ExxonMobil Medicare Supplement Plan. Summary Plan Description

Transcription

1 ExxonMobil Medicare Supplement Plan Summary Plan Description 201

2 About Medicare Supplement - Information Sources - Introduction - Plan at a Glance Eligibility and Enrollment The Prescription Drug Program Other Plan Provisions Accepting Assignment Covered Expenses Exclusions Coordination of Benefits Claims Partners in Health Continuation Coverage Administrative and ERISA Information Key Terms Benefit Summary ExxonMobil Medicare Supplement Plan SPD As of January 2015 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 2015 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. Phone Numbers: Express Scripts Pharmacy Mail-order Pharmacy: (international, use appropriate country access code depending on country from which you are calling)* For questions regarding Retail Prescriptions Express Scripts: (international, use appropriate country access code depending on the country from which you are calling)* Address: Express Scripts Pharmacy Mail-order Pharmacy: P.O. Box Dallas, TX Non-network and Coordination of Benefits Retail Prescriptions Claims Processing: Express Scripts ATTN: Commercial Claims P.O. Box 2872 Clinton, IA

3 page 2 *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 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 (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 El Paso, TX Benefits Administration Retirees and survivors can enroll/change coverage on the ExxonMobil Benefits Service Center website at 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: or 800-TDD-TDD4 ( ) for hearing impaired Address: ExxonMobil Benefits Service Center PO Box Dallas, TX 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 Retiree Online Community Internet Site Can be accessed by retirees and survivors only at ExxonMobil Benefits Service Center at Xerox Internet Site Can be accessed by everyone at

4 page 3 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 shown on page 1.

5 page 4 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 page 6. 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 page 10. Other Plan Provisions You must satisfy an annual deductible of $300 before the Plan starts paying. 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. 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 page 18. 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 page 25. Covered and Excluded Expenses The Plan provides benefits for many, but not all, types of treatment, care and services. See page 28 for Covered Expenses and page 31 for Exclusions. Coordination of Benefits The Plan treats Medicare coverage as another group plan for purposes of coordinating benefits. See page 33. 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 page 35. Partners in Health Tools and resources are available to you and your family members to help you better manage your health care. See page 38. COBRA Your family members who lose eligibility may continue medical coverage for a limited time in certain circumstances. See page 40.

6 page 5 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 page 44. Key Terms This is an alphabetized list of words and phrases, with their definitions, used in this SPD. See page 50. Benefit Summary Key features of the Plan and Medicare are highlighted. See page 56.

7 About Medicare Supplement Eligibility and Enrollment - Eligible Retiree - Eligible Family Members - Eligibility for Medicare - Enrolling in Medicare - When Plan Eligibility Ends The Prescription Drug Program Other Plan Provisions Accepting Assignment Covered Expenses Exclusions Coordination of Benefits Claims Partners in Health Continuation Coverage Administrative and ERISA Information Eligibility and Enrollment Q. Who can participate in the Plan? A. There are three conditions for eligibility for the Plan. You must: Be eligible for Medicare; Be an eligible retiree or eligible family member; and Have been covered by an employer-sponsored group medical plan immediately before Plan eligibility. You will have to show loss of coverage under an employer sponsored group medical plan (any group medical plan sponsored by either the Corporation or another employer) to enroll any time after your Medicare eligibility. You have 60 days from the date of loss of coverage under an employer sponsored group medical plan to provide documentation of loss of this coverage and enroll in the ExxonMobil Medicare Supplement Plan. If you do not enroll within 60 days from your loss of coverage you will not have another opportunity to enroll. Eligible Retiree For purposes of the Plan, you are an eligible retiree if you attained retiree status from: ExxonMobil; Exxon; Mobil; or Superior Oil Company. Key Terms Benefit Summary Retirees of Station Operators, Inc. doing business as ExxonMobil Company Operated Retail Stores (CORS) are not eligible for coverage under this plan. Eligible Family Members For purposes of the Plan, eligible family members include: The spouse of an eligible retiree. The surviving spouse, who has not remarried, of a deceased eligible retiree. The surviving spouse, who has not remarried, of a deceased employee. The child of an eligible retiree.

