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2022 Benefits summary

2022 Benefits summary on the ExxonMobil Employee Medical Plan - Aetna Select option

All non-emergency specialty and hospital services require a prior referral from your PCP. Call member services to inquire if a referral is required prior to the services being rendered.

Type of Service or Supply

Benefit Level

Lifetime Maximum

No lifetime maximum

Individual Annual Out-of-Pocket Limit Includes Pharmacy


Family Annual Out-of-Pocket Limit Including Pharmacy


If an employee and one or more eligible family members are covered under this option, after one covered family member meets the individual out-of-pocket maximum, benefits for that individual are payable at 100% by the Plan. Once the family meets the family out-of-pocket maximum, benefits for all covered family members are payable at 100%.

Preventive Care

Preventive Care Office Visits

No charge

One Routine Physicals & Immunizations

No charge

Routine gynecological examinations and PAP smears performed by your PCP. You may also visit a participating gynecologist for a routine GYN exam and PAP smear without a referral

No charge (direct access / no referral)

Routine mammograms for female Plan participants age 35, or over

No charge

Well-child care from birth (including Immunizations and booster doses)

No charge

Prostate Cancer Screening(PSA) and digital exam for males age 40 and over, and for males considered to be at high risk who are under age 40, as directed by physician

No charge

Colorectal cancer screening and at normal risk for developing colon cancer

No charge

Bone mass measurements to determine an individual's risk of osteoporosis

No charge

Routine immunizations (except those required for travel or work)

No charge

Primary Care

Non-routine PCP Office Visits Including Telemedicine

$25 copay per visit

Non-routine home visits by your PCP

Subject to copay

Allergy Treatment- Routine injections at PCP’s office, with or without physician encounter

$25 copay per visit

Hearing Aids

Not covered (See Exclusions section for information about the Amplifon Hearing Health Care (formerly HearPo) Discount Program and the Hearing Care Solutions Discount Program)

Specialty And Outpatient Care

Specialist Office Visits Including Telemedicine

$40 copay per visit

Walk in Clinic (Retail Clinic)

$40 copay per visit

Prenatal Care (applies to standard global maternity services and initial visit)

$40 copay per visit (no referral required)

Maternity (childbirth/delivery services)

90% coverage

Fertility Services authorized by Progyny for in-network benefits

90% coverage

Allergy Testing

$40 co-pay per visit

Imaging (CT/PET scans, MRIs)

90% coverage
some tests may require prior approval by Aetna

Diagnostic X-rays and Outpatient Labs associated with an office visit.

No additional charge

Therapy (speech, occupational, physical)

$40 copay per visit

Chiropractic Care

$40 copay per visit - 20 visits per calendar year

Outpatient Rehabilitation

$40 copay per visit

Home Health Care

90% coverage

Prosthetic Devices
90% coverage
some prostheses must be approved in advance by Aetna

To see a list of procedures that require precertification, please reference the National Precertification List* on the Aetna member website.

Inpatient Services (Precertification required)

Hospital Room and Board and Other Inpatient Services

90% coverage

Skilled Nursing Facilities

90% coverage

Hospice Facility

90% coverage

Surgery and Anesthesia

Inpatient Surgery

90% coverage

Outpatient Surgery

90% coverage

Mental Health and Substance Use Treatment

Office Visit

$25 or $40 copay per visit

Outpatient Services

90% coverage

Inpatient Treatment (including residential treatment centers)

90% coverage

Urgent and Emergency Care

Urgent Care

$60 copay per visit

Emergency Room

$150 copay (waived if admitted)


90% coverage

Prescription Drugs through Express Scripts (No annual maximum benefit)

Annual out-of-pocket maximum

Combined with medical out-of-pocket maximum

Short-term (30-day supply)* **

$15 copay – generic formulary drugs
30% copay – brand-name formulary drugs. $145 maximum per prescription
45% copay – non-formulary drugs. $165 maximum per prescription

Long-term (90-day supply)*

$30 copay – generic formulary drugs
30% copay – brand-name formulary drugs. $145 maximum per prescription
45% copay – non-formulary drugs. $165 maximum per prescription

National Precertification List on the Aetna member website

* 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.

** 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, subsequent refills must be purchased as a 90-day supply at a Smart90 retail pharmacy (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.

*** Formulary 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 Plan’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.

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