Index

About Dental

Eligibility and Enrollment

Dental PPO

Covered Expenses

Exclusions

Payments

Claims

Continuation Coverage

Administrative and ERISA Information

Key Terms

Benefit Summary
 

orange square Benefit Summary

Please note: This chart provides only a brief summary of benefits under this Plan. It is not intended to include all ExxonMobil Dental Plan provisions. Non-network benefits are subject to reasonable and customary limits.

Annual Deductible:
  • Individual
  • Family
 $50
$150
Annual Dental Maximum: $2,000 per covered person
Covered Services
Preventive Services: 95% (no deductible)
  • Oral examinations*  
  • Bitewing X-rays*  
  • Prophylaxis and/or Periodontal cleanings (first three cleanings per calendar year)  
  • Fluoride applications*
  • Full mouth or panoramic x-rays (limited to once in any three consecutive years)
  • Tooth sealants 
  • Space maintainers (for children under age 14)  
  • Emergency exams and x-rays (if no other treatment that day)
General Services: 80% after deductible
  • Fillings 
  • Extractions 
  • General anesthetics 
  • Injected antibiotics 
  • Oral surgery (see page 53)
  • Pre-surgery oral exams
  • Periodontics (treatment of gums) 
  • Endodontics (root canals) 
  • Denture and bridge repairs 
  • Periodontal cleanings (fourth and fifth cleanings per calendar year)
Major Services: 50% after deductible
  • Original bridges and dentures
  • Replacement of unserviceable bridges and dentures
  • Crown and gold restorations
Orthodontic Services:** 50% (no deductible)
  • Orthodontia lifetime maximum
 $2,000 per covered person
* Limited to three times each calendar year.
** Orthodontia benefits are paid based on treatment plan, not payment schedule.

Payment for the following oral surgery procedures is coordinated with the patient’s medical plan:

ADA Code Description
D4210 Gingivectomy or Gingivoplasty – 4 or more contiguous teeth or bounded teeth spaces per quadrant
D4211 Gingivectomy or Gingivoplasty - 1 to 3 contiguous teeth or bounded teeth spaces per quadrant
D4220 Gingival curetage
D4240 Gingival flap procedure, including root planning, 4 or more contiguous teeth or bounded teeth spaces per quadrant
D4241 Gingival flap procedure, including root planning, 1-3 teeth per quadrant
D4245 Apically positioned flap
D4250 Muco-gingival surgery, per quadrant
D4260 Osseous surgery, including flap entry and closure, 4 or more teeth or bounded teeth spaces per quadrant
D4263 Bone replacement graft-first site in quadrant
D4264 Bone replacement graft-each additional site in quadrant
D4265 Biological materials to aid in soft & osseous tissue regeneration
D4266 Guided tissue regeneration-resorbable barrier, per site
D4267 Guided tissue regeneration-non-resorbable barrier, per site (includes membrane removal)
D4268 Surgical revision procedure, per tooth
D4270 Pedicle soft graft-per graft
D4271 Free soft tissue grafts-per graft, including donor site
D4273 Subepithelial connective tissue graft procedure, per tooth (includes donor site surgery)
D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area)
D4320 Provisional Splinting-Intracoronal
D4321 Provisional Splinting-Extracoronal
D7220 Removal of impacted tooth, soft tissue
D7230 Removal of impacted tooth, partially bony
D7240 Removal of impacted tooth, completely bony
D7241 Removal of impacted tooth, completely bony with unusual surgical complications
D7260 Oroantral fistula closure
D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth
D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)
D7285 Biopsy of Oral Tissue-Hard
D7286 Biopsy of Oral Tissue-Soft
D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report
D7310 Alveoplasty in conjunction with extractions, per quadrant. (We consider this incidental to the extractions when performed at the same time as extractions and on 4 tooth sockets or less.)
D7320 Alveoplasty not in conjunction with extractions, per quadrant
D7340 Vestibuloplasty-ridge extension (secondary epithelialization)
ADA Code Description
D7350 Vestibuloplasty,- ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue
D7471 Removal of lateral exostosis, maxilla or mandible
D7910 Suture, small wound-up to 5 cm
D7911 Suture, complicated-up to 5 cm
D7912 Suture, complicated-over 5 cm
D7920 Skin graft (identify defect covered and graft location)
D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or facial bones-autogenous or nonautogenous, by report
D7960 Frenulectomy
D7970 Excision of hyperplastic tissue, per arch
D7971 Excision of pericoronal gingival
D7996 Implant-mandible for augmentation purposes (excluding alveolar ridge)
D9220 Deep sedation/general anesthesia-first 30 minutes
D9221 Deep sedation/general anesthesia-each additional 15 minutes
D9241 Intravenous conscious sedation/analgesia-first 30 minutes
D9242 Intravenous conscious sedation/analgesia- each additional 15 minutes

For more information, please contact: Aetna Member Services: (800) 255-2386 or visit www.aetna.com