8 page 7 The child, whose surviving parent has not remarried, of a deceased employee or eligible retiree. A person who becomes an eligible family member of an ExxonMobil eligible retiree by marriage after becoming eligible for Medicare. To participate in the Plan under this provision, prior group health coverage is not required. However, the person must be added as a covered family member within 30 days of becoming eligible. Eligibility for Medicare In general, you are eligible for Medicare if you are at least 65 years of age or have received Social Security disability benefits for 24 consecutive months. Anyone, including children, can be eligible for Medicare by virtue of a disability as described on page 51. No one becomes eligible for Medicare as the dependent of someone who is eligible for Medicare. For example: If you are 65 years of age and your spouse is 61 and not disabled, you are eligible for Medicare but your spouse is not; or If you are under age 65 and not disabled and have a spouse either over 65 or eligible due to disability, your spouse is eligible for Medicare but you are not. Enrolling in Medicare If you are receiving Social Security benefits, your Social Security office should contact you with information about Medicare before your 65 th birthday. If you are not receiving Social Security benefits or if you have not been contacted by Social Security and are nearing your 65 th birthday, contact your local Social Security office. To receive maximum benefits from the Plan and Medicare, you must enroll in both: Part A covers hospital care and care in a skilled-nursing facility. There is no premium for most Part A participants. Part B covers physician bills and some out-of-hospital expenses. A premium for Part B is deducted from your Social Security check. Contact Medicare for current premium information. If your spouse worked in a job not covered by Social Security or did not work long enough to qualify for free Part A coverage, the Plan pays full benefits with or without Part A coverage. The spouse must, however, sign up for Part B to receive maximum benefits.

9 page 8 Enrolling in Medicare Advantage (Part C) or Medicare Part D Participants who choose to enroll in a Medicare Advantage (Part C) plan which provides a Medicare prescription drug benefit or Medicare Part D Prescription Drug Plan will no longer be eligible for outpatient prescription drug coverage under the Plan. If you enroll in a Medicare Part C plan which provides a Medicare prescription drug benefit or Part D program and continue your Plan participation, your required contributions remain the same, but you will not be eligible for outpatient prescription drug benefits under the Plan. Questions About Medicare? Contact Social Security Administration: Call toll free Access the Web site at Enrolling in the Plan The ExxonMobil Benefits Service Center (EMBSC) contacts retirees and their spouses and surviving spouses shortly before their 65 th birthdays. If you have not been contacted by the time you become eligible for Medicare, contact the EMBSC. This is particularly important if you become eligible for Medicare by virtue of disability rather than age. You should also contact the EMBSC when your child or spouse becomes eligible for Medicare. Important Notice About Becoming Medicare-Eligible Retirees or survivors or covered family members of a retiree or survivor who become Medicare eligible either due to age or Social Security disability status are no longer eligible to participate in the ExxonMobil Medical Plan (POS II Options and HMO Options). Medicare eligible participants must change their Company-provided coverage from the ExxonMobil Medical Plan to the ExxonMobil Medicare Supplement Plan and enroll in Medicare Parts A and B. (Note: There are no HMO options under the ExxonMobil Medicare Supplement Plan). Even if you enroll in the ExxonMobil Medicare Supplement Plan, but choose not to enroll in Medicare Parts A and B, you will receive no reimbursement from the ExxonMobil Medicare Supplement Plan for claim expenses that would have been paid by Medicare had you been enrolled. The ExxonMobil Medical Plan is not available to retirees and survivors who are Medicare-eligible. Don't Be Without Coverage! Notify the ExxonMobil Benefits Service Center as soon as you or your family members receive notice of eligibility for Medicare Parts A and B due to either age or disability.

10 page 9 When Plan Eligibility Ends Eligibility for the Plan ends: When a participant fails to make the required contributions. When you cancel your coverage in writing. For a spouse following a divorce. For a surviving spouse and stepchildren upon remarriage. For children upon the marriage of the surviving parent. For the surviving spouse and children of an employee who died with less than 15 years of ExxonMobil benefit service after a period from the date of death equal to twice the deceased employee's length of ExxonMobil benefit service. If, at some future date, the Plan is terminated or replaced. If you cancel your coverage, you will not be allowed to re-enroll in the future. Also, if you are not covered under this or another medical plan to which ExxonMobil contributes, your otherwise eligible family members cannot continue coverage under any ExxonMobil medical plans.

