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2023 Benefits summary

ExxonMobil Employee Medical Plan – Cigna OAPIN Network Only option

2023 In-Network benefits schedule

In-Network Benefits	How this Plan Works
Preventive Services
Preventive Care Office Visit	No charge
Routine Physicals & Immunizations	No charge
Well Woman Care (including Pap Test)	No charge
Mammograms	No charge
Well Baby Care (including Immunizations)	No charge
Preventive Screenings (including Basic Lab Tests, Mammography, Colorectal/Prostate Cancer)	No charge
Physician Services
Telemedicine Consultation, using Cigna designated telemedicine providers	Urgent Care - $25 copay MDLIVE PCP - $25 copay MDLIVE Behavioral - $25 copay MDLIVE Specialist - $40 copay MDLIVE Wellness - No Charge
Primary Care Physician Office Visit	$25 co-pay
Specialty Care Physician Office Visit	$40 co-pay
Surgery Performed in the Physician's Office	No charge after the $25 PCP or $40 Specialist copay
Allergy Treatment/Injections	No charge after either the office visit copay or the actual charge, whichever is less
Inpatient Hospital - Facility Services
Semi Private Room and Board	90% coverage up to the out-of-pocket maximum
Private Room	90% of the Hospital's negotiated rate for a semi-private room, up to the out-of-pocket maximum, then 100% of the Hospital’s negotiated rate for semi-private room
Special Care Units (ICU/CCU)	90% coverage, up to the out-of-pocket maximum
Operating Room, Recovery Room, Oxygen Anesthesia and Respiratory/Inhalation Therapy	90% coverage, up to the out-of-pocket maximum
Inpatient Professional Services
Anesthesiologists	90% coverage, up to the out-of-pocket maximum
Radiologists, Pathologists	90% coverage, up to the out-of-pocket maximum
Surgeon	90% coverage, up to the out-of-pocket maximum
Assistant Surgeon or Co-Surgeon	90% coverage, up to the out-of-pocket maximum
Physician Visit	90% coverage, up to the out-of-pocket maximum
Nursing Care	90% coverage, up to the out-of-pocket maximum
Mastectomy and Breast Reconstruction	90% coverage, up to the out-of-pocket maximum
Diagnostic and Therapeutic Laboratory and X-ray	90% coverage, up to the out-of-pocket maximum
Hemodialysis	90% coverage, up to the out-of-pocket maximum
Radiation Therapy and Chemotherapy	90% coverage, up to the out-of-pocket maximum
Organ Transplant Services	90% coverage, up to the out-of-pocket maximum
Outpatient Facility Services
Operating Room, Recovery Room, Procedure Room, and Treatment	90% coverage, up to the out-of-pocket maximum
Outpatient Professional Services
Anesthesiologists and Respiratory/Inhalation Therapy	90% coverage, up to the out-of-pocket maximum
Radiologists, Pathologists	90% coverage, up to the out-of-pocket maximum
Surgeon	90% coverage, up to the out-of-pocket maximum
Assistant Surgeon or Co-Surgeon	90% coverage, up to the out-of-pocket maximum
Physician Visit/Charges for Outpatient Surgery	90% coverage, up to the out-of-pocket maximum
Hemodialysis	90% coverage, up to the out-of-pocket maximum
Mastectomy and Breast Reconstruction	90% coverage, up to the out-of-pocket maximum
Diagnostic and Therapeutic Laboratory and X-ray	90% coverage, up to the out-of-pocket maximum
Radiation Therapy and Chemotherapy	90% coverage, up to the out-of-pocket maximum
Emergency and Urgent Care Services
Telemedicine Consultation, using Cigna designated telemedicine providers	$25 copay
Urgent Care Facility	$60 copay
Free-Standing ER or Outpatient Facility	$150 copay
Hospital Emergency Room	$150 copay, Waived if admitted
Ambulance	90% coverage, up to the out-of-pocket maximum
Independent Lab Services
Physician's Office	No Charge after office visit copay
Lab Facility	90% coverage, up to the out-of-pocket maximum
Hospital Outpatient	90% coverage, up to the out-of-pocket maximum
Skilled Nursing
Facility Services	90% coverage, up to the out-of-pocket maximum
Skilled Nursing Room and Board	90% coverage, up to the out-of-pocket maximum
Contract Year Maximum: 60 Days Also including Rehabilitation Hospitals and Sub-Acute Facilities
Home Health Care
Contract Year Maximum: Unlimited	90% coverage, up to the out-of-pocket maximum
Hospice
Inpatient	90% coverage, up to the out-of-pocket maximum
Outpatient	90% coverage, up to the out-of-pocket maximum
Rehabilitative Therapy (including Speech, Occupational, Physical, Chiropractic, Pulmonary, Cardiac and Cognitive Therapy)
Inpatient	90% coverage, up to the out-of-pocket maximum
Maximum of 60 days per contract year for any combination of outpatient therapies (unlimited for covered mental health conditions including autism spectrum disorder and other developmental delays)	$40 copay
Maternity
Initial Visit to Confirm Pregnancy	$25 PCP or $40 Specialist copay
