Benefit summary

Benefit summary of the ExxonMobil Vision Plan

Please note: This chart provides only a brief summary of benefits under the ExxonMobil Vision Plan. They are not intended to include all provisions.

ExxonMobil Vision Plan
Summary of Benefits

Service Area: Unites States
Group Number: 928104
Member Services: 877-303-2415
Provider Website: (


Services shown are limited to once per calendar year.


In network you pay

Non-network you pay *

Comprehensive exam


Anything over $40

Retinal screening photography




$35 copay

Copay not applicable

• Private practice and retail chain providers

over $150

over $45

Spectacle lenses
• Single vision
• Bifocals
• Trifocals
• Lenticular


Anything over:

Lens options
• Standard scratch resistant coating
• Polycarbonate lenses up to age 19
• Tier 1 through 4 Progressives • Tier 1 through 4 Anti-Reflective



Contact lenses (in lieu of eyeglassses)

• Formulary contact lenses
• Medically necessary contact lenses
• Non-Formulary contact lenses • Contact lenses fit & evaluation


$0 for up to 8 boxes
Anything over $200 $0 if received in conjunction with purchasing formulary contact lenses

Anything over:

$200 100%

Laser Vision Correction

Laser Surgery: UnitedHealthcare partners with QualSight LASIK to provide our members with access to discounted laser vision correction providers. Member savings represent up to 35% off

the national average price of Traditional LASIK. For more information, visit

* In the “Non-network you Pay”, the member will still have to pay up front the full out of pocket amount for out of network services and then seek reimbursement for the amounts covered as detailed above. For example, on the comprehensive exam, member pays all out of pocket and then requests reimbursement of up to $40.