11 About Medicare Supplement Eligibility and Enrollment The Prescription Drug Program - Short-Term Prescriptions - Long-Term Prescriptions - Comparing Retail Pharmacy with Express Scripts Pharmacy - Covered Prescriptions - Limitations Other Plan Provisions Accepting Assignment Covered Expenses Exclusions Coordination of Benefits Claims Partners in Health Continuation Coverage Administrative and ERISA Information Key Terms Benefit Summary The Prescription Drug Program Q. Does the Plan cover outpatient prescription drugs? A. Yes, but only if you are not enrolled in Medicare Part D or a Medicare Part C plan that provides a Medicare prescription drug benefit. The Plan's prescription drug benefits offer cost-saving ways to buy outpatient prescription drugs: A network of local participating retail pharmacies for short-term prescriptions. Express Scripts Pharmacy, the mail-order service for long-term or maintenance prescriptions. Express Scripts Specialty Pharmacy. No deductible is required. Note: Prescription medications, including injections, billed by and provided in a hospital or a doctor's office are not covered under the prescription drug program but may be covered medical expenses under the Medicare Supplement Plan. Medications billed to you by a pharmacy vendor are not covered under the Medicare Supplement Plan. For Certain Prescription Drugs: You must call Express Scripts for pre-certification of certain prescription drugs. This applies whether you are inside or outside the United States. In the therapeutic chapters listed below, 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 a participant or the prescribing physician. These classes are proton pump inhibitors, sleep agents, depression, osteoporosis, respiratory, cardiovascular, triptans, growth hormone, stimulants for Attention Deficit Hyperactivity Disorder (ADHD), prostate therapy drugs, topical steroids and stroke prevention. Additional prior authorization rules apply to certain therapeutic chapters of drugs; 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. 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 a drug in any of these therapeutic chapters, contact Express Scripts to determine whether your drug is covered without precertification. You must identify yourself as a member of the Express Scripts retail pharmacy program to receive Plan savings. Call Express Scripts at or check the Express Scripts web site at to locate a participating retail pharmacy near you.

12 page 11 Short-Term Prescriptions A short-term prescription is written for a drug taken for a limited period of time, such as an antibiotic for a specific illness or if your doctor wants you to try the prescription before having a long-term prescription filled. The Plan provides benefits for up to a 34- day supply. See page 16 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 co-payment of the discounted cost. There are no claims to file. A non-participating pharmacy of your choice, where you will pay the full retail price and file a claim for partial reimbursement of the cost. To receive the discounted price: Present your prescription and either your prescription drug identification card or the primary participant's identification number at a participating network pharmacy. The pharmacist enters the prescription and the primary participant's identification number into the pharmacy's computer system to confirm: That you are a participant or family member covered by this option. That it is a covered prescription. Your share of the prescription's cost. You do not file a claim. The term primary participant refers to the participant whose identification number is used for identification purposes. The primary participant is the retiree, survivor or individual who elected COBRA coverage. Covered family members use the primary participant's identification number to access all medical benefits. Be sure to give identification cards or the primary participant's identification number to your spouse and any covered family members who may live away from home. Note: Family members who elect COBRA coverage must use their own identification number after the date they enroll as a COBRA participant. Refills Too Soon? Refills can be obtained if prescribed and needed. You must have used at least 75% of the previous prescription, based on the dosage prescribed, before you can obtain a refill and receive Plan benefits. Co-Payments For prescription drugs purchased at a participating retail pharmacy, you pay a percentage of the discounted cost of the drugs. Type of Drug: Retail Pharmacy Percentage Co- Payment: Generic drugs 30% Formulary preferred brand name drugs 30% Formulary non-preferred brand name drugs 50%

