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.
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.
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
P.O. Box 981106
El Paso, TX 79998-1106
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.
|Express Scripts Pharmacy:|
Express Scripts Home Delivery Pharmacy
Home Delivery Pharmacy:
|For questions regarding Retail Prescriptions:|
Direct Reimbursement Claim Form:
*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:
ATTN: Commercial Claims
P.O. Box 14711
Lexington, KY 40512-4711
Direct Reimbursement Claim Forms may also be faxed to:
To visit Express Scripts website: www.express-scripts.com.
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:
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
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 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:
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
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.
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.
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.
Key features of the MPO are highlighted. See Benefit summary.
This is an alphabetized list of words and phrases, with their definitions, used in this SPD. See Key terms.
Eligibility and enrollment
Eligibility and enrollment details for the Medicare Primary Plan Option
There are several conditions for eligibility for the MPO. You must:
- Be an eligible retiree or eligible family member,
- Be enrolled in Medicare Parts A and B and continue to pay any required premiums,
- Provide a Medicare Beneficiary Identifier (MBI), located on your Medicare card to ExxonMobil Benefits Service Center (EMBSC),
- Have a residential U.S. street address on file with CMS,
- Not be enrolled in another group or individual Medicare Advantage plan (Part C)
- Not be enrolled in an individual Medicare Part D prescription drug plan in the open market (Part D). You may only be enrolled in a group Medicare Part D, also referred to as Employer Group Waiver Plan (EGWP) if a former employer enrolls you.
How to enroll
Retirees have three opportunities to enroll in the in the ExxonMobil Retiree Medical Plan:
- At retirement, or
- Upon loss of other employer coverage, or
- When first eligible to be enrolled in Medicare as your primary plan.
There is no opportunity to enroll yourself in the MPO at any other time, including during annual enrollment. If you are 65 or older at the time of your retirement or you are about to turn 65 while participating in the Retiree Medical Plan option, and have other employer coverage, you must waive coverage to maintain eligibility (please refer to the Other Employer Sponsored coverage - Waiving MPO section).
Eligible spouses may be added to your coverage at one of the three enrollment opportunities listed above or if you experience a change in status. Eligible spouses cannot be added to your coverage at any other time, including during annual enrollment.
Post-Retirement changes in status
The following describes all the change in status events that allow changes in status post-retirement that apply to the ExxonMobil Retiree Medical Plan.
Add your spouse and any new eligible family members to the applicable ExxonMobil Retiree Medical Plan option.
Divorce – Retiree and spouse enrolled in ExxonMobil health plans
You must 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 to the applicable ExxonMobil Retiree Medical Plan option.
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 to the applicable ExxonMobil Retiree Medical Plan option.
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 subject to the applicable waiver.
You lose eligibility because of a change in your employment status, e.g., retiree to rehired employee.
Your MPO participation will automatically be suspended at the date of rehire and you will be covered under the ExxonMobil Medical Plan.
You change your US residential address to a Non-US address affecting your eligibility to participate in the MPO
You must remove yourself and all eligible family members from the ExxonMobil Retiree Medical Plan.
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 and must enroll in the MPO
Your disabled child becomes entitled to enroll in Medicare as their primary plan, even if your child is not actually enrolled in Medicare
You must remove coverage for your child.
Judgment, decree, or other court order requiring you to cover a family member.
Add new eligible family members.
Other Employer Sponsored coverage – Waiving MPO
You can waive your enrollment in MPO and preserve your eligibility to enroll at a later date (if the MPO is still an available option at that time) at either one of the 2 scenarios described below:
Retirees / spouses turning 65 while participating in the Retiree Medical Plan option: If you/your spouse are turning 65 and are covered under another Employer Sponsored Health Plan through either your own active employment or as a dependent of your spouse’s active employment, you/your spouse can waive coverage for the Medicare Primary Option (MPO). You/your spouse have 90 days to waive: you must request a waiver form to EMBSC (1-800-682-2847) and return it signed anytime within 60 days prior to becoming Medicare eligible and up to the end of the month you turn 65 years old. You/your spouse can then enroll in MPO at a later date when the other Employer Sponsored Health plan ends, with proof of loss of coverage. You have 90 days from loss of coverage to enroll, after which you/your spouse will not be eligible to enroll in MPO.
New retirees over the age of 65: If you are retiring from ExxonMobil and over the age of 65 and are eligible for other coverage through another employer sponsored health plan and want to waive enrollment in MPO, you must sign a waiver within 60 days of retirement date from ExxonMobil. You and your spouse (if applicable) must return a signed waiver to EMBSC (1-800-682-2847) by end of the 60th day of retirement. You and your spouse (if applicable) can then enroll in MPO at a later date when the other plan ends, with proof of loss of coverage. You have 90 days from loss of coverage to enroll, after which you and your spouse (if applicable) will not be eligible to enroll in MPO.
Important Note: If you have not reached 65 at the time of your retirement, and have been covered by another employer-sponsored group medical plan immediately before Plan eligibility, you will have to show loss of coverage under that employer sponsored group medical plan to enroll any time after your Medicare eligibility. You have 90 days from the date of loss of coverage under an employer sponsored group medical plan to provide documentation of loss of this coverage and enroll in the Medicare Primary Option (MPO). If you do not enroll within 90 days from your loss of coverage you will not have another opportunity to enroll.
For purposes of the MPO, you are an eligible retiree if you attained retiree status from:
- Mobil, or
- Superior Oil Company.
- Expatriates 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 and waive home country health coverage. If you choose not to enroll, there will be no opportunity to enroll at a later point in time during retirement.
Retirees of Station Operators, Inc. doing business as ExxonMobil Company Operated Retail Stores (CORS) are not eligible for coverage under the MPO.
Eligible family members
For purposes of the MPO, eligible family members who are also eligible to be enrolled in Medicare as their primary medical plan include:
- The spouse of an eligible retiree.
- The surviving spouse, who has not remarried, of a deceased eligible retiree or deceased employee.
NOTE: A dependent child of a retiree, deceased retiree, or deceased employee is not eligible for coverage under the MPO, with the exception of a grandfathered population of dependent children who were participating in the ExxonMobil Retiree Medical Plan, Medicare Supplement Plan option on December 31, 2018.
A person who becomes the spouse of an eligible retiree after becoming entitled to be enrolled in Medicare may be added to the MPO within 60 days of becoming eligible without demonstrating loss of coverage under another employer-sponsored medical plan. See change in status chart. Family members who are not entitled to be enrolled in Medicare as their primary medical plan may be eligible for coverage under the Retiree Medical Plan option of the ExxonMobil Retiree Medical Plan. See the SPD for the Retiree Medical Plan option for more information.
Enrolling in the MPO
The ExxonMobil Benefits Service Center (EMBSC) and Aetna contact retirees and their spouses and surviving spouses shortly before their 65th birthdays. If you have not been contacted by the time you become eligible for Medicare, contact the EMBSC at 1-800-682-2847. This is particularly important if you or your spouse become eligible for Medicare by virtue of disability rather than age. Your enrollment in the MPO is subject to your Medicare Parts A & B effective date that occurs the first of the month in which you turn age 65 (if your birthday is on the first of the month, coverage begins the first of the prior month prior), providing an MBI (Medicare Beneficiary Identifier), providing a physical US address, not be enrolled in other individual or group Medicare Part C, or individual Medicare Part D Prescription drug plan. However, if you do not comply with the requirements listed above by the effective date, you will remain covered under your current medical plan option for a period not exceeding 3 months after your retirement month or the month in which you turn 65.
When you receive your Medicare Beneficiary Identifier (MBI) red, white, and blue ID card, contact the EMBSC at 1-800-682-2847. For the hearing impaired, call 1-800-TDD-TDD4 (1-800-833-8334) and provide EMBSC with your Medicare information to complete your enrollment under the MPO. You’ll first receive a letter directly from Aetna confirming your MPO effective date of coverage, followed by your Aetna Medicare ID card.
