the Medicare Primary Option (MPO), and the Medicare Supplement Plan (or MSP).

Hospital

An institution which:

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

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

Medical necessity or medically necessary

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

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

The Administrator-Benefits has the exclusive and final authority to determine if a service or supply is medically necessary.

Medical precertification

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

Mental health condition 

Neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or behavioral disorder or disturbance with a diagnosis code from the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (5th ed. 2014) (DSM-V), or its successor publication, and which is appropriately treated by the Mental Health Network. Such a condition will be considered a mental health condition, regardless of any organic or physical cause or contributing factor.

Mental health preferred provider organization (MHPPO)

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

Mental health provider 

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

Network

Providers and facilities that participate in the Retiree Medical POS II network or mental health PPO network available under the RMP POS II option.

Non-network

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

Nurse

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

Out-of-network area

Geographic areas that do not fall within the medical POS II or mental health PPO network.

Out-of-pocket limit 

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

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

Outpatient prescription drug

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

Physician

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

Predetermination

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

Primary participant

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

Private duty nursing

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

Reasonable and customary limits

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

Retiree

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

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

Retiree Medical Plan (RMP)

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

Retiree Medical Plan POS II Option (Point of Service) 

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

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.

Spouse; marriage

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

Surgical procedure

This term refers to the following:

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

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

Survivor/ surviving spouse

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

Suspended retiree

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

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

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

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

Treatment of last resort

With respect to a covered person's specific medical condition, any hospital confinement, examination, surgical, medical or other treatment, service or supply that is not determined to be medically necessary for the treatment of such condition by virtue of being experimental or investigative, but that is authorized by the Administrator-Benefits under the following conditions:

  • the covered person's condition is life-threatening, and
  • the treatment must be authorized by the Administrator-Benefits, and the treatment must be recommended by a specialty-matched physician(s) chosen to review the treatment in question after considering:
  • the scientific basis, if any, for the treatment,
  • the prior use of appropriate treatment alternative, and
  • the potential efficacy of the treatment, the patient's physical condition, and the status of any government review of the treatment's use to address such condition.

For purposes of Treatment of Last Resort, a person's condition is considered to be life-threatening if there is a reasonable likelihood that it will result in the person's death within a matter of months or it is likely premature death will occur without early treatment.

Urgent care 

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

Year 

Calendar year, January 1 through December 31.

Benefit summary

Benefits summary of the Retiree Medical Plan - POS II A and B options

Please note: These charts provide only a brief summary of benefits under the RMP POS II A and RMP POS II B. They are not intended to include all provisions. Non-network and out-of-network area benefits are subject to reasonable and customary limits.

ExxonMobil Retiree Medical Plan / POS II A option
2021 Summary of Benefits / Plan Code: 1021

Service Area: Worldwide
POS II Group Number: 476599
Member Services: 800-255-2386
Provider Website: www.aetna.com
Choice® POS II 

Services POS II Network Non-Network Out-of-Network Area

Annual Deductible
(Individual/Family)

$500 / $1000 $700 / $1400 $500 / $1000
Out-of-Pocket Maximum
(Individual/Family)
$4,500 / $9,000 $18,000 / $36,000 $4,500 / $9,000
Individual Lifetime Maximum Unlimited Unlimited Unlimited
Separate Lifetime Maximum for Bariatric Surgery $25,000 $25,000 $25,000
Inpatient Hospital Services for Medical¹ (managed by Aetna), Mental Health and Substance Abuse treatment (managed by Magellan) $300 deductible
75% coverage
$600 deductible
55% coverage
$300 deductible
75% coverage

Precertification
Reference the Aetna National Precertification List
for a list of procedures requiring precertification (for mental health and substance abuse treatment, contact Magellan)

            
Provider initiates You initiate;
$500 penalty for failure to precertify inpatient care
You initiate;
$500 penalty for failure to precertify inpatient care
Outpatient Surgery and Associated Diagnostic Lab and X-ray Services 75% coverage 55% coverage 75% coverage
Physician Services* POS II Network Non-Network Out-of-Network Area

Surgeon/Hospital Doctor Visits

75% coverage 55% coverage 75% coverage
Office Visit
(including most diagnostic lab and X-ray services)²
Primary care:
$40 copay³
Specialist:
$60 copay³
55% coverage 75% coverage

Preventive Care
(including most diagnostic lab and X-ray services)²

*Physician services include Mental Health providers. PCP selection is not required.

100% coverage 100% coverage 100% coverage
Services POS II Network Non-Network Out-of-Network Area

Emergency Care

$100 copay4
75% coverage
$100 copay4
75% coverage
$100 copay4
75% coverage
Maternity 75% coverage 55% coverage 75% coverage

Chiropractic Care

  • Calendar Year Limit5
$60 copay
$1,000
55% coverage $1,000 75% coverage $1,000
  1. Precertification is required for all inpatient care, including mental health and substance abuse.
  2. Excludes MRI, CAT scan, PET/Spect, Muga Scan, Thallium stress test, Angiography and Myelography.
  3. Not subject to deductible.
  4. Charge applied to hospital deductible if admitted.
  5. Applies to all chiropractic expenses regardless of network status of provider.


IMPORTANT NOTE:
This chart provides only a brief summary of benefits under this option. It is not intended to include all Retiree Medical POS II A option provisions.

