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%. |