13 page 12 Examples: Generic drug purchased at a retail network pharmacy discounted cost of medication is $24. You pay 30% co-payment ($24 x.30) = $7.20 Preferred brand name drug purchased at a retail network pharmacy (if no generic is available) cost of medication is $42. You pay 30% co-payment ($42 x.30) = $12.60 Non-preferred brand name drug purchased at a retail network pharmacy (if no generic is available) cost of medication is $64. You pay 50% co-payment ($64 x.50) = $32 Retail Refill Limitation For the third and subsequent refills of a long-term or maintenance drug, which is a drug you take for an extended period of time, such as for ongoing treatment of diabetes, arthritis, a heart condition or high blood pressure, you will pay an additional 25% percentage co-payment. The additional 25% co-payment does not apply to your annual prescription drug out-of-pocket maximum. For example, the percentage co-payment for a generic maintenance drug purchased at a retail network pharmacy is 55%. Cost of a Generic Maintenance Medication Obtained at a Retail Pharmacy $50.00 Cost of generic maintenance drug (30-day supply) Percentage of Co-payment If you purchase the generic maintenance drug at retail $50.00 Cost of generic drug (30-day supply) x 30% Percentage co-payment $15.00 Your percentage co-payment if you purchase the generic on the first fill and next 2 refills If you purchase the drug on the third refill: Your copayment will be $50.00 x 55% = $27.50 The additional $12.50 paid to purchase the third and subsequent refills will not count toward meeting your annual out-of-pocket maximum Retail Pharmacy Percentage Co-Payment for the third and subsequent refill of a long-term maintenance drug: Generic drugs 55% Formulary preferred brand name drugs 55% Formulary non-preferred brand name drugs 75%

14 page 13 Using a Non-Participating Pharmacy or Not Identifying Yourself as a 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 co-payment 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. Full retail cost of preferred brand name prescription (non-discounted) Discounted cost Ineligible cost Ineligible cost 30% co-payment ($40 x.30) Without Express Scripts Discount $ $ $ $ $ With Express Scripts Discount N/A $ $ 0.00 $ Your cost $ $ Long-Term Prescriptions A long-term or maintenance drug is one you take for an extended period of time, such as for ongoing treatment of diabetes, arthritis, heart condition or high blood pressure. The Plan generally provides benefits for up to a 90-day supply through the mail-order prescription service. See page 16 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. Express Scripts Pharmacy Mail-Order Pharmacy With Express Scripts Pharmacy, the mail-order 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 co-payment in an envelope. If you are paying via check or money order, you may obtain a calculation of your percentage co-payment 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 co-payment and you will receive notification of the deduction with your medication.

15 page 14 For each prescription filled, you pay: Type of Drug: Express Scripts Pharmacy Percentage Co-Payment: Generic drugs 25% Preferred brand name drugs 25% Non-preferred brand name drugs 45% Your prescription will be delivered to the address on your order form within 14 working days. By law, prescriptions may not be sent outside the U.S. Refills You may order refills by calling Express Scripts or sending in the refill label provided with your previous order. You may also order refills through Express Scripts web site. You should order a refill about three weeks before your current supply will be exhausted, but remember that you must have used at least 75% of the previous prescription based on the prescribed dosage. Comparing Retail Pharmacy with Express Scripts Pharmacy This example shows how you can save money by purchasing long-term medication through the mail-order pharmacy. Assume you purchase a 90-day supply of a preferred brand name drug: At a Participating Retail Pharmacy: Through Express Scripts Pharmacy: $ Cost of preferred brand name drug (30-day supply) $ Cost of preferred brand name drug (90-day supply) x 30% Percentage co-payment x 25% Percentage co-payment $32.40 Your co-payment for a 30-day supply or $97.20 for a 90-day supply You pay $97.20 for a 90-day supply $81.00 Your co-payment You pay $81.00 for a 90-day supply. By purchasing a 90-day supply of this prescription through mail order, you would save $ That is $64.80 a year for one prescription. Note this example does not include in the calculation the additional 25% co-payment for the third and any subsequent refills from a participating retail pharmacy. Actual savings may be greater. Whether you fill prescriptions through Express Scripts Pharmacy, at a local pharmacy or through Express Scripts Specialty Pharmacy: Your payments and co-payments under the outpatient prescription drug benefits do not apply toward your deductible for other benefits under the Plan. Your prescription drug payments and co-payments 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. Additionally, there is a per prescription out-of-pocket maximum for drugs purchased at retail and through mail order, as shown in the table. The additional cost for purchasing brand-name prescription drugs when a generic is available, in addition to the additional coinsurance charged for purchasing third and subsequent refills of maintenance medications obtained at retail pharmacies, will not count toward your annual out-of-pocket maximum.

