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Benefit Summary
Information on the Benefit Summary for the ExxonMobil Retiree Medical Plan - Cigna OAPIN Network Only option
2023 In-Network Benefit Summary
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In-Network Benefits |
How this Plan Works |
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Preventive Services |
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Preventive Care Office Visit |
No charge |
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Routine Physicals & Immunizations |
No charge |
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Well Woman Care (including Pap Smear Test) |
No charge |
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Mammograms |
No charge |
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Well Baby Care (including Immunizations) |
No charge |
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Preventive Screenings (including Basic Lab Tests, Mammography, Colorectal/Prostate Cancer) |
No charge |
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Physician Services |
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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 |
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Primary Care Physician Office Visit |
$25 copay |
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Specialty Care Physician Office Visit |
$40 copay |
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Surgery Performed in the Physician's Office |
No charge after the $25 PCP or $40 Specialist copay |
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Allergy Treatment/Injections |
No charge after either the office visit copay or the actual charge, whichever is less |
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Inpatient Hospital - FacilityServices |
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Semi Private Room and Board |
90% coverage up to the out-of-pocket maximum |
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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 |
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Special Care Units (ICU/CCU) |
90% coverage, up to the out-of-pocket maximum |
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Operating Room, Recovery Room, Oxygen Anesthesia and Respiratory/Inhalation Therapy |
90% coverage, up to the out-of-pocket maximum |
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Inpatient Professional Services |
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Anesthesiologists |
90% coverage, up to the out-of-pocket maximum |
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Radiologists, Pathologists |
90% coverage, up to the out-of-pocket maximum |
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Surgeon |
90% coverage, up to the out-of-pocket maximum |
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Assistant Surgeon or Co-Surgeon |
90% coverage, up to the out-of-pocket maximum |
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Physician Visit |
90% coverage, up to the out-of-pocket maximum |
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Nursing Care |
90% coverage, up to the out-of-pocket maximum |
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Mastectomy and Breast Reconstruction |
90% coverage, up to the out-of-pocket maximum |
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Diagnostic and Therapeutic Laboratory and X-ray |
90% coverage, up to the out-of-pocket maximum |
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Hemodialysis |
90% coverage, up to the out-of-pocket maximum |
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Radiation Therapy and Chemotherapy |
90% coverage, up to the out-of-pocket maximum |
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Organ Transplant Services |
90% coverage, up to the out-of-pocket maximum |
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Outpatient Facility Services |
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Operating Room, Recovery Room, Procedure Room, and Treatment |
90% coverage, up to the out-of-pocket maximum |
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Outpatient Professional Services |
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Anesthesiologists and Respiratory/Inhalation Therapy |
90% coverage, up to the out-of-pocket maximum |
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Radiologists, Pathologists |
90% coverage, up to the out-of-pocket maximum |
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Surgeon |
90% coverage, up to the out-of-pocket maximum |
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Assistant Surgeon or Co-Surgeon |
90% coverage, up to the out-of-pocket maximum |
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Physician Visit/Charges for Outpatient Surgery |
90% coverage, up to the out-of-pocket maximum |
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Hemodialysis |
90% coverage, up to the out-of-pocket maximum |
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Mastectomy and Breast Reconstruction |
90% coverage, up to the out-of-pocket maximum |
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Diagnostic and Therapeutic Laboratory and X-ray |
90% coverage, up to the out-of-pocket maximum |
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Radiation Therapy and Chemotherapy |
90% coverage, up to the out-of-pocket maximum |
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Emergency and Urgent Care Services |
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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 |
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Urgent Care Facility |
$60 copay |
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Free-Standing ER or Outpatient Facility |
$150 copay |
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Hospital Emergency Room |
$150 copay* *Waived if admitted |
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Ambulance |
90% coverage, up to the out-of-pocket maximum |
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Independent Lab Services |
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Physician's Office |
No Charge after office visit copay |
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Lab Facility |
90% coverage, up to the out-of-pocket maximum |
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Hospital Outpatient |
90% coverage, up to the out-of-pocket maximum |
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Skilled Nursing |