Subsequent Visits (Pre-Natal, Post-Natal, Physician’s Delivery Charges subject to global maternity fee)	90% coverage, up to the out-of-pocket maximum
Office Visits in addition to the global maternity fee when performed by an OB/GYN or Specialist	$25 PCP or $40 Specialist copay
Delivery (Inpatient Hospital, Birthing Center)	90% coverage, up to the out-of-pocket maximum
Women’s Family Planning
Preventive Family Planning Services (office visits, lab and radiology tests, counselling, contraceptive devices, tubal ligation; excludes reversals)	No charge
Men’s Family Planning
Office Visit	$25 PCP or $40 Specialist copay
Surgical Treatment:(includes Vasectomy; excludes Reversals):	90% coverage, up to the out-of-pocket maximum
Inpatient Facility	90% coverage, up to the out-of-pocket maximum
Outpatient Facility	90% coverage, up to the out-of-pocket maximum
Physician's Services	90% coverage, up to the out-of-pocket maximum
Fertility Services
Office Visit	$25 PCP or $40 Specialist copay
Surgical Treatmentauthorized by Progynyfor in-network benefits	90% coverage, up to the out-of-pocket maximum
Inpatient Facilityauthorized by Progynyfor in-network benefits	90% coverage, up to the out-of-pocket maximum
Outpatient Facilityauthorized by Progynyfor in-network benefits	90% coverage, up to the out-of-pocket maximum
Physician's Servicesauthorized by Progynyfor in-network benefits	90% coverage, up to the out-of-pocket maximum
Lifetime Maximum: Surgical treatment limited to 2 “smart cycles” as defined and authorized by Progyny (3 cycles if required for first pregnancy)
Durable Medical Equipment
Contract Year Maximum: Unlimited	90% coverage, up to the out-of-pocket maximum
External Prosthetic Appliances	90% coverage, up to the out-of-pocket maximum
Diabetes Services
Diabetes Management Medical Equipment - including blood glucose monitors, monitors designed to be used by blind individuals; insulin pumps and associated appurtenances; insulin infusion devices; and podiatric appliances for the prevention of complications associated with diabetes.	90% coverage, up to the out-of-pocket maximum
Diabetes Supplies - including test strips for blood glucose monitors, visual reading and urine test strips, lancets and lancet devices, insulin and insulin analogs, injection aids, syringes, prescriptive and non-prescriptive oral agents for controlling blood sugar levels, and glucagon emergency kits.	Same as Prescription Drug Copayment
Pharmacy Benefits
The designation of a prescription drug as Generic, Preferred Brand or Non-Preferred Brand is per generally accepted industry sources and adopted by Cigna.
Preventive Care Prescription Drugs – Including contraception and other medications as provided for by applicable law	No charge
Retail Prescription Drugs/30 day supply - No coverage for Injectable Infertility Drugs Generic Preferred Brand* Non-Preferred Brand*	20% co-insurance per prescription order or refill. The maximum co-pay is $105 per prescription. 30% co-insurance per prescription order or refill. The maximum co-pay is $125 per prescription. 45% co-insurance per prescription order or refill. The maximum copay is $135 per prescription.
Home Delivery Drugs/90 day supply - No coverage for Injectable Infertility Drugs Generic Preferred Brand* Non-Preferred Brand*	20% coinsurance per prescription order or refill. The maximum copay is $155 per prescription. 30% co-insurance per prescription order or refill. The maximum co-pay is $175 per prescription. 45% coinsurance per prescription order or refill. The maximum copay is $200 per prescription
Mental Health and Substance Use Disorder Benefits
Telemedicine Behavioral Health Consultation using Cigna designated telemedicine provider	$25 copay
Individual, Family or Group Therapy Office Visit	$25.00 Primary Care: Psychologist/psychiatrist counseling/services, $40.00 Specialist: Habilitative / rehabilitative services
Inpatient Treatment – includes Hospital, Residential Treatment Facilities, and Partial Hospitalization	90% coverage, up to the out-of-pocket maximum
Intensive Outpatient Treatment – includes Applied Behavior Analysis (ABA) for Autism Spectrum Disorder	90% coverage, up to the out-of-pocket maximum
Home Health Services – includes ABA for Autism Spectrum Disorder	90% coverage, up to the out-of-pocket maximum
Annual Out of Pocket Maximum
Individual Out of Pocket Maximum	$3,000
Family Out of Pocket Maximum	$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%.

*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 may be contacted by Cigna and asked if you would like to enroll in the program. If you choose not to enroll in the program, a 30% coinsurance with no maximum, and any amount you pay will not count towards your Deductible or Out-of-Pocket Maximums.

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