16 Retail Per Prescription Out-of-Pocket Maximum (30-day or less supply) page 15 Mail Per Prescription Out-of-Pocket Maximum (Generally 90-day supply Generic $50 $100 Preferred Brand Name Drugs $115 $200 Non-Preferred Brand Name Drugs $170 $300 Covered Prescriptions The Plan covers drugs, medicines and supplies that are: Obtainable only with a physician's prescription or are specifically covered expenses (see Covered Expenses on page 28); Approved by the U.S. Food and Drug Administration for the specific diagnosis; Medically necessary (see page 53); Not experimental or investigational. Generic Drugs The program encourages consideration of generic alternatives, which are less expensive to you and the Plan. About half of all brand name medications have a generic equivalent available. By law, the brand name and generic medications must meet the same standards for safety, purity, strength and effectiveness. The pharmacist will only dispense generics which receive FDA approval and only if authorized by your doctor. Note: If both generic and brand name drugs are available to treat your condition, your percentage co-payment amount will depend on which medication you select. If you purchase the brand name drug, you are responsible for paying the generic drug percentage co-payment PLUS the difference in cost between the generic drug and the brand name drug up to the brand per prescription maximum. This difference in cost will not count toward your annual prescription drug out-of-pocket maximum. Here is an example of how you can save by choosing a generic drug at a retail pharmacy when a brand-name drug is available on the Plan's formulary list of medications. Cost Difference Between Percentage Co-Payment Brand and Generic $ Cost of preferred brand-name drug (30-day supply) $50.00 Cost of generic drug (30-day supply) $ Cost difference If you purchase the generic drug: $50.00 Cost of generic drug (30-day supply) x 30% Percentage co-payment $15.00 Your co-payment if you purchase the generic If you purchase the brand name drug: Your copayment will be $ $50.00 (cost difference) = $65.00 The additional $50 does not count toward your annual prescription drug out-of-pocket maximum.

17 page 16 Available Alternatives Sometimes, a generic drug or a less expensive brand name drug which provides the same therapeutic effect, but at a lower cost to you, may be available. If so, the network system will inform the pharmacist that a less expensive alternative medication is available to fill your prescription. A pharmacist from the network or Express Scripts Pharmacy may contact your doctor to discuss the generic or less expensive brand name alternative. If the doctor authorizes a substitution, the pharmacist will dispense it based solely on your doctor's agreement. If Express Scripts Pharmacy fills a prescription with a generic or an alternative brand name drug, your order will include an explanation of the doctor's change and a credit for any excess co-payment. 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 mail order and retail, are screened by the network's computerized drug monitoring service. This service analyzes all of your prescriptions in the system for potential problems such as adverse drug interactions, drug duplications and unusually high or low dosages. This service will also detect if a refill is requested too soon. If a potential problem is detected, the drug monitoring service transmits a message to the pharmacist. The pharmacist will contact your doctor about the potential problem or otherwise resolve the issue before dispensing the prescription. Of course, your doctor makes the final decision about any change in your prescription or course of treatment. Limitations In most cases, the pharmacist will fill the prescription according to the doctor's written orders. However, there are some limitations: If the prescription is written for an amount that is greater than the Plan covers, the pharmacist will fill the prescription up to the Plan limit. You have the option to buy the additional amount at that time if purchasing at a retail pharmacy, but there is no Plan benefit. If the medicine is a controlled substance or if there is a manufacturer's or prescription benefit manager's directive, a smaller amount may be provided. You must use at least 75% of the prescription, based on the dosage prescribed, before you can obtain a refill and receive Plan benefits. When a Prescription Drug Becomes Available Over the Counter When a prescription medication becomes available over the counter, so that it can be purchased without a prescription, at the same strength and for the same use, it will no longer be covered under the Prescription Drug Program. In addition, other drugs in the same therapeutic class may be excluded from the program, but this determination will be made on a case by case basis, based on available clinical data. Special Rules for Coordinating Benefits for Prescriptions If you or your family members are covered under any other group medical plan, the Plan coordinates benefits with that plan, as described on pages In addition, information about the other coverage is provided to the outpatient prescription drug network.

