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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	$3,000
Family Annual Out-of-Pocket Limit Including Pharmacy	$6,000
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)
Ambulance	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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