If you do not enroll in Medicare Parts A and B and provide your Medicare Beneficiary Identifier (MBI) (located on your Medicare card) to the EMBSC by the end of the third month following either the month you turn age 65 or the month you retire, you and any eligible family members will lose coverage under the ExxonMobil Retiree Medical Plan and you will not have an opportunity to re-enroll at a later date, unless you waive coverage (see Eligibility and Enrollment Section)
When the MPO eligibility ends
Eligibility for the MPO ends:
- When a participant fails to make the required contributions to the MPO (see section Cancellation and Reinstatement Process for more information) or Medicare Parts A or B.
- When you cancel your coverage in writing.
- For a spouse following a divorce.
- For a surviving spouse and stepchildren upon remarriage (all coverage ends under the ExxonMobil Retiree Medical Plan).
- For children (children that were part of the Medicare Supplement Plan by December 31, 2018) upon the marriage of the surviving parent.
- For the surviving spouse and children (children that were part of the Medicare Supplement Plan by December 31, 2018) of an employee who died with less than 15 years of ExxonMobil service after a period from the date of death equal to twice the deceased employee's length of ExxonMobil benefit service.
- If, at some future date, the MPO is terminated or replaced.
If you cancel your coverage or did not properly waive coverage, you will not be allowed to re-enroll in the future. Also, if you are not covered under this or another medical plan to which ExxonMobil contributes, your otherwise eligible family members cannot continue coverage under any ExxonMobil medical plans.
Cancellation and Reinstatement Process effective January 1, 2022
Cancellation of EMRMP due to non-payment of premiums:
Cancellations due to non-payment of plan premiums will be prospective, with a 3 month grace period starting 1st month of unpaid contributions, so participants may pay owed contributions within that grace period to avoid cancellation. For example, if retiree has not made payments for their January, February, and March premiums during that 3 month timeframe, coverage will be cancelled effective April 1.
Reinstatement of EMRMP:
Once your coverage has been terminated, you can request to be reinstated upon showing good cause. The EMRMP (or its designee) will review requests for reinstatements on a case-by-case basis. If an individual has been involuntarily disenrolled for failure to pay plan premiums, they may request reinstatement no later than 60 calendar days following the effective date of disenrollment.
Reinstatement for good cause will occur only when:
- Reinstatement is requested no later than 60 calendar days following the effective date of disenrollment (in the example, 60 days from April 1)
- The individual has been determined to meet the criteria specified below (i.e., receives a favorable determination); and
- Within three (3) months of disenrollment for nonpayment of plan premiums, the individual pays in full the plan premiums owed at the time they were disenrolled (in the example, within 3 months from April 1).
If you fail to pay premiums within the grace period, your coverage is terminated, and you fail to show good cause, you and your eligible dependents will not have an opportunity to re-enroll at a future date in the EMRMP. You are still responsible for paying all owed premiums incurred during the grace period in which you were still part of the EMRMP.
Requests for reinstatement must be accompanied by a credible statement (verbal or written) explaining the unforeseen and uncontrollable circumstances causing the failure to make timely payment. An individual may make only one reinstatement request for good cause in the 60-day period. Generally, these circumstances constitute good cause:
- A serious illness, institutionalization, and/or hospitalization of the member or their authorized representative (i.e. the individual responsible for the member’s financial affairs), that lasted for a significant portion of the grace period for plan premium payment;
- Prolonged illness that is not chronic in nature, a serious (unexpected) complication to a chronic condition or rapid deterioration of the health of the member, a spouse, another person living in the same household, person providing caregiver services to the member, or the member’s authorized representative (i.e., the individual responsible for the member’s financial affairs) that occurs during the grace period for the plan premium payment;
- Recent death of a spouse, immediate family member, person living in the same household or person providing caregiver services to the member, or the member’s authorized representative (i.e., the individual responsible for the member’s financial affairs); or
- Home was severely damaged by a fire, natural disaster, or other unexpected event, such that the member or the member’s authorized representative was prevented from making arrangement for payment during the grace period for plan premium;
- An extreme weather-related, public safety, or other unforeseen event declared as a Federal or state level of emergency prevented premium payment at any point during the plan premium grace period. For example, the member’s bank or U.S. Post Office closes for a significant portion of the grace period.
There may be situations in addition to those listed above that result in favorable good cause determinations. If an individual presents a circumstance which is not captured in the listed examples, it must meet the regulatory standards of being outside of the member’s control or unexpected such that the member could not have reasonably foreseen its occurrence, and this circumstance must be the cause for the non-payment of plan premiums. The Plan expects non-listed circumstances will be rare.
Examples of circumstances that do not constitute good cause include:
- Allegation that bills or warning notices were not received due to unreported change of address, out of town for vacation, visiting out of town family, etc.;
- Authorized representative did not pay timely on member’s behalf;
- Lack of understanding of the ramifications of not paying plan premiums;
- Could not afford to pay premiums during the grace period; or
- Need for prescription medicines or other plan services.
The EMBSC (ExxonMobil Business Service Center) is the appointed designee reviewing reinstatement requests and making good cause determinations.
Benefits summary of the Medicare Primary Option
For full information about medical/surgical amounts, refer to the Evidence of Coverage (EOC) on the Aetna website at ExxonMobil.AetnaMedicare.com. The following section provides a summary of the items under the MPO that might be of interest to you.
|Annual Deductible Per covered individual||$300
|Out-of-Pocket Maximum Per covered individual||$3,000 *|
|Medical Individual Lifetime Maximum||Unlimited|
|Preventive Care||Covered at 100%; deductible waived|
|Primary Care office visit||You pay 20% after deductible|
|Specialty Care office visit||You pay 20% after deductible 80% of covered charges less any Medicare payment|
|Labs||You pay 0% after deductible 80% of covered charges less any Medicare payment|
|X-rays & complex imaging
||You pay 20% after deductible|
|Inpatient hospital stay (prior authorization may be required)||You pay $500 copay after deductible|
|Home health care||Covered at 100% after deductible|
|Outpatient surgery||You pay 20% after deductible|
|Emergency Room||You pay $50 copay; deductible waived|
|Urgent Care||You pay $35 copay; deductible waived|
|Private Duty Nursing||You pay 20% after deductible|
|Skilled Nursing Facilities (unlimited days)||You pay $0 for day(s) 1-20; you pay 20% on the 21st day up to the end of confinement|
|Outpatient mental health & substance use rehabilitation||You pay 20% after deductible|
|Routine hearing exam||Covered at 100%; deductible waived|
|Hearing aid reimbursement||$500 every 36 months; deductible waived|
|Routine vision exam||Covered at 100%; deductible waived|
|Acupuncture||You pay 20% after deductible|
|Enhanced chiropractic services||You pay 20% after deductible|
|Non-emergency transportation (not covered by Medicare)***||Maximum of 40 one-way trips and no more than 60 miles each.|
*Once you have spent $3,000 the annual out-of-pocket amount for covered expenses (including your deductible, 20% coinsurance and copays), the MPO's reimbursement level is 100% of the covered charges during the remainder of that year. Please refer to the EOC and the SOC located on the Aetna website to understand what expenses apply towards your annual out of pocket.
**Telehealth services covered when provided by PCP, specialist, behavioral health, or urgent care providers. Member cost share will apply based on services rendered.
*** The transportation service will accommodate urgent requests for hospital discharge, dialysis, and trips that your medical provider considers urgent. You may arrange transport by calling 1-855-814-1699, Monday through Friday, from 8 AM to 8 PM, in all time zones. (For TTY/TDD assistance please dial 711.). Details will be available on the Aetna Medicare website (exxonmobil.aetnamedicare.com).
Coverage for vaccines:
- Covered by Original Medicare and not MPO – you pay $0:
- Covid-19 vaccine
- Covered under Aetna Medicare Advantage – you pay $0 (deductible waived):
- Yearly Flu shots
- Hepatitis B shots
- Pneumococcal shots
- Diabetic supplies
- Infusion drugs
- Check the Prescription drug program section to learn about vaccines covered under Express Scripts.
Prior Authorization for Medical services
Preauthorization is required for some treatments. Examples include (but not restricted to): durable medical equipment (e.g. wheelchairs, hospital beds, walker, etc.), Health Home Care, complex imaging (MRI, PET scans, etc.), some surgeries, and scheduled inpatient admissions, among others.