18 page 17 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 mail-order prescription service). After the primary plan has paid, you may file a claim with the Plan for reimbursement of any remaining amount; the procedure is the same as when a non-participating pharmacy is used. The Plan will pay the lesser of what would have been paid if the claim was not filed with the primary plan or the amount not paid by the primary plan. Medicare Advantage (Part C) Plans, Medicare Part D, and The Prescription Drug Program Participants who choose to enroll in a Medicare Advantage (Part C) plan which provides a Medicare prescription drug benefit or Medicare Part D Prescription Drug Plan will no longer be eligible for outpatient prescription drug coverage under the Plan. If you enroll in a Medicare Part C plan which provides a Medicare prescription drug benefit or Part D program and continue your Plan participation, your required contributions remain the same, but you will not be eligible for outpatient prescription drug benefits under the Plan. Pre-Certification: Preferred DrugStep Therapy Rules You must call Express Scripts for pre-certification 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 proton pump inhibitors, sleep agents, depression, osteoporosis, respiratory, cardiovascular, triptans, growth hormone, stimulants for Attention Deficit Hyperactivity Disorder, prostate therapy drugs, topical steroids, and stroke prevention, there will be targeted drugs determined by Express Scripts which will not be covered unless pre-certified by Express Scripts. Non-targeted drugs will be covered without such authorization and will continue to be dispensed with no further action by either you or the prescribing physician. If you have a question regarding a drug in any of these therapeutic chapters, contact Express Scripts to determine whether your drug is covered. You will be notified directly by Express Scripts if you are affected by these rules. Prior Authorization Rules New prior authorization rules apply to certain therapeutic chapters of drugs; some therapies in this section will be monitored for appropriate pharmacogenomics parameters. These classes are miscellaneous immunological agents, central nervous system/miscellaneous neurological therapy, biotechnology/adjunctive cancer therapy, central nervous system/headache therapy, central nervous system/analgesics, neurology/miscellaneous psychotherapeutic agents, and miscellaneous pulmonary agents. In addition, anabolic steroids, high cost antibiotics, anti-emetics, antivirals, narcotics, acne dermatologicals and topical pain medications may trigger a prior authorization. Oral oncology medications will also be limited to ensure appropriate use. Certain drugs within each chapter as determined by Express Scripts will only be covered to the extent they are authorized by Express Scripts. If you have a question regarding coverage for a drug in any of these therapeutic chapters, contact Express Scripts. You will be notified directly by Express Scripts if you are affected by these rules. Split-Fill Program Express Scripts split fill program applies to certain select specialty conditions where participants often stop or change therapy early in treatment due to side effects or their ability to tolerate treatment. This program will provide smaller initial fills (15-day supply) and clinical support to participants as they begin their therapy. Coinsurance and the per prescription maximum will be applied on a prorated basis so that the participant will not be disadvantaged financially. This program is designed to help manage side-effects, eliminate wasted medications and manage specialty drug costs.

19 About Medicare Supplement Eligibility and Enrollment The Prescription Drug Program Other Plan Provisions - Deductibles - Annual Out-of-Pocket Limit - No Lifetime Limit - Mental Health Treatment - Transition Benefits - Examples - In-Home Skilled-Nursing Care Accepting Assignment Covered Expenses Exclusions Coordination of Benefits Claims Partners in Health Continuation Coverage Administrative and ERISA Information Key Terms Benefit Summary Other Plan Provisions Q. How does the Plan work? A. In addition to outpatient prescription drugs, the Plan covers certain other expenses. You and the Plan share costs for covered treatment and services. You must satisfy an annual deductible before the Plan considers expenses for payment. Once the annual deductible is met, the Plan's reimbursement level - when combined with Medicare - is 80% for the following expenses: covered charges that are paid by Medicare at less than 80%, claims from outside the U.S., and in-home skilled nursing care. The Plan also includes an annual out-of-pocket limit that includes your deductible. If you should meet your annual out-of-pocket limit, the Plan's reimbursement level when combined with Medicare is 100% of most covered charges for the rest of that calendar year. For examples, please see chart on page 57. Deductibles Each year you must meet the deductible before any expenses, other than outpatient prescription drugs, are eligible for reimbursement by the Plan. You may become eligible for the Plan during a year in which you have met part or all of the deductibles under another medical plan to which ExxonMobil contributes. Those amounts apply to your deductible for the Plan, but do not apply to Medicare deductibles. Annual Out-of-Pocket Limit The Plan protects you against most extremely high medical expenses. It does so by limiting your annual out-of-pocket payments for most covered expenses to $3,000 per person. Once you have spent $3,000 for covered expenses (including your deductibles), the Plan's reimbursement level when combined with Medicare is 100% for most covered charges during the remainder of that year. For the year in which you become eligible for the Plan, this limit includes your out-ofpocket amounts for covered expenses while participating in any medical plan to which ExxonMobil contributes.

