In-network co-pay schedule

Information on the in-network co-pay schedule for the ExxonMobil Retiree Medical HMO - Cigna OAPIN Plan

2017 In-Network co-pay schedule


Benefit percentage/maximums

If you or any one of your Eligible Family Members, while covered, incurs Covered Expenses described below, Cigna will pay an amount determined as follows for the Covered Expenses, after deducting the applicable Participating Provider Service Co-payment shown in The In-Network Co-Pay Schedule:

  • 100% of the Covered Expenses incurred for charges for Emergency Services, provided that:
  • the Emergency Services are received from or pre-authorized by the person's Primary Care Physician; or
  • the Emergency Services are not pre-authorized, but are authorized by the Provider Organization after receipt of timely notice, within 48 hours of admission in the case of Hospital Confinement or as soon as reasonably possible. Before benefits are payable, the applicable Emergency Care Co-payment shown in the In-Network Co-Pay Schedule will be deducted from such Covered Expenses, except that the Emergency Room Co-payment will be waived if the person becomes Confined in a Hospital due to that Injury or Sickness:
  • 100% of any other Covered Expenses incurred for charges made by, or authorized care arranged by, a Participating Provider.
  • 100% of the expenses for mental health and substance abuse treatment
  • 100% of the expenses incurred for vision, hearing and speech screenings provided by the Primary Care Physician for persons age 17 and under.
  • 100% of the expenses incurred for charges made by a Participating Provider for any Vision Care listed in The In-Network Co-Pay Schedule, including basic vision screening, refraction, and tono-metric testing as part of a complete eye examination, but not to exceed the Maximum shown in the In-Network Co-Pay Schedule for such care.
  • 100% of the expenses incurred for charges made by a Participating Provider for: (a) routine care of a newborn child prior to discharge from the Hospital nursery; (b) routine physical examinations; and (c) immunizations.

No Cigna OAPIN option benefits are payable unless the services or supplies are Covered Expenses recommended by and received from, or approved by, Participating Providers and are authorized by the person's Primary Care Physician and the Provider Organization, except in the case of Emergency Services. For Emergency Services from non-participating providers, participants must submit a claim no later than 60 days after the first Emergency Service is provided or as soon as reasonably possible. The claim should contain an itemized statement of treatment, expenses, and diagnosis.  In the case of mental illness or substance abuse treatment, other than Hospital Confinement solely for detoxification, authorization by the Primary Care Physician will be waived.