Preauthorization is not required for urgent care or emergency care, where:
- Urgent: unforeseen medical illness or injury that requires immediate medical care
- Emergency: requires immediate attention to prevent loss of life, or loss of limb (includes loss of function).
Your in-network Aetna Medicare Advantage provider is responsible for getting services preauthorized. Physicians contacted with Aetna have instructions on how to submit preauthorization. Time frame starts once full/completed information is received. For some services, when provided by an out-of-network provider (provider who accepts Medicare assignment but is not in the Aetna PPO network), it is recommended to get pre-authorization. More information can be found in the Schedule of Cost Sharing (SOC).
Mental health treatment
Medicare only pays for outpatient mental health care and professional services when they are provided by a health care professional who can be paid by Medicare. You should inform your provider that you participate in an Aetna Medicare Advantage Plan before you schedule treatment and provide them with your Aetna Medicare Advantage card. If your mental health profession provider does not accept Medicare Advantage, there is no coverage at all.
For more information regarding your mental health coverage, please refer to the EOC in the Aetna website. Also, you may contact Aetna Medicare Services (see contact info in Resources).
The MPO covers a wide range of medically necessary health care services, tests, treatments and supplies. For more information on what are covered expenses, please refer to EOC and SOC found at the Aetna Medicare website. These documents have detailed information in regards to services covered for you under the Medical Benefits Chart in the SOC. The Summary of Benefits (SOB) also describes the benefits provided.
Type of providers
Aetna Medicare Advantage PPO with Extended Service Area (ESA) has an open access feature that provides the same level of coverage in or out of network. It is important to understand that you may see any doctor, as long as they are eligible to receive Medicare payment.
The list of Aetna Medicare Advantage PPO providers can be found at ExxonMobil Aetna Medicare website.
Read carefully the 3 types of providers below:
1. Accepts Medicare and accepts Medicare Assignment:
If your doctor or other health care providers accept assignment, they accept the amount Medicare approves as payment in full for that service or supply. It’s an agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the deductible and coinsurance. The MPO will cover 80%, including the limiting charge. For example: if the Medicare approved amount is $100, so the provider bills $100. Then the MPO will cover $80 (80%), and you must still pay the difference between the Medicare-approved amount and the amount Medicare and the Plan pay (percentage copayment), which in this example is $20.
2. Accepts Medicare but does not accept Medicare assignment:
These are called non-participating providers. These providers accept Medicare but not the Medicare approved amount. They can charge you more than the Medicare-approved amount, but only up to a limit called “the limiting charge.” (15% above the Medicare-approved). The MPO will cover 80%, including the limiting charge. For example: if the Medicare approved amount is $100, and the provider bills $115, then the MPO will cover $92 (80%), and you are responsible for $23.
3. Does not accept Medicare – Medicare Opt-out providers:
Certain doctors and other health care providers who don’t want to work with the Medicare program may “opt out” of Medicare. Medicare doesn’t pay for any covered items or services you receive from an opt-out doctor or other provider, except in the case of an emergency or urgent need. You would be responsible for 100% of the services.
Special Note: Medicare approved amount (or Medicare fee schedule) is the amount a doctor or supplier can bill for Medicare covered services. It may be less than the actual amount a doctor or supplier charges.
Continuity of care
If you are participating under another option of the ExxonMobil Retiree Medical Plan or the ExxonMobil Medical Plan when you become eligible for Medicare and need assistance transitioning your care to doctors who accept Medicare and the MPO, Aetna team will work with you and your doctor to make sure the benefits are applied correctly. For more information, please refer to the Continuity of Care information located at ExxonMobil Aetna Medicare website.
Coordination of benefits
Coordination of benefits for the MPO
Coordination of benefits rules determine which plan is primary. The primary plan pays claims first before another insurance plan processes the claims. If you are enrolled in another retiree medical plan, you should contact your employer-sponsored retiree medical plan. Or you can review the other plan’s information and documents to make sure you know which plan is primary.
Your Aetna coverage is provided through a contract with ExxonMobil. You (or your spouse) may also get medical coverage from another employer or retiree group. Call the ExxonMobil Benefits Service Center (EMBSC) if you have any questions regarding coordination of your coverage. You can also call Aetna’s Member Services if you have any questions (Phone numbers for Member Services are printed on your member ID card).
Medicare Advantage Plans
If you are enrolled in another Medicare Advantage Plan, Centers for Medicare and Medicaid Services (CMS) does not allow you to be enrolled in two Medicare Advantage Plans. You will have to decide which plan is best for you.
Special rules apply to coordinating benefits for prescription drugs. See Covered prescriptions for details.
Additional information about your medical benefits
Here’s how the Aetna Medicare Advantage PPO with ESA MPO works:
- You must pay a MPO deductible each plan year. However, you are not responsible for separate Medicare Parts A and B deductibles, since the MPO replaces Medicare.
- The MPO then pays a share of the Medicare-allowable rates for covered services.
- You pay the remaining portion of charges, called coinsurance, up to the out-of-pocket maximum.
- Once you reach the annual out-of-pocket maximum, the MPO pays 100 percent of most covered expenses for the rest of the plan year.
The prescription drug program
Prescription drug program information for the MPOThe MPO covers outpatient prescription drugs only if you are not enrolled in a Medicare Part D plan. The MPO's prescription drug benefits offer cost-saving ways to buy outpatient prescription drugs:
- A network of local participating retail pharmacies for short-term prescriptions.
- Express Scripts Pharmacy, the home delivery pharmacy, and participating Smart90 retail pharmacies (e.g. Walgreens, CVS) for long-term or maintenance prescriptions.
- Express Scripts Specialty Pharmacy, Accredo, for prescriptions requiring special handling.
No deductible is required.
A vaccine program is available at participating network pharmacies through Express Scripts (www.expressscripts.com), in addition to current coverage available through physician/medical facilities:
- Members may conveniently receive common vaccinations at their retail pharmacy at no cost. Coverage includes vaccines such as COVID-19, Flu, Hepatitis A, B and A&B, Pneumonia, Shingles/Zoster, Meningitis, Tetanus/Diptheria/Pertussis, Human papillomavirus (HPV), etc.
- Members are not required to provide a prescription to receive vaccines.
- Members will need to present their prescription ID card to ensure that the vaccine is processed under the pharmacy benefit.
Note: Prescription medications, including injections, billed by and provided in a hospital or a doctor's office are typically not covered under the prescription drug program but may be covered medical expenses under the MPO. For more information please refer to the Schedule of Cost Sharing (SOC) in the ExxonMobil Aetna Medicare website. Medications billed to you by Express Scripts are not covered under the medical portion of the MPO.
For certain prescription drugs:
You must call Express Scripts for precertification of certain prescription drugs.
In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the MPO will cover another (usually more expensive) drug.
Additionally, as part of Express Scripts’ Advanced Utilization Management (AUM) program, certain targeted drugs will not be covered unless pre-certified by Express Scripts, based on medical evidence submitted by your physician.
Non-targeted drugs are covered without precertification or prior authorization. Refer to the Prescription drug program section for more details.
You must identify yourself as a member of the Express Scripts retail pharmacy program to receive the benefit.
Call Express Scripts at 800-695-4116 or check the Express Scripts web site at www.express-scripts.com to locate a participating retail pharmacy near you.
Zostavax and Shingrix are both covered under your prescription drug plan. For more information contact Express Scripts 1-800-695-4116. You can also visit www.express-scripts.com. The copay structure for vaccines is the same as it is for other branded medications: Retail Brand 30% max $125.
A short-term prescription is written for a drug taken for a limited period of time, such as an antibiotic for a specific illness or if your doctor wants you to try the prescription before having a long-term prescription filled. Short-term prescriptions are provided for up to a 34-day supply. See Covered prescriptions for limitations.
You have the choice of filling your prescriptions at:
- A local participating retail pharmacy (part of Express Script's extensive network of retail pharmacies), where you will pay your share — copayment — of the discounted cost. There are no claims to file.