20 page 19 Certain expenses do not count toward this out-of-pocket limit, including: Your share of the costs of outpatient prescription drugs. Your share of the cost of in-home skilled nursing care. Charges above the Plan's reasonable and customary limits or the Medicare limiting charge. Charges not covered by the Plan, such as the difference in cost between a private and semiprivate hospital room. To receive credit for medical deductibles and out-of-pocket expenses paid under another ExxonMobil plan, attach an explanation of benefits from that plan showing up-to-date information about your expenses when filing your first claim. No Lifetime Limit There is no lifetime maximum for the Plan. Mental Health Treatment Like other types of covered medical expenses where the Plan may provide a benefit even though Medicare does not, the Plan will reimburse 80% of reasonable and customary charges for covered mental health treatment. Medicare only pays for outpatient mental health care and professional services when they are provided by a health care professional who can be paid by Medicare. You should ask your provider if they accept Medicare payment before you schedule treatment. If Medicare does not cover mental health treatment, the Plan will reimburse 80% of reasonable and customary charges. For example, mental health treatment rendered outside the U.S. is not covered by Medicare; however, it is covered under the Plan. Transition Benefits A transition benefit will be provided under the Plan when medically appropriate as determined by Aetna. A transition benefit will be provided: If such medical expenses were covered under a medical plan that was sponsored by ExxonMobil, and the covered person was participating in a medical plan sponsored by ExxonMobil that covered such care immediately prior to the covered person becoming Medicare eligible and moving into the Plan, and expenses for such care are excluded from coverage by Medicare; and a transition benefit request form is submitted to Aetna by the covered person's treating physician.

21 page 20 Examples Example 1 Care in a Skilled-Nursing Facility and the Annual Out-of-Pocket Limit: This example assumes you have met all Medicare and Plan deductibles when, following a period of hospitalization, you enter a Medicare-approved skilled-nursing facility. You remain there 100 days. The facility charges and Medicare approves $300 a day. The total bill is $30,000. It also assumes you have covered out-of-pocket expenses of $900 before you entered the skilled-nursing facility. How the Benefit is Calculated Medicare pays: All of the first 20 days x $300 per day All but $ per day for days ($300 - $157.50) x 80 days $6,000 + $11,400 Total $17,400 The ExxonMobil Plan pays 80% of covered charges minus the amount paid by Medicare: $300 per day x 100 days = $30,000 $30,000 x.80 = $24,000 $24,000 - $17,400 = $ 6,600 The Preliminary Results Medicare pays $17,400 The ExxonMobil Plan pays $ 6,600 You would pay + $ 6,000 Total $30,000 The Actual Results - Applying Your Annual Out-of-Pocket Limit Because the Plan limits your annual out-of-pocket expenses to $3,000, and you had already incurred $900 in out-of-pocket expenses, the $30,000 bill is paid as follows: Medicare pays $17,400 The ExxonMobil Plan pays $ 10,500 You would pay $ 2,100 Total $ 30,000 For skilled-nursing facility services to be considered for payment by the Plan, certain requirements must be met, see page 29.

22 page 21 Example 2 Major Surgery: This example assumes a seven-day hospital stay for major surgery. In addition to hospital charges, there are fees for a surgeon and an anesthesiologist. It also assumes you have not met the Part A deductible but that you have met the Part B and the Plan deductibles and that all providers accept Medicare assignment. Here is what such a procedure might cost: Medicare-approved hospital charges $22,000 Medicare-approved amount for surgeon and anesthesiologist +$1,875 Total Medicare-approved amount $23,875 How the Benefit Is Calculated Medicare pays: All of the Medicare-approved hospital charges except the Part A deductible $22,000 - $1,260 (Part A deductible) = $20,740 80% of surgeon's and anesthesiologist's Medicare-approved amount $1,875 x.80 = $1,500 The Plan starts with the total Medicare-approved amount. 80% of Medicare-approved hospital charges minus Medicare payment $22,000 x.80 = $17,600 $17,600 - $20,740 = $0 80% of surgeon's and anesthesiologist's bills minus Medicare payment $1,875 x.80 = $1,500 $1,500 - $1,500 = $0 You Pay Medicare Part A deductible $1,260 20% of surgeon's and anesthesiologist's bills $1,875 x.20 = $375 Total = $1,635 The Results In this example, the $23,875 in expenses is paid as follows: Medicare pays $ 22,240 The Plan pays $ 0 You pay $1,635 Total $23,875 Of the total charges, Medicare paid 93%, and you paid the remaining 7%. Because Medicare paid more than 80%, the Plan pays $0.

