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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 -
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 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%. 

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