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Benefits Summary
Benefits Summary for the ExxonMobil Employee Medical Plan - Cigna OAPIN Network Only option
2021 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 |
| Prostate Cancer Screening | No charge |
| Physician Services | |
| Telemedicine Consultation, using Cigna designated telemedicine providers | $25 copay |
| Primary Care Physician Office Visit | $25 co-pay |
| Routine Physicals & Immunizations (Hearing Exams) | $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 visits per contract year for any combination of 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 |
| Family Planning | |
| Preventive Family Planning Services (office visits, lab and radiology tests, counselling, contraceptive devices, tubal ligation; excludes reversals) | No charge |
| 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 Treatment authorized by Progyny for in-network benefits | 90% coverage, up to the out-of-pocket maximum |
| Inpatient Facility authorized by Progyny for in-network benefits | 90% coverage, up to the out-of-pocket maximum |
| Outpatient Facility authorized by Progyny for in-network benefits | 90% coverage, up to the out-of-pocket maximum |
| Physician's Services authorized by Progyny for 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 | $200 deductible, then 100% up to a $1,000 per Contract Year 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 - Preferred Brand Non-Preferred Brand |
20% co-insurance per prescription order |
|
Home Delivery Drugs/90 day supply - No coverage for Injectable Infertility Drugs Preferred Brand Non-Preferred Brand |
20% coinsurance per prescription order |
| Mental Health and Substance Abuse Benefits | |
| Telemedicine Behavioral Health Consultation using Cigna designated telemedicine provider |
$25 copay |
| Individual, Family or Group Therapy Office Visit | $40 copay |
| 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%. | |