This information is applicable to all non-represented employees participating in the Medical Plan. Applicability to represented employees is governed by local bargaining requirements.

Prescription Drugs

Annual out-of-pocket maximum for
prescription drugs:

$2,500 per individual / $5,000 per family
  Short-Term Retail CoPay* ** *** Express Scripts, Accredo, or Smart90 Pharmacy**

 

(up to 34-day supply) Maximum Per Prescription (up to 90-day supply)
Maximum Per Prescription

Generic Drugs 30% $50 25%
$100


Preferred****
Brand Drugs
30% $125 25%
$250


Non-Preferred
Brand Drugs
50% $200 45%
$400



* If using a non-network pharmacy, you pay 100% of the difference between the actual cost and the discounted network cost plus retail copays.
** If your doctor prescribes a brand name drug for which a generic equivalent is available, you will be responsible for paying the generic copay and the full difference in the cost between the brand name and the generic equivalent. The difference in the cost between the brand and the generic does not apply to the annual out-of-pocket maximum for prescription drugs.
*** You must present Express Scripts or Medco Prescription Card or Social Security number of participant or benefits will be paid at the non-network level.
**** Preferred means Express Scripts’ formulary  of preferred prescription drugs. Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits.  However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program.  If the specialty medication being purchased qualifies for copay assistance, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program.  If you choose not to enroll in the program, you will be responsible for the higher copayment.

ExxonMobil Medical Plan / POS II B option
2021 Summary of Benefits / Plan Code: 1022

Service Area: Worldwide
POS II Group Number: 476599
Member Services: 800-255-2386
Provider Website: www.aetna.com
Choice® POS II 
(for mental health and substance abuse, access www.magellanassist.com)

Services POS II Network Non-Network Out-of-Network Area

Annual Deductible
(Individual/Family)

$300 / $600 $600/ $1200 $300 / $600
Out-of-Pocket Maximum
(Individual/Family)
$3,000 / $6,000 $15,000 / $30,000 $3,000 / $6,000
Individual Lifetime Maximum Unlimited Unlimited Unlimited
Separate Lifetime Maximum for Bariatric Surgery $25,000 $25,000 $25,000
Inpatient Hospital Services for Medical¹ (managed by Aetna), Mental Health and Substance Abuse treatment (managed by Magellan) $200 deductible
80% coverage
$400 deductible
60% coverage
$200 deductible
80% coverage

Precertification
Reference the Aetna National Precertification List for a list of
procedures requiring precertification (for mental health and substance abuse treatment, contact Magellan)

Provider initiates You initiate;
$500 penalty for failure to precertify inpatient care
You initiate;
$500 penalty for failure to precertify inpatient care
Outpatient Surgery and Associated Diagnostic Lab and X-ray Services 80% coverage 60% coverage 80% coverage
Physician Services* POS II Network Non-Network Out-of-Network Area

Surgeon/Hospital Doctor Visits

80% coverage 60% coverage 80% coverage
Office Visit
(including most diagnostic lab and X-ray services)²
Primary care:
$25 copay³
Specialist:
$40 copay³
60% coverage 80% coverage

Preventive Care
(including most diagnostic lab and X-ray services)²

100% coverage 100% coverage 100% coverage
Services POS II Network Non-Network Out-of-Network Area

Emergency Care

$100 copay4
80% coverage
$100 copay4
80% coverage
$100 copay4
80% coverage
Maternity 80% coverage 60% coverage 80% coverage

Chiropractic Care

  • Calendar Year Limit5
$40 copay3
$1,000
60% coverage $1,000 80% coverage $1,000
  1. Precertification is required for all inpatient care, including mental health and substance abuse.
  2. Excludes MRI, CAT scan, PET/Spect, Muga Scan, Thallium stress test, Angiography and Myelography.
  3. Not subject to deductible.
  4. Charge applied to hospital deductible if admitted.
  5. Applies to all chiropractic expenses regardless of network status of provider.


IMPORTANT NOTE:
This chart provides only a brief summary of benefits under this option. It is not intended to include all Retiree Medical POS II A Option provisions.

This information is applicable to all non-represented employees participating in the Medical Plan. Applicability to represented employees is governed by local bargaining requirements.

Prescription Drugs

Annual out-of-pocket maximum for prescription drugs:

$2,500 per individual / $5,000 per family
  Short-Term Retail Copay* ** *** Express Scripts, Accredo, or Smart90 Pharmacy**

 

(up to 34-day supply) Maximum Per Prescription (up to 90-day supply)
Maximum Per Prescription

Generic Drugs 30% $50 25%
$100


Preferred****
Brand Drugs
30% $125 25%
$250


Non-Preferred
Brand Drugs
50% $200 45%
$400



* If using a non-network pharmacy, you pay 100% of the difference between the actual cost and the discounted network cost plus retail copays.
** If your doctor prescribes a brand name drug for which a generic equivalent is available, you will be responsible for paying the generic copay and the full difference in the cost between the brand name and the generic equivalent. The difference in the cost between the brand and the generic does not apply to the annual out-of-pocket maximum for prescription drugs.
*** You must present Express Scripts or Medco Prescription Card or Social Security number of participant or benefits will be paid at the non-network level.
**** Preferred means Express Scripts’ formulary  of preferred prescription drugs. Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits.  However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program.  If the specialty medication being purchased qualifies for copay assistance, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program.  If you choose not to enroll in the program, you will be responsible for the higher copayment.

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