- A non-participating pharmacy of your choice, where you will pay the full retail price and file a claim for partial reimbursement of the cost.
To receive the discounted price:
- Present your prescription and either your prescription drug identification card or the primary participant's identification number at a participating network pharmacy.
- The pharmacist enters the prescription and the primary participant's identification number into the pharmacy's computer system to confirm:
- That you are a participant or family member covered by this option.
- That it is a covered prescription.
- Your share of the prescription's cost.
- You do not file a claim.
The term primary participant refers to the participant whose identification number is used for identification purposes. The primary participant is the retiree, survivor, or individual who elected COBRA coverage. Covered family members use the primary participant's identification number to access all medical benefits. Be sure to give identification cards or the primary participant's identification number to your eligible family members.
Refills too soon?
You may order refills by calling Express Scripts or sending in the refill label provided with your previous order. You may also order refills through Express Scripts’ website. You should order a refill about three weeks before your current supply will be exhausted, but remember that you must have used about three quarters of the previous prescription based on the prescribed dosage.
Short Term Retail Pharmacy Co-Pay* ** *** ****
Long Term Express Scripts, or Smart90 Pharmacy
(up to 34-day supply)
Maximum Per Prescription
(up to 90-day supply)
Maximum Per Prescription
Formulary Brand Drugs
Non-Formulary Brand Drugs
*If using a non-network pharmacy, you pay 100% of the difference between the actual cost and the discounted network cost plus retail copays.
** If your doctor prescribes a brand name drug for which a generic equivalent is available, you will be responsible for paying the generic copay and the full difference in the cost between the brand name and the generic equivalent. The difference in the cost between the brand and the generic does not apply to the annual out-of-pocket maximum for prescription drugs.
*** You must present your Express Scripts Prescription Card or identification number of the primary participant or benefits will be paid at the non-network level.
**** Preferred means Express Scripts’ formulary of preferred prescription drugs. Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits. However, many of these medications may be available at no cost when purchased through the MPO’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.
Prescription drugs — Annual out-of-pocket maximums for prescription drugs--$2,500/individual
For short-term prescription drugs purchased at a participating retail pharmacy, you pay a percentage of the discounted cost of the drugs.
Generic short-term drug purchased at a retail network pharmacy — discounted cost of medication is $24.
You pay 30% copayment ($24 x .30) = $7.20
Preferred brand name short-term drug purchased at a retail network pharmacy (if no generic is available) — cost of medication is $42.
You pay 30% copayment ($42 x .30) = $12.60
Non-preferred brand name short-term drug purchased at a retail network pharmacy (if no generic is available) — cost of medication is $64.
You pay 50% copayment ($64 x .50) = $32
Short-term retail refill limitation for maintenance medications
A long-term or maintenance medication is a drug you take for an extended period of time, such as for the ongoing treatment of diabetes, arthritis, a heart condition, or blood pressure. After the third short-term fill of a maintenance medication at a participating or non-participating retail pharmacy, subsequent refills must be purchased as a 90-day supply at a Smart90 retail pharmacy (e.g. Walgreens, CVS) or Express Scripts home delivery pharmacy. If you continue to purchase short-term fills of a long-term or maintenance medication after the third fill, you will be responsible for 100% of the cost.
Using a non-participating pharmacy or not identifying yourself as an Express Scripts participant
You are not eligible for a discounted price if you:
- Have your prescription filled at a non-participating pharmacy, or
- Do not identify yourself as an Express Scripts participant at a network pharmacy.
In either case:
- You pay the full non-discounted price of the prescription at the time of purchase.
- You must submit a completed Direct Reimbursement Claim Form to Express Scripts. You may obtain a claim form by calling Express Scripts at the number shown in the front of this SPD.
- You will be responsible for 100% of the difference between the non-discounted and discounted cost of the prescription (the ineligible cost) plus your percentage copayment portion of the discounted cost.
This example shows how you would save money when you use a network pharmacy and show your prescription ID card. In this case, you would save $10.
|Without Express Scripts Discount||With Express Script Discount|
|Full retail cost of preferred brand name prescription (non-discounted)
30% copayment ($40 x .30)
|Your cost||$ 22.00||$ 12.00|
A long-term or maintenance drug is one you take for an extended period of time, such as for ongoing treatment of diabetes, arthritis, heart condition, or high blood pressure. The MPO generally provides benefits for up to a 90-day supply through a participating Smart90 retail pharmacy (e.g. Walgreens, CVS) or Express Scripts home delivery pharmacy. See Covered prescriptions for limitations.
If you need maintenance medication immediately, ask your doctor for two prescriptions — one for an immediate supply to be filled at a local pharmacy and a second for an extended supply to be ordered by mail or at a Smart90 retail pharmacy.
After the third short-term fill of a maintenance medication at a participating or non-participating retail pharmacy, subsequent refills must be purchased as a 90-day supply at a Smart90 retail pharmacy (e.g. Walgreens, CVS) or Express Scripts home delivery pharmacy. If you continue to purchase short-term fills of a long-term or maintenance medication after the third fill, you will be responsible for 100% of the cost.
Express scripts pharmacy — home delivery pharmacy
With Express Scripts Pharmacy, the home delivery pharmacy, you save money and have the convenience of home delivery. Ask the doctor to write a prescription for up to a 90-day supply with appropriate refills. Enclose your original prescription(s) and payment of your percentage copayment in an envelope. If you are paying via check or money order, you may obtain a calculation of your percentage copayment from the Express Scripts web site or by calling Express Scripts directly. If you are paying via credit card, Express Scripts will deduct the appropriate percentage copayment, and you will receive notification of the deduction with your medication.
For each prescription filled, you pay:
|Type of Drug||Express Scripts Pharmacy Percentage Copayment|
|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 website. You should order a refill about three weeks before your current supply will be exhausted, but remember that you must have used about three quarters of the previous prescription based on the prescribed dosage.
You can also fill or refill a long-term prescription at a participating Smart90 (e.g. Walgreens, CVS) retail pharmacy.
Comparing retail pharmacy with Express Scripts Pharmacy
This example shows how you can save money by purchasing long-term medications through either the Express Scripts home delivery or a Smart90 retail pharmacy.
Assume you purchase a 90-day supply of a preferred brand name drug:
|At a Participating Retail Pharmacy:||Through Express Scripts, or Smart90 Pharmacy:|
|$ 108.00||Cost of preferred brand name drug
Cost of preferred brand name drug
|x 30%||Percentage copayment||x 25%||Percentage copayment|
|$ 32.40||Your copayment for a 30-day supply or $97.20 for a 90-day supply||$ 81.00||Your copayment|
|You pay $97.20 for a 90-day supply||You pay $81.00 for a 90-day supply|
By purchasing a 90-day supply of this prescription through Express Scripts home delivery or at a Smart90 retail pharmacy, you would save $16.20. That is $64.80 a year for one prescription.
Whether you fill prescriptions through Express Scripts Pharmacy, at a local pharmacy or through Express Scripts Specialty Pharmacy:
- Your payments and copayments under the outpatient prescription drug benefits do not apply toward your deductible for other benefits under the MPO.
- Your prescription drug payments and copayments do not apply toward your annual medical out-of-pocket limit.
- Your prescription drug annual out-of-pocket maximum is $2,500 for each individual in your family, or $5,000 for your entire family.
- The additional cost for purchasing brand-name prescription drugs when a generic is available, as well as the full cost for purchasing subsequent refills of maintenance medications after the third fill obtained at retail pharmacies that are not part of the Smart90 network (e.g. Walgreens, CVS), will not count toward your annual out-of-pocket maximum.
|Short-Term Per Prescription Out-of-Pocket Maximum (30-day or less supply)||Long-Term Per Prescription Out-of-Pocket Maximum (Generally 90-day or less supply)|
|Generic||30% with a $50.00 max||25% with a $100.00 max|
|Preferred brand name drugs||30% with a $125.00 max||25% with a $250.00 max|
|Non-preferred brand name drugs||50% with a $200.00 max||45% with a $400.00 max|
The MPO covers drugs, medicines and supplies that are:
- Obtainable only with a physician's prescription, or are specifically covered expenses(see Covered expenses).