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Facility Services |
90% coverage, up to the out-of-pocket maximum |
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Skilled Nursing Room and Board |
90% coverage, up to the out-of-pocket maximum |
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Contract Year Maximum: 60 Days including Rehabilitation Hospitals and |
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Home Health Care |
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Home Health Care Services |
90% coverage, up to the out-of-pocket maximum |
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Hospice |
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Inpatient |
90% coverage, up to the out-of-pocket maximum |
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Outpatient |
90% coverage, up to the out-of-pocket maximum |
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Rehabilitative Therapy (including Speech, Occupational, Physical, Chiropractic, Pulmonary, Cardiac and Cognitive Therapy) |
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Inpatient |
90% coverage, up to the out-of-pocket maximum |
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Maximum of 60 days per contract year for any combination of outpatient therapies |
$40 copay |
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Maternity |
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Initial Visit to Confirm Pregnancy |
$25 PCP or $40 Specialist copay |
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Subsequent Visits (Pre-Natal, Post-Natal, Physician’s Delivery Charges subject to global maternity fee) |
90% coverage, up to the out-of-pocket maximum |
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Office Visits in addition to the global maternity fee when performed by an OB/GYN or Specialist |
$25 PCP or $40 Specialist copay |
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Delivery (Inpatient Hospital, Birthing Center) |
90% coverage, up to the out-of-pocket maximum |
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Women’s Family Planning |
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Preventive Family Planning Services (office visits, lab and radiology tests, counselling, contraceptive devices, tubal ligation; excludes reversals) |
No charge |
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Men’s Family Planning |
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Office Visit |
$25 PCP or $40 Specialist copay |
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Surgical Treatment:(includes Vasectomy; excludes Reversals): |
90% coverage, up to the out-of-pocket maximum |
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Inpatient Facility |
90% coverage, up to the out-of-pocket maximum |
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Outpatient Facility |
90% coverage, up to the out-of-pocket maximum |
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Physician's Services |
90% coverage, up to the out-of-pocket maximum |
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Durable Medical Equipment |
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Contract Year Maximum: Unlimited |
90% coverage, up to the out-of-pocket maximum |
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External Prosthetic Appliances |
90% coverage, up to the out-of-pocket maximum |
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Diabetes Services |
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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 |
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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 |
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Pharmacy Benefits |
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The designation of a prescription drug as Generic, Preferred Brand or Non-Preferred Brand is per generally accepted industry sources and adopted by Cigna. |
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Retail Prescription Drugs/30 day supply |
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Generic |
20% coinsurance per prescription order or refill. The maximum copay is $105 per prescription. |
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Preferred Brand* |
30% coinsurance per prescription order or refill. The maximum copay is $125 per prescription. |
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Non-Preferred Brand* |
45% coinsurance per prescription order or refill. The maximum copay is $135 per prescription. |
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Participating Retail, or Cigna Home Delivery Prescription Drugs/90 day supply |
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Generic |
20% coinsurance per prescription order or refill. The maximum copay is $155 per prescription. |
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Preferred Brand* |
30% coinsurance per prescription order or refill. The maximum copay is $175 per prescription. |
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Non-Preferred Brand* |
45% coinsurance per prescription order or refill. The maximum copay is $200 per prescription. |
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Mental Health and Substance Use Disorder Benefits |
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Telemedicine Behavioral Health Consultation using Cigna designated telemedicine provider |
$25 copay |
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Individual, Family or Group Therapy Office Visit |
$25.00 Primary Care: Psychologist/psychiatrist counseling/services, $40.00 Specialist: Habilitative / rehabilitative services |
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Inpatient Treatment – includes Hospital, Residential Treatment Facilities, and Partial Hospitalization |
90% coverage, up to the out-of-pocket maximum |
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Intensive Outpatient Treatment |
90% coverage, up to the out-of-pocket maximum |
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Annual Out-of-Pocket Maximum |
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Individual Out-of-Pocket Maximum |
$3,000 |
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Family Out-of-Pocket Maximum |
$6,000 |
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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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*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.