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2023 Benefits summary

2023 Benefits summary on the ExxonMobil Employee Medical Plan – Open Access Aetna Select option

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 as recommended by the USPSTF

Preventive Care Office Visits

No charge

Routine Physicals & Immunizations

No charge

Routine gynecological examinations and PAP smears performed by a participating PCP or a participating gynecologist

No charge

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 after age 45 or for high risk patients

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-routinePCP Office Visits Including Telemedicine

$25 copay per visit

Non-routinehome visits by your PCP

90 % coverages

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)

$4025 copay per visit

Maternity (childbirth/delivery services)

90% coverage

Fertility Servicesauthorized by Progynyfor in-network benefits

90% coverage

Allergy Testing

$40 copay 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 Disorder Treatment*

Office Visit

$25 copay per visit

Habilitative and rehabilitative therapy for a diagnosis of autism, developmental disorder, or attention deficit disorder

$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

MinuteClinic®walk-in visit

100% coverage

Participating CVS/Target MinuteClinics

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% coinsurance – brand-name formulary drugs ($125 maximum per prescription)
50% coinsurance – non-formulary drugs ($200 maximum per prescription)

Long-term (90-day supply)*

$30 copay – generic formulary drugs
25% coinsurance – brand-name formulary drugs ($200 maximum per prescription)
50% coinsurance – non-formulary drugs ($400 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 and is included in the drug list linked here, 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, a 30% coinsurance with no maximum will apply, and any amount you pay will not count towards your deductible or out-of-pocket maximums.

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