- Approved by the U.S. Food and Drug Administration for the specific diagnosis.
- Not experimental or investigational.
- Prescription smoking deterrent medications.
- Outpatient prescription drugs unless you are enrolled in Medicare Part D.
The program encourages consideration of generic alternatives, which are less expensive to you and the MPO. The majority of brand name medications have a generic equivalent available. By law, the brand name and generic medications must meet the same standards for safety, purity, strength, and effectiveness. The pharmacist will only dispense generics which receive FDA approval and only if authorized by your doctor.
Note: If both generic and brand name drugs are available to treat your condition, your percentage copayment amount will depend on which medication you select. If you purchase the brand name drug, you are responsible for paying the generic drug percentage copayment PLUS the full difference in cost between the generic drug and the brand name drug. This difference in cost will not count toward your annual prescription drug out-of-pocket maximum.
Here is an example of how you can save by choosing a generic drug at a retail pharmacy when a brand-name drug is available on the MPO's formulary list of medications.
|Cost Difference between Brand and Generic||Percentage Copayment|
|$100.00||Cost of preferred brand-name drug (30-day supply)||$50.00||Cost of generic drug
|$50.00||Cost of generic drug
|x 30%||Percentage copayment|
|$50.00||Cost difference||$15.00||Your copayment if you purchase the generic|
|*If you purchase the brand name drug:
Your copayment will be $15.00 + $50.00 (cost difference) = $65.00
The additional $50 does not count toward your annual prescription drug out-of-pocket maximum.
Sometimes, a generic drug or a less expensive brand name drug which provides the same therapeutic effect, but at a lower cost to you, may be available. If so, the network system will inform the pharmacist that a less expensive alternative medication is available to fill your prescription. A pharmacist from the network or Express Scripts Pharmacy may contact your doctor to discuss the generic or less expensive brand name alternative. If the doctor authorizes a substitution, the pharmacist will dispense it based solely on your doctor's agreement. If Express Scripts Pharmacy fills a prescription with a generic or an alternative brand name drug, your order will include an explanation of the doctor's change and a credit for any excess copayment.
The network formulary program
A formulary is a list of commonly prescribed medications within particular therapeutic categories. The drugs on the list have been selected based on their effectiveness and cost. To be included in the formulary list, a drug must meet rigorous standards of approval by the Express Scripts Pharmacy and Therapeutic Committee - a group of nationally recognized medical professionals.
It is always up to your doctor to decide which medications to prescribe. If you have questions about the Express Scripts formulary, you should contact Express Scripts directly.
Drug monitoring service
All prescriptions, both home delivery and retail, are screened by the network's computerized drug monitoring service.
This service analyzes all of your prescriptions in the system for potential problems such as adverse drug interactions, drug duplications, and unusually high or low dosages. This service will also detect if a refill is requested too soon. If a potential problem is detected, the drug monitoring service transmits a message to the pharmacist. The pharmacist will contact your doctor about the potential problem or otherwise resolve the issue before dispensing the prescription. Of course, your doctor makes the final decision about any change in your prescription or course of treatment.
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 MPO covers, the pharmacist will fill the prescription up to the MPO limit. You have the option to buy the additional amount at that time if purchasing at a retail pharmacy, but there is no MPO benefit.
- If the medicine is a controlled substance or if there is a manufacturer's or prescription benefit manager's directive, a smaller amount may be provided.
- For most prescriptions, you must use about three quarters of the previous prescription, based on the dosage prescribed, before you can obtain a refill and receive MPO benefits.
- During natural disasters, you may be able to replace lost or damaged medications without having used 75% of the previous prescription.
Special rules for coordinating benefits for prescriptions
If you or your family members are covered under any other group medical plan, the MPO coordinates benefits with that plan, as described in the Coordination of benefits section of this SPD. In addition, information about the other coverage is provided to the outpatient prescription drug network.
When a pharmacist reviews your family member's eligibility information in the network system, a code will indicate if your family member has other coverage that should pay benefits first. In these cases, you must first pay according to the primary plan provisions (i.e., you cannot purchase prescriptions using the Express Scripts card or through the home delivery prescription service). After the primary plan has paid, you may file a claim with the MPO for reimbursement of any remaining amount; the procedure is the same as when a non-participating pharmacy is used. The MPO will pay the lesser of what would have been paid if the claim was not filed with the primary plan or the amount not paid by the primary plan.
Medicare Part D and the Prescription Drug Program
Participants who choose to enroll in an individual Medicare Part D prescription drug plan will no longer be eligible for coverage under the MPO. However, a participant can be enrolled in an Employer Group Waiver Plan (EGWP) Part D plan.
Specialty medications, including injectable 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 MPO’s copay assistance program. If the specialty medication being purchased qualifies for copay assistance, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program. If you choose not to enroll in the program, you will be responsible for the higher copayment.
Advanced utilization management program
In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the MPO will cover another (usually more expensive) drug. Prior authorization and preferred drug step therapy rules are designed to encourage the use of effective, lower-cost drugs.
As part of Express Scripts’ Advanced Utilization Management (AUM) program, certain targeted drugs will not be covered unless pre-certified by Express Scripts, based on medical evidence submitted by your physician. In addition, some therapies will be monitored for appropriate pharmacogenomics parameters, and oral oncology medications will be limited to ensure appropriate use. Please visit www.express-scripts.com to more information about your medications and if they require a coverage review. If you have a question regarding a drug on the AUM program list, contact Express Scripts at the number listed in the Information Sources section of this SPD.
Precertification: preferred drug step therapy rules
You must call Express Scripts for precertification of certain prescription drugs described below:
Preferred drug step therapy rules are used for certain therapeutic chapters of drugs, to encourage the use of effective, lower-cost drugs by excluding some targeted medications from coverage. In the therapeutic chapters including: proton pump inhibitors, sleep agents, depression, osteoporosis, respiratory, cardiovascular, migraine growth hormone, stimulants for Attention Deficit Hyperactivity Disorder, prostate therapy drugs, topical steroids, and stroke prevention, there will be targeted drugs determined by Express Scripts which will not be covered unless pre-certified by Express Scripts. Non-targeted drugs will be covered without such authorization and will continue to be dispensed with no further action by either you or the prescribing physician. If you have a question regarding a drug in any of these therapeutic chapters, contact Express Scripts to determine whether your drug is covered. You will be notified directly by Express Scripts if you are affected by these rules.
Prior authorization rules
New prior authorization rules apply to certain therapeutic classes of drugs; some therapies in this section will be monitored for appropriate pharmacogenomics parameters. These classes include miscellaneous immunological agents, central nervous system/miscellaneous neurological therapy, biotechnology/adjunctive cancer therapy, central nervous system/headache therapy, central nervous system/analgesics, neurology/miscellaneous psychotherapeutic agents, and miscellaneous pulmonary agents. In addition, anabolic steroids, high cost antibiotics, anti-emetics, antivirals, narcotics, acne dermatological 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
MPO 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.
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 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.
Filling claims for the Medicare Primary Option
Your medical care provider submits claims directly to Aetna for payment. After the deductible has been met, Aetna pays the appropriate amount, and the provider bills you for the appropriate coinsurance. Under the MPO, Aetna is the primary payer of your medical claims.
Aetna has a contract with Medicare that allows them to process claims for all of your medical treatment with the exception of hospice care which is covered directly by Original Medicare.
If you need to file a claim, please refer to the EOC or contact Aetna member services for assistance.
You may obtain claim forms by contacting Aetna or through their website. See Information sources at the front of this SPD.
You must submit your medical claims to Aetna within one calendar year of the date you received the service, item, or Part B drug.
Outpatient prescription drug claims
You do not have to file a claim for outpatient prescription drugs if you:
- Use a participating network retail pharmacy and identify yourself as an Express Scripts participant, or
- Purchase drugs through Express Scripts Pharmacy, the home delivery pharmacy.
