2017 Co-payment schedule

Co-payment schedule for the ExxonMobil Retiree Medical HMO - Aetna Select Plan

All non-emergency specialty and hospital services require a prior referral from your PCP. Call member services to inquire if a referral is required prior to the services being rendered.

National Precertification List on the Aetna member website

* If your doctor prescribes a brand name drug for which a generic equivalent is available, you will be responsible for paying the generic copay and the difference in the cost between the brand name and the generic equivalent. The difference in the cost between the brand and the generic does not apply to the annual out-of-pocket maximum for prescription drugs.

** Maintenance medications will be covered for three fills at a retail pharmacy. You will be responsible for 100% of the cost of subsequent fills at a retail pharmacy. Any refill submitted to the Express Scripts mail order pharmacy will be subject to the mail order pharmacy copayments.