23 page 22 Example 3 Traveling or Living Outside the United States: Medicare does not generally cover medical care received while traveling or living outside the United States. The Plan pays for certain covered expenses at 80% after your annual medical deductible has been met. (See page 37, Expenses Incurred Outside the United States, for more information). In this example, you incur $22,000 in covered medical expenses while vacationing in Europe. How the Benefit is Calculated Medicare does not cover these expenses. The Plan pays 80% of covered charges after you pay the annual $300 deductible. Total medical expenses $22,000 $22,000 - $300 = $21,700 $21,700 x.80 = $17,360 You Pay Plan deductible $300 20% of $21,700 = $4,340 Total = $4,640 The Preliminary Results Medicare pays $ 0 The Plan pays $17,360 You would pay + $4,640 Total $22,000 The Actual Results - Applying Your Annual Out-of-Pocket Limit Because the Plan limits your annual out-of-pocket expenses to $3,000, the bill is paid as follows: Medicare pays $ 0 The Plan pays $19,000 You would pay + $3,000 Total $22,000 See the claims section for information about filing a claim and the Coordination of Benefits section to learn how the Plan coordinates benefits.

24 page 23 In-Home Skilled-Nursing Care With few exceptions, Medicare does not cover skilled-nursing care at home. If you need nursing care at home, there are two types of care one is covered by the Plan and the other is not: Skilled-nursing care is care that only licensed medical professionals can provide. Feeding someone intravenously is an example of skilled-nursing care. This type of care is covered by the Plan but generally not by Medicare. However, Medicare does cover some intermittent short-term service if a homebound patient needs occasional skilled-nursing care but only in limited situations. Custodial care is care which primarily helps people meet personal needs and daily living activities care which does not require the services of a licensed medical professional. Helping someone eat, walk, bathe and dress even if ordered by a physician, and even if performed by a licensed professional are examples of custodial care. Custodial care is not covered by either Medicare or the Plan. A hospital, nursing home or other facility that mainly provides nursing or rehabilitation services cannot be considered your home. If you think you need in-home skilled-nursing care, contact Aetna immediately. Aetna must pre-approve this care. When considering whether nursing care is a covered expense, the critical question is: Does the care require the presence of licensed medical personnel to perform, observe, evaluate or teach? If the answer is no, the Plan does not cover such care. The severity of a patient's condition is not a factor. A patient with an ongoing and steadily deteriorating condition may require constant attention, but may rarely require the services of a licensed medical professional. Only services requiring such a professional are covered. If the answer is yes, the Plan covers in-home skilled-nursing care if you meet these conditions: Care has been approved in advance by Aetna. (See Information Sources at the front of this SPD.) A physician must certify the care is medically necessary. The care given must actually be skilled-nursing care as described on this page. A registered nurse, a licensed practical nurse or a licensed vocational nurse must provide the care. After you meet the Plan's annual deductible, the Plan pays 80% of the reasonable and customary cost of in-home skilled-nursing care with these limits: The Plan covers as much as 24-hour-a-day care for up to 30 days in any calendar year. The Plan covers up to 16 hours a day for as long as the care is needed. None of the money you spend on in-home skilled-nursing care counts toward your annual out-of-pocket limit.

25 page 24 Example 1 In-Home Skilled-Nursing Care: In this example, you have satisfied plan requirements for in-home skilled-nursing care, and you have met the annual deductible. You have not had any other charges for inhome skilled-nursing care during this calendar year. You need such care for four hours a day for 42 days. Assuming this care costs $40 an hour, the daily cost is $160 a day. The cost for 42 days is $6,720. How the Benefit is Calculated Medicare does not pay for this type of service. The Plan pays 80% of covered charges: $160 a day x 42 days = $6,720 $6,720 x.80 = $5,376 You pay 20% of covered charges for four hours of care a day: $6,720 x.20 = $1,344 The Results The $6,720 bill is paid as follows: Medicare pays $0 The Plan pays $5,376 Your share $1,344 None of your share of the cost of in-home skilled-nursing care applies to your annual out-of-pocket limit. The Plan will never pay 100% of in-home skilled-nursing care expenses.