Otherwise, you must submit a completed Direct Reimbursement Claim Form to Express Scripts. You may obtain a claim form by calling Express Scripts at the number shown in the front of this SPD.
Expenses incurred outside the United States
MPO will cover services outside the United States for emergency or urgent care only. For more information, please refer to the EOC or SOC, or contact Aetna member services (See Information sources at the front of this SPD.)
Claim denial and reconsideration
If all or part of a claim is denied, Aetna will provide you with a written explanation, including the MPO provisions supporting the denial and describing additional information, if any, that may improve the claim's likelihood of being approved. See Evidence of Coverage (EOC) and Administrative and ERISA information.
Right of reimbursement and subrogation
Aetna has the right and responsibility to collect for covered Medicare services for which Medicare is not the primary payer. Please refer to Aetna Medicare Advantage EOC for further details.
COBRA Continuation coverage
Continuation coverage for the Medicare Primary Option
COBRA continuation coverage for retirees is offered in the time of retirement and for covered family members upon the occurrence of certain events.
Continuation coverage rights under COBRA
You are required to be given the information in this section because you are covered under a group health plan (the Retiree Medical Plan). This section contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan under certain circumstances when coverage would otherwise end. This section generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it.
The right to COBRA coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to your spouse and children, if they are covered under the Plan when they would otherwise lose their group health coverage or other rights under the Plan. This section does not fully describe COBRA coverage or other rights under the Plan. For additional information about your rights and obligations under the Plan and under federal law, you should review this SPD or contact the ExxonMobil Benefits Service Center at the telephone numbers or address listed under Benefits Administration in the Contacts for COBRA rights Under the ExxonMobil Retiree Plan section.
Your spouse and your family members may have other options available when they lose group health coverage. For example, they may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, y the costs of monthly premiums may be lower. Additionally, they may qualify for a 30-day special enrollment period for another group health plan for which they are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.
Determination of Benefits Administration Entity to Contact:
- Exxon, ExxonMobil, Mobil, XTO or Superior Oil Retirees, or their Survivors, or their covered family members contact ExxonMobil Benefits (http://www.exxonmobil.com/benefits) or contact the ExxonMobil Benefits Service Center;
- Former Exxon, ExxonMobil or XTO Employees and their covered family members, who have elected and are participating through COBRA, contact the ExxonMobil COBRA Administration.
The contact information for each of these entities is as shown in the Contacts for COBRA Rights Under the ExxonMobil Medical Plan section.
What is COBRA coverage?
COBRA coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a qualifying event. Specific qualifying events are listed later in this section. If a specific qualifying event occurs and any required notice of that event is properly provided to the ExxonMobil Benefits Service Center, COBRA coverage must be offered to each person losing coverage who is a qualified beneficiary. You, your spouse, and your children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Certain newborns, newly adopted children, and alternate recipients under QMCSOs may also be qualified beneficiaries. This is discussed in more detail in separate paragraphs below. Under the Plan, qualified beneficiaries who elect COBRA coverage must pay the entire cost of COBRA coverage (employee plus employer portions) plus a 2% administrative fee.
Who is entitled to elect COBRA?
If you are the spouse of a retiree, you will be entitled to elect COBRA if you lose coverage under the Plan because any of the following qualifying events happens:
- The retiree dies,
- You become divorced from the retiree. Also, if the retiree reduces or eliminates your group health coverage in anticipation of a divorce, and a divorce later occurs, then the divorce may be considered a qualifying event for you even though your coverage was reduced or eliminated before the divorce.
A person enrolled as the retiree’s child will be entitled to elect COBRA if he or she loses coverage under the Plan because any of the following qualifying events happens:
- The retiree dies,
- The child stops being eligible for coverage under the Plan as a child.
When is COBRA coverage available?
When the qualifying event is the death of a retiree, the Plan will offer COBRA coverage to qualified beneficiaries. You need to notify the ExxonMobil Benefits Service Center of any other qualifying events.
For the other qualifying events (divorce of the retiree resulting in the spouse or a child losing eligibility for coverage), a COBRA election will be available to you only if you notify and provide the appropriate forms to the ExxonMobil Benefits Service Center or ExxonMobil COBRA Administration within 60 days after the later of (1) the date of the qualifying event or (2) the date on which the qualified beneficiary loses (or would lose) coverage under the terms of the Plan as a result of the qualifying event. Current retirees or survivors may give notice of qualifying events by logging onto ExxonMobil Benefits located or by calling eh ExxonMobil Benefits Service Center.
Please note: Notice is not effective until either a change is made on ExxonMobil Benefits or the proper information is received by the ExxonMobil Benefits Service Center. If notice is not submitted during the 60-day notice period, then all qualified beneficiaries will lose their right to elect COBRA.
Election of COBRA
Each qualified beneficiary will have an independent right to elect COBRA. Covered retirees and spouses (if the spouse is a qualified beneficiary) may elect COBRA on behalf of all qualified beneficiaries, and parents may elect COBRA on behalf of their children. Any qualified beneficiary for whom COBRA is not elected within the 60-day election period specified in the Plan’s COBRA election notice WILL LOSE HIS OR HER RIGHT TO ELECT COBRA.
How long does COBRA coverage last?
COBRA coverage is a temporary continuation of Plan coverage that lasts between 18-36 months depending on the qualifying event.
Your covered spouse and covered dependent may qualify for up to 36 months of continuation coverage, if they qualify due to one of the following qualifying events:
- You die;
- You and your spouse get a divorce; or
- An enrolled child no longer meets the definition of “child” under the terms of the Plan.
When COBRA Coverage Ends
COBRA coverage can end before the end of the maximum coverage period for several reasons:
- The premium for your continuation coverage is not paid on time.
- If after electing continuation coverage, you become covered by another group health plan, unless the plan contains any exclusions or limitations with respect to any pre-existing condition you or your coverage dependents may have.
- If after electing continuation coverage, you first come eligible for and enroll in Medicare Part A , Part B or both.
- Exxon Mobil Corporation no longer provides group health coverage to any of its eligible employees or eligible retirees.
Are there other coverage options besides COBRA continuation coverage?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a special enrollment period. Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.
More information about individuals who may be qualified beneficiaries during COBRA
A child born to, adopted by, or placed for adoption with a covered retiree during a period of COBRA coverage is considered to be a qualified beneficiary provided that, if the covered retiree is a qualified beneficiary, the covered retiree has elected COBRA coverage for himself or herself.
The child's COBRA coverage begins when the child is enrolled in the Plan, whether through special enrollment or open enrollment, and it lasts for as long as COBRA coverage lasts for other family members of the retiree. To be enrolled in the Plan, the child must satisfy the otherwise-applicable Plan eligibility requirements (for example, regarding age).
Cost of COBRA coverage
A person who elects continuation coverage may be required to pay 102% of the cost to the Plan to maintain the coverage. A person who elects continuation coverage must pay the required contributions within 45 days from the date coverage is elected retroactively to the date benefits terminated under the Plan.
If you have questions
Questions concerning your plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visitwww.healthcare.gov.
Keep your plan informed of address changes
In order to protect your family's rights, you should keep the Benefits Service Center informed of any changes in your address as well as the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Benefits Service Center.
Contacts for COBRA rights under the ExxonMobil Retiree Medical Plan
The following sets out the contact numbers based on your status under the Retiree Medical Plan. Failure to notify the correct entity could result in your loss of COBRA rights.
If your status is not listed, call the ExxonMobil Benefits Service Center.
Retirees and their covered family members:
ExxonMobil Benefits Service Center
Monday – Friday 8:00 a.m. to 6:00 p.m. (U.S. Eastern Time)
Web: ExxonMobil Benefits
ExxonMobil Benefits Service Center
Address: P.O. Box 18025
Norfolk, VA 23501-1867
Former employees and family members who have elected and are participating through COBRA:
ExxonMobil COBRA Administration
Monday - Friday except certain holidays
8:00 a.m. to 7:00 p.m. (U.S. Central Time)
Wageworks National Accounts Services
ExxoMobil COBRA Administration
P.O. Box 2968
Alpharetta, GA 30023-2968
Administrative and ERISA information
Administrative and ERISA information for the MPO
This section contains technical information about the MPO and identifies its administrator. It also contains a summary of your rights with respect to the MPO and instructions about how you can submit an appeal if your claim for benefits is denied.
