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Medicare Primary Option

Summary plan description of the Medicare Primary Option as of January 2022

About the Medicare Primary Option

The ExxonMobil Retiree Medical Plan (EMRMP) is comprised of two separate options: the Retiree Medical Plan option and the Medicare Primary Option (MPO). The information described in this document along with the 2022 Evidence of Coverage (EOC), the Summary of Benefits (SOB) and the Schedule of Cost Sharing (SOC) found on Aetna Medicare Website constitute the Summary Plan Description (SPD) for the MPO. If there is a conflict or difference between this SPD and the ExxonMobil Retiree Medical Plan document or the EOC, the ExxonMobil Retiree Medical Plan document or EOC will govern, as applicable.

There are two component parts of the MPO: 1) medical benefits are provided through the Medicare Advantage PPO with an Extended Service Area (ESA) also known as Group Medicare Part C and administered by Aetna; and 2) prescription drug benefits are administered by Express Scripts.

Information sources

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

Please read carefully:

For copy of the Evidence of Coverage (EOC):

Go to the Aetna Medicare website at ExxonMobil.AetnaMedicare.com. Evidence of coverage can be found under Coverage & benefits tab, in section “Plan Benefits and Star Ratings” or you can request a copy of the EOC by contacting Aetna Member Services at 1-833-595-1012 (TTY: 711).

For claims administration:

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

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

Aetna:

Refer to the EOC and SOC for those services that may require prior authorization. For claims, either download a copy of the form from ExxonMobil Aetna Medicare website (ExxonMobil.AetnaMedicare.com) or call Member Services and ask for the form. Phone numbers for Member Services are printed on your member ID card. Mail your request for payment together with any bills or receipts to the PO Box address below.

Phone numbers and website:

Aetna Medicare Services:
(1) 833-595-1012 (TTY: 711)
Monday Friday 7 a.m. - 8 p.m. (U.S Central Time)
Except certain holidays
Automated Voice Response Hours: 24 hours a day, 7 days a week
Website: ExxonMobil.AetnaMedicare.com

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

Express Scripts:

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

Phone Numbers: Address:
Express Scripts Pharmacy:

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

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

For questions regarding Retail Prescriptions: 

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

Direct Reimbursement Claim Form:
Express Scripts
ATTN: Commercial Claims
P.O. Box 14711
Lexington, KY 40512-4711
Direct Reimbursement Claim Forms may also be faxed to: 608-741-5475 

*To be able to reach this international access line for Express Scripts, please use the appropriate access number (e.g., AT&T Direct Service) for the country you are calling from. Another way to locate retail network pharmacies and order refills is via the Express Scripts website at www.express-scripts.com.

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.

Benefits Administration

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

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

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

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

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

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

ExxonMobil Aetna Medicare website:

Introduction

The Medicare Primary Option (MPO), is an option under the ExxonMobil Retiree Medical Plan for retirees, their eligible spouses and eligible surviving spouses who are also eligible for Medicare. Medical coverage under this option is provided through the Aetna Medicare Plan (PPO) with Extended Service Area (ESA), a type of Medicare Advantage plan which combines the same benefits as Medicare Part A (hospital insurance), Medicare Part B (medical insurance), and extra medical benefits all under one plan, commonly referred to as Medicare Part C. It is designed to work with Medicare Parts A and B and must follow the rules set by Medicare. You must be enrolled in and continue to pay premiums for Medicare Part A and Part B in order to continue your enrollment in the MPO.

The Prescription drug coverage is administered separately by Express Scripts.

If you enroll in another Medicare Advantage (Part C) plan or if you enroll in an individual Medicare Part D prescription drug plan, you cannot be enrolled in the MPO.

MPO at a glance

Eligibility

Retirees and their eligible spouses or surviving spouses who are also eligible for Medicare as their primary plan may participate. See Eligibility and enrollment.

The prescription drug program

The MPO offers cost-saving ways to buy outpatient prescription drugs at local participating network pharmacies, Smart90 pharmacies (e.g. Walgreens, CVS), and through home delivery. See Prescription drug program.

Claims

Your providers will submit all of your medical claims directly to Aetna. If your provider requires you to pay upfront, you will need to submit the claim directly to Aetna to the address provided on your ID card. For assistance on how to submit your claim, please contact Aetna member services (1) 833-595-1012 (TTY: 711) or go to ExxonMobil.AetnaMedicare.com (under View your Plan / Get a Form).

As for outpatient prescription drug claims, please refer to Claims section in this SPD.

See Claims.

COBRA

COBRA continuation coverage for retirees is only offered in the time of retirement. Eligible family members may be eligible to continue medical coverage through COBRA for a limited time in certain circumstances. See Continuation coverage.

Administrative and ERISA information

The MPO 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.

Benefit summary

Key features of the MPO are highlighted. See Benefit summary.

Key terms

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

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