Medicare Supplement Plan

Summary plan description of the ExxonMobil Medicare Supplement Option as of January 2017

About the Medicare Supplement Plan

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

The Medicare numbers used in this SPD are current for 2016 but are subject to change. The dollar amounts in the examples are for explanation purposes only and may not reflect what a specific service might cost or how much Medicare and the Plan would pay toward that service.

Information sources

When you need information, you may contact:

Prescription drug program -Express Scripts is the claims processor for outpatient prescription drugs provided through mail order for long-term prescriptions or a local retail pharmacy for short-term prescriptions.

*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 web site at www.express-scripts.com.

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

Phone Numbers:

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

Address:

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

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

Phone Numbers:

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

Address:

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

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

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

Introduction

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

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

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

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

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

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

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

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

Plan at a glance

Eligibility

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

The prescription drug program

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

Other plan provisions

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

Accepting assignment

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

Covered and excluded expenses

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

Coordination of benefits

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

Claims

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

COBRA

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

Administrative and ERISA information

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

Key terms

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

Benefit summary

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