The MPO is a part of the ExxonMobil Retiree Medical Plan.
MPO 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
The Plan Administrator for the ExxonMobil Retiree Medical Plan is the Administrator-Benefits. The Administrator-Benefits is the Manager-Global Benefits Design, Exxon Mobil Corporation. You may contact the Administrator-Benefits at the following address. Legal process may be served upon the Administrator-Benefits c/o ExxonMobil by serving the Corporation's Registered Agent for Service of Process, Corporation Service Company (CSC).
Medicare Primary Option
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 under the Medicare Primary Option.
Aetna and Express Scripts have been designated as the Named Fiduciary for the MPO and have complete authority to review all denied claims for benefits under the MPO.
Type of plan
The ExxonMobil Retiree Medical Plan is a welfare plan under ERISA providing medical benefits.
The ExxonMobil Retiree Medical Plan (of which the Medicare Primary option is a part) is identified with government agencies under two numbers: the Employer Identification Number, 13-5409005, and the Plan Number (PN), 540.
The plan year is the calendar year.
The MPO is partly funded through participant and company contributions and partly fully insured. The MPO includes an employer group Medicare Part C arrangement that is fully insured and the prescription drug benefits administered by Express Scripts that are self-insured. Each year, ExxonMobil determines the rates of required participant contributions to the ExxonMobil Retiree Medical Plan. These rates are based on past and projected Plan experience. Participant contributions are paid to a Trustee who manages the funds under the terms of a Trust Agreement between ExxonMobil and the Trustee. The Trustee for the EMRMP is:
The Northern Trust Company
50 S. LaSalle
Chicago, IL 60675
The claims administrator provides information about claims payment and benefit pre-determinations. The claims administrator is Aetna for medical claims and for prior authorization for some treatments; Express Scripts is the claims administrator for prescription drugs claims. See information sources.
Claims fiduciary and appeals
The claims fiduciary is the person to whom all appeals are filed. The claims fiduciary is Aetna for medical appeals and Express Scripts for prescription drug appeals.
Members who are dissatisfied with the resolution of an adverse decision or complaint have the right to appeal to Aetna (medical) or Express Scripts (prescription drugs) or to file a complaint with the appropriate Department of Insurance (in the case of medical). Aetna / Express Scripts have full and final discretionary authority to construe and interpret the terms of the MPO in its application to any participant or beneficiary and to decide any and all claim appeals.
For Medical appeals, please refer to Chapter 7 of the EOC. Appeals are submitted to:
Medical Level 1 and 2 Appeals
Prescription Drug Appeals
Aetna Medicare Part C Appeals & Grievances
For the MPO there are 3 level of appeals after level 2, for a total of 5 levels of appeals. At level 3, your appeal is reviewed by an Administrator Law Judge or attorney adjudicator who works for the Federal Government. Level 4 is reviewed by the Medicare Appeals Council who is part of the Federal Government. Level 5 is reviewed by a judge at the Federal District Court and this is the last step of the appeal process for the MPO related medical benefits.
Benefit claims procedures
For medical coverage decisions, appeals, complaints and grievances, please read carefully the Chapter 7 of the Evidence of Coverage (EOC), located on Aetna’s Website at ExxonMobil.AetnaMedicare.com.
It provides with detailed explanation of:
- How to ask for a coverage decision, or make an appeal.
- How to ask to cover a longer inpatient hospital stay if you think your doctor is discharging you too soon.
- How to ask to keep covering certain medical services if you think coverage is ending too soon.
- Taking your appeal to Level 3 and beyond.
- How to make a complaint about quality of care, waiting times, customer service, or other concerns.
You can also find information under the Contact Us section, option Request coverage, file an appeal or make a complaint in the ExxonMobil.AetnaMedicare.com website.
If your claim for benefits is denied completely or partially, you, your beneficiary, or designated representative will receive written notice of the decision. The notice will describe:
- The specific reason(s) for the denial, and
- The process for requesting an appeal.
You should be aware that the claims administrators have the right to request repayment if they overpay a claim for any reason.
Filing a Level 1 appeal
If your claim is denied, you, your beneficiary, or your designated representative may appeal the decision to the appropriate claims fiduciary.
For medical services, please refer to EOC, Chapter 7.
To start an appeal related to medical services, you, your doctor, or your representative, must contact the Claims Administrator. If you are asking for a standard appeal, make your standard appeal in writing by submitting a request. If you are asking for a fast appeal, make your appeal in writing or call the Claims Administrator. You must make your appeal request within 60 calendar days from the date on the written notice the Claims Administrator sent to tell you the answer to your request for a coverage decision. You can ask for a copy of the information regarding your medical decision and add more information to support your appeal.
The review will take into account all comments, documents, records and other information submitted relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. You will receive a response to the appeal within a designated response time as follows:
30 calendar days
If additional time is needed to decide on your claim because of special circumstances, you will be notified within the claim response period. However, if an extension is requested and granted, the law stipulates that no additional time must be allowed.
Filing a Level 2 appeal
If your first level of appeal is denied, you will receive written notice of the decision. Your case will automatically be sent on to the next level of the appeals process. During the Level 2 Appeal, the Independent Review Organization reviews the Claims Administrator’s decision for your first appeal. This organization decides whether the decision we made should be changed. You may review Section 5.4 of chapter 7 of the EOC for further details on this Level 2 Appeal.
Future of the ExxonMobil Retiree Medical Plan
ExxonMobil has the right to change, suspend, withdraw, amend, modify or terminate the ExxonMobil Retiree Medical Plan or any of its provisions at any time and for any reason. A change also may be made to required contributions and future eligibility for coverage, and may apply to those who retired in the past, as well as those who retire in the future. If any material changes are made in the future, you will be notified. For health plans, certain rules apply regarding what happens when a plan is changed, terminated or merged.
Expenses incurred before the effective date of a Plan change or termination will not be affected. Expenses incurred after a Plan is terminated will not be covered. If a Plan cannot pay all of the incurred claims and plan expenses as of the date the Plan is changed or terminated, ExxonMobil will make sufficient contributions to the Plan to make up the difference.
Your rights under ERISA
As a participant in the ExxonMobil Retiree Medical Plan (the 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 Plan, including collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.
- Obtain, upon written request to the Administrator-Benefits, copies of documents governing the operation of the Plan, including collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated SPD. The administrator may require a reasonable charge for the copies.
- Receive a summary of the Plan's annual report. The Administrator-Benefits is required by law to furnish each participant with a copy of this summary annual report.
In addition, review Chapter 6 of the EOC, which discusses additional rights and responsibilities that you have under the MPO. Additional legal notices are provided in Chapter 9 of the EOC.
Prudent actions by Plan fiduciaries
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate the 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, including your employer, your union, or any other person, may discriminate against you in any way to prevent you from obtaining a plan benefit or exercising your rights under ERISA.
Enforce your rights
- If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.
- Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of the MPO documents or the latest summary annual report from the MPO option and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Administrator-Benefits to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator.
- If you have a claim and an appeal for benefits, which are denied or ignored, in whole or in part, you may file suit in a federal court. Such lawsuit must be filed in the United States District Court for the Southern District of Texas, Houston, Texas, or in the United States District Court for the federal judicial district where the employee currently works. If a retiree or terminee, the suit must be filed in the last location worked prior to termination of employment. Beneficiaries must also file in the same federal judicial district that the employee or retiree would be required to file. Any such lawsuits must be brought within one year of the date on which an appeal was denied. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.
Assistance with your questions
If you have any questions about your MPO option, you should contact Aetna Medicare 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.
A note regarding the ExxonMobil Retiree Medical Plan
The ExxonMobil Retiree Medical Plan is a retiree only plan. A retiree only health plan is exempt from most provisions of the PPACA. As a retiree only plan the Plan will not include the consumer protections of PPACA that apply to the other plans.
