Index

About Dental

Eligibility and Enrollment

Dental PPO

Covered Expenses

Exclusions

Payments

Continuation Coverage

Administrative and ERISA Information

Key Terms

Benefit Summary

Claims

Q. When must claims be filed?

A. All dental claims must be filed within two years of receiving the services.

Before filing a dental claim, consider whether the expense may be covered under your medical plan. Be sure to read the information under the heading Medical Claims for Dental Work on page 31.

Claims for Non-Network Provider Care

The Plan has contracted with Aetna to process claims. See Information Sources at the front of this SPD for the address and telephone number.

Before visiting a dentist who is not in the Aetna Dental PPO network, obtain a claim form from Aetna, or the ExxonMobil Me, or ExxonMobil Family Web sites for yourself and/or each eligible dependent having work done. Fill out the form with personal data about yourself or your family member. Give the form to the dentist. In many cases, the dentist will file the claim for you. If the dentist returns the form to you, send it and the dentist's itemized bill to Aetna. Keep a copy of the completed form for your records.

Keep these facts in mind when using the Plan:

• Most dentists expect payment in full for services at the time the work is done, and
• When you file a claim form, benefits will be sent to you unless you specifically indicate that Aetna should pay the dentist directly.

In order to be reimbursed under the Plan, claims must be received by Aetna within two years from the date the expense was incurred. It is the participant's responsibility to ensure that claims are filed in a timely manner. If you or your dental provider submits claims past the claim filing deadline, those claims will not be covered by the Plan. You may be responsible for payment.

Explanation of Benefits

Aetna will send you an explanation of benefits (EOB) for each claim. The EOB will show what service was performed, how much the dentist charged, and what the covered charge is under the Plan. It shows if a deductible or co-payment was involved as well as the calculation used to determine your benefit.

You can view your EOBs online by signing up for Aetna Navigator^TM. Just go to the Aetna Navigator Web site at www.AetnaNavigator.com and follow the instructions.

Claim Denial and Reconsideration

If all or part of a claim is denied, Aetna will provide you with a written explanation, including the reason for the denial. See the Administrative and ERISA Information section in this SPD.

Claims Outside the United States

To receive dental care when traveling or working outside the United States, generally you must pay the dental bills first. For reimbursement, submit a claim form and an itemized bill. If the original bills are in a foreign language, you should obtain an English translation, if possible, of the services rendered.

Bills should be submitted in the appropriate foreign currency. The claims administrator (Aetna) will convert the bill to U.S. dollars as of the date of processing.

Right of Reimbursement

If your claim results from an accident that is the fault of another party, you must reimburse any amount paid by the Plan that you recover from the responsible party. The Plan does not require reimbursement from any personal insurance you may carry, such as medical coverage under your automobile insurance. If you recover money from the responsible party (or that party's insurance coverage), your failure to reimburse the Plan for the amount it paid may result in loss of eligibility to participate in the Plan for you and your otherwise eligible dependents.

Coordination of Benefits

If you are covered by more than one group dental plan, you are entitled to coverage from all plans in which you participate, but not to the extent that you collect more than 100% of the amount of the allowable charges. However, if you or a dependent are covered under an individual plan, the coordination of benefits provision does not apply.

One of the plans covering you is considered the primary plan. Claims must be filed first with the primary plan. After the primary plan pays, file the claim with the secondary plan, including a copy of the bills and an explanation of benefits including the amount paid by the primary plan.

Example:
If you, as an employee, are covered by this Plan, then this Plan is primary for you. If your spouse is covered by another dental plan and you are covered under that plan, then your spouse's plan is secondary for you. Also, if your spouse is covered by their employer's dental plan and this Plan, his or her plan is primary and this Plan is secondary.

This Plan is primary for retirees who are not working, regardless of other coverage under a spouse's plan.

The primary plan always pays benefits first, without considering the other plan. The secondary plan then pays based on its provisions — up to the total allowable expenses covered by that plan or up to the total of all covered expenses.

Coverage of a Dependent Child

When a dependent child is covered under both parents' plans, the "birthday rule" is used; the plan of the parent whose birthday occurs earlier in the year is the primary plan. The other parent's plan is secondary. If both parents have the same birthday or your spouse's plan has not adopted the birthday rule, the ExxonMobil Dental Plan will consider the plan which has covered the dependent child longer as primary.

There are special rules for children of divorced or separated parents. Unless specifically ordered otherwise by a court decree, the plan of the parent with custody, if he or she has not remarried, is primary and the plan of the non-custodial parent is secondary. If the parent with custody remarries, that parent's plan is primary, the stepparent's plan is secondary and the plan of the non-custodial parent is last.

Retirees Covered by Two Plans

If a retiree covered by the Plan obtains a full-time job in which he or she is covered by the new employer's dental plan, that plan becomes the primary plan and this Plan is secondary.

When the retiree leaves the last employer, the plan in which the retiree was covered for the longer period becomes the primary plan and the other plan is secondary.

Medicare As Primary
If you become entitled to Medicare, Medicare is assumed to be the primary plan except in the following circumstances:

• Medicare is secondary for employees and dependents age 65 or older who are covered by the Plan through their current employment or the current employment of a spouse.
• Medicare is secondary for employees and dependents under age 65 who are entitled to Medicare on the basis of permanent disability who are covered under the Plan either through their current employment or the current employment of a family member.
• Medicare is secondary for 30 months for employees and dependents under age 65 who are entitled to Medicare solely on the basis of end stage renal disease (ESRD) who are covered under the Plan as a result of current or former employment of the employee or dependent. In the event an employee or dependent who is entitled to Medicare on account of ESRD becomes eligible on account of age or disability, Medicare will remain secondary for the duration of the 30-month coordination of benefits period.

Payments
If payment for covered dental expenses should have been made under this Plan, but has been made under any other plan, any insurance company or other organization may be reimbursed an amount the Administrator-Benefits determines will satisfy the intent of coordination of benefits provisions. That amount will be considered to be benefits paid under this Plan and shall fully discharge any obligation to make such payments.

Medical Claims for Dental Work

Some medical plans cover certain dental procedures by a dentist or oral surgeon. Dental procedures that may be covered by your medical plan include:

• Drugs prescribed by your dentist (would be covered by your prescription plan).
• Treatment of fractures or dislocations of the jaw.
• Treatment of teeth and surrounding tissue damaged due to an injury sustained while covered by the Plan.
• Certain cutting procedures in the mouth.

For information on which procedures performed by a dentist or oral surgeon may be considered to be medical in nature, please review the oral surgery grid on page 53 or contact Aetna Member Services.

If you incur such charges, file your claim for medical benefits first. If more than one group medical plan is involved, make sure you have submitted the claim to every group medical plan before submitting for dental claim processing.

After all the medical plans have responded, submit a dental claim form with the medical EOB form(s) explaining the determination of benefits under the medical plan(s), along with a copy of your bill, to Aetna.

This process enables you to maximize all benefits available to you under your medical plan(s) and the ExxonMobil Dental Plan.

If you participate in the ExxonMobil Medical Plan POS II option, you do not need to file again with the ExxonMobil Dental Plan. Your claim will be processed with no further action required on your part.

If you are an employee who participates in the ExxonMobil Pre-Tax Spending Plan Health Care Flexible Spending Account, Aetna will automatically process any eligible expenses remaining from your dental claim and send you the spending account reimbursement, if any. This means that, in most cases, you will not need to file a separate pre-tax claim form.