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: www.exxonmobilvision.com (https://em.myuhcvision.com/MWP/Landing)

Services shown are limited to once per calendar year.

Service	In network you pay	Non-network you pay *
Comprehensive exam	$0	Anything over $40
Retinal screening photography	$0	100%
Materials	$35 copay	Copay not applicable
Frames • Private practice and retail chain providers	Anything over $150	Anything over $45
Spectacle lenses • Single vision • Bifocals • Trifocals • Lenticular	$0	Anything over: $40 $60 $80 $80
Lens options • Standard scratch resistant coating • Polycarbonate lenses up to age 19 • Tier 1 through 4 Progressives • Tier 1 through 4 Anti-Reflective	$0	100%
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 $0 Anything over $200 $0 if received in conjunction with purchasing formulary contact lenses	Anything over: $200 $210 $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 vision.qualsight.com

* 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.

Print Articles