Women's Health and Cancer Rights Act of 1998
If you have a mastectomy, at any time, and decide to have breast reconstruction, based on consultation with your attending physician, the following benefits will be subject to the same percentage copayment and deductibles which apply to other plan benefits:
- Reconstruction of the breast on which the mastectomy was performed,
- Surgery and reconstruction of the other breast to produce a symmetrical appearance, and
- Prostheses, and
- Physical complications in all stages of mastectomy, including lymphedema.
The above benefits will be provided subject to the same deductibles, copayments and limits applicable to other covered services.
If you have any questions about your benefits, please contact Aetna Member Services.
Coverage for maternity hospital stay
Under federal law, the Plan may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section, or require that a provider obtain authorization from the Plan for prescribing a length of stay not in excess of the above periods. The law generally does not prohibit an attending provider of the mother or newborn, in consultation with the mother, from discharging the mother or newborn earlier than 48 or 96 hours, as applicable.
List of key terms in the Medicare Primary Option
A physician who accepts Medicare assignment agrees to accept no more than the Medicare-approved amount as total payment for a service.
The amount on which Medicare bases its payments for a particular service.
Generally, all the time from the first day of employment until you leave the company's employment. Excluded are:
- Unauthorized absences,
- Leaves of absence of over 30 days (except military leaves or leaves under the Federal Family and Medical Leave Act),
- Certain absences from which you do not return,
- Periods when you work as a non-regular employee or as a special-agreement person, in a service station, car wash, or car-care center operations, or
- When you are covered by a contract that requires the company to contribute to a different benefit program, unless a special authorization credits the service.
The portion of covered expenses you pay. For some services the coinsurance will be a percentage of the cost of the service once the deductible has been satisfied. For outpatient prescription drugs there is a percentage copayment.
Expenses that are eligible for reimbursement under the MPO. Some expenses must be Medicare-approved to be covered. All expenses must meet MPO requirements including medical necessity.
The amount of covered expenses you incur before a MPO begins to pay. Medicare and the MPO have separate and different deductibles.
You may qualify for Social Security and Medicare by virtue of a disability, even if you are less than age 65.
For purposes of the MPO, eligible family members who are also eligible to be enrolled in Medicare as their primary medical plan include:
- The spouse of an eligible retiree.
- The surviving spouse, who has not remarried, of a deceased eligible retiree or deceased employee.
- The child of an eligible retiree, deceased eligible retiree, or deceased employee who was enrolled in the Medicare Supplement Plan on December 31, 2018 (grandfathered disabled children).
NOTE: Effective January 1, 2019, a dependent 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.
If your dependent or your spouse become eligible for Medicare you need to notify this event. For grandfathered disabled children participating in the MPO, ExxonMobil no longer considers an escalation / appeal after a decision has been taken. If Aetna confirms the dependent is no longer disabled, that decision is final.
A person who becomes the spouse of an eligible retiree after becoming entitled to be enrolled in Medicare may be added to the MPO within 90 days of becoming eligible without demonstrating loss of coverage under another employer-sponsored medical plan.
Family members who are not eligible to be enrolled in Medicare as their primary medical plan may be eligible for coverage under one of the Retiree Medical Plan options of the ExxonMobil Retiree Medical. See the SPD for the Retiree Medical Plan option of your choice for more information.
In the MPO, an eligible retiree is a person who:
- Retired with retiree status from ExxonMobil,
- Retired with retiree status from Exxon,
- Retired with retiree status from Mobil or Superior Oil,
- Is a former Exxon or ExxonMobil employee who retired with retiree status from Exxon or ExxonMobil and is not currently working for ExxonMobil as a regular or non-regular employee
Retirees of Station Operators, Inc. doing business as ExxonMobil Company Operated Retail Stores (CORS) are not eligible for coverage under this MPO.
- 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.
The Plan sponsored by Exxon Mobil Corporation which provides medical benefits for eligible retirees, survivors and their family members, and includes the Retiree Medical Plan (RMP) and the Medicare Primary Option (MPO) as constituent parts.
Medically necessary care and equipment provided at home by a Medicare-certified agency on a part-time or intermittent basis by skilled nurses, home-health aides, occupational, physical or speech therapists and those providing medical social services.
An institution which is engaged primarily in providing medical care and treatment of sick and injured persons on an inpatient basis at the patient's expense which is:
- Accredited by the Joint Commission on Accreditation of Hospitals,
- A hospital, psychiatric hospital or a tuberculosis hospital, as those terms are defined in Medicare (or as may be amended by Medicare in the future), which is qualified to participate and eligible to receive payments under and in accordance with the provisions of Medicare, or
- An institution which:
- maintains on its premises diagnostic and therapeutic facilities for surgical and medical diagnosis and treatment of sick and injured persons by or under the supervision of a staff of duly qualified physicians,
- continuously provides on its premises twenty four hour a day nursing service by or under the supervision of registered graduate nurses, and
- functions continuously with organized facilities for operative surgery on its premises.
The maximum amount a physician may require a Medicare beneficiary to pay for a covered service if the physician does not accept assignment.
Services or supplies that are: legal; ordered by a physician or clinical psychologist; safe and effective in treating the condition for which ordered; part of a course of treatment generally accepted by the American medical community; of a proper quantity, frequency and duration for treating the condition for which ordered; not redundant when combined with other services and supplies used to treat the condition for which ordered; not experimental, meaning unproven by long-term clinical studies; and for the purpose of restoring health or extending life.
Neurosis, psychoneurosis, psychopathy, psychosis, or mental or emotional disease or behavioral disorder or disturbance with a diagnosis code from the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV), or its successor publication, and which is otherwise covered by Medicare. Such a condition will be considered a mental health condition, regardless of any organic or physical cause or contributing factor.
See skilled-nursing care.
A registered graduate nurse (RN), a licensed vocational nurse (LVN), or a licensed practical nurse (LPN).
Services and supplies provided by a hospital or skilled-nursing facility required to treat a patient. Excluded are fees for room and board and fees charged by physicians, private-duty or special nursing services.
A prescription drug or medicine obtained through either a retail pharmacy or through a home delivery prescription service (including insulin and associated diabetic supplies if acquired through a prescription). A prescription drug or medicine, including injections, obtained or administered in a physician's office or in a hospital are not considered outpatient prescription drugs.
That part of Medicare which pays certain hospital and skilled-nursing facility bills.
That part of Medicare which pays certain physician and other medical bills.
That part of Medicare that provides Medicare Advantage plans.
That part of Medicare which pays certain outpatient prescription drug bills.
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.
The participant whose Social Security number or Aetna Member Identification Number is used for identification purposes. The primary participant is the retiree, survivor or individual who elected COBRA coverage. Covered family members use the primary participant's Social Security number or Aetna Member Identification Number to access all benefits.
Private duty nursing
Continuous, substantial and complex in-home nursing care requiring services that can only be provided by a licensed medical professional, has been prescribed by a treating physician, provided on an hourly basis and is determined to be medically necessary. Private duty nursing provides more individual and continuous skilled care than the care that can be provided in a skilled nurse visit through a home health agency.
Generally, a person at least 55 years old who retires as a regular employee with 15 years of service or someone who is retired by the company and entitled to long-term disability benefits under the ExxonMobil Disability plan after 15 or more years of benefit service, regardless of age.
Retirees who have been rehired as regular or non-regular employees are not eligible for the ExxonMobil Retiree Medical Plan.
One of the parts of the ExxonMobil Retiree Medical Plan which provides medical benefits for Pre-Medicare eligible retirees, survivors, and their family members. It includes the Retiree Medical Plan POS II and other self-funded options.
Room, 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.
Care requiring services only licensed medical professionals can provide in the home or in a skilled-nursing facility. Both Medicare and the MPO cover such care when prescribed by a treating physician and determined to be medically necessary. These types of services are sometimes called non-custodial nursing care.
A Medicare-approved institution meeting government-prescribed standards for skilled-nursing care or skilled-rehabilitation services. The MPO covers only Medicare-approved skilled-nursing facilities.
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.
A surviving unmarried spouse of a deceased ExxonMobil regular employee or retiree.