Index

About Dental

Eligibility and Enrollment

Dental PPO

Covered Expenses
- Preventive Services
- Emergency Treatment
- General Services
- Major Services
- Orthodontic Services

Exclusions

Payments

Claims

Continuation Coverage

Administrative and ERISA Information

Key Terms

Benefit Summary

 

orange square Covered Expenses

Q. What types of dental services are covered by the Plan?

A. The Plan divides dental services into four categories:

For all coverage, benefits are payable only for charges up to the reasonable and customary amount for similar services and supplies in the area. PPO dentists' charges are always within the reasonable and customary amount (see page 26).

To be covered, an expense must be incurred by a plan participant for preventive dental care or for the care and treatment of dental disease or accidental injury and such service or treatment must be:

An expense or charge is generally considered incurred on the date the service is provided, with these exceptions:

  • Fixed bridges, crowns, inlays, onlays, or gold restorations are considered incurred on the first day of preparation of the tooth or teeth involved.
  • Full or partial dentures are considered incurred on the date the impression is taken.
  • Endodontics are considered incurred on the date the tooth is opened for root canal therapy.
  • Dental implants are considered incurred on the date the cap is placed on the post and not when the post is inserted. In some cases, dental implant costs are subject to an Alternative Course of Treatment limitation (see page 26).

orange square Preventive Services

To promote oral health and improve overall health of participants, the Plan pays 100%, or as otherwise specified, of covered charges for the following preventive services with no deductible:

  • Diagnostic oral examinations and periodic oral prophylaxis (limited to three times each calendar year).
  • Diagnostic supplementary (bite-wing) x-rays (limited to three times each calendar year).
  • Following comprehensive periodontal therapy, a total of up to 5 cleanings (treatments) will be covered in a calendar year. The cleanings can be either all periodontal or some combination of periodontal and prophylaxis, provided that of the five total cleanings, no more than three are for prophylaxis in a calendar year. The first three cleanings, whether periodontal or prophylaxis, are covered at 100% of covered charges and the additional fourth and fifth cleanings are covered at 80% of covered charges. Periodontal treatments will be covered each calendar year, without additional periodontal therapy, if a continuing need is determined through the clinical evaluation of the dentist.
  • Topical stannous fluoride application (limited to