Healthcare forms and useful links

Health and Dependent Care Flexible Spending Account Claim Form
Please note that Aetna supports the Flexible Spending Account reimbursement process for all options under the ExxonMobil Medical Plan and ExxonMobil International Medical and Dental Plan. Participants in Cigna OAPIN, Cigna International Medical and Dental Plan, and Aetna POS and Aetna Select options should all utilize this form.

The following IRS Publications located on the irs.gov website:

• IRS Publication 502 - Medical and Dental Expenses
• IRS Publication 503 - Child and Dependent Care Expenses
• IRS Publication 2441 - Instructions for Child and Dependent Care Expenses
• IRS Form 2441 - Child and Dependent Care Expenses

Vision

U.S. Expats & Rotators mail order anti-malarials

ExxonMobil Malaria Chemoprophylaxis Prescription Fax Order Form

• Word document (you can edit, save and attach to an e-mail)
• PDF document(you can print, write on changes, bring or mail to prescriber - changes cannot be saved)

Medical information and disclosure

Affordable Care Act

Under the Affordable Care Act, you may receive one or more Forms 1095.

Form 1095-C from ExxonMobil

• Full-time employee (during any time of the year) - Yes
• Non-full-time employees - Only if enrolled in any of the following plans options:
• POS II
• Aetna Select
• Cigna OAPIN
• OE students - No

Form 1095-B from insurance carrier

• Full-time employee (during any time of the year) - n/a
• Non-full-time employees - Only if enrolled in any of the following plans options:
• HMO Illinois, Blue Cross/Blue Shield - Chicago
• OE students - No

By January 31, a Form 1095 will be mailed to your address on record. It will contain information about the offer of health coverage, who was covered, and when, for the previous calendar year. While the information on this form may assist in preparing a federal tax return, it is not required. Form 1095 can be kept with your tax records.