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 2023 Summary of Benefits
Service Area: Unites States Group Number: 928104 Member Services: 877-303-2415 Provider Website:www.exxonmobilvision.com

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 • Premium progressive tier I through IV • Anti-reflective tier I through IV	$0	100%
Contact lenses(in lieu of eyeglasses) • Covered-in-full elective contact lenses • Medically necessary contact lenses • All other elective contact lenses	$0 $0 Anything over $200	100% Anything over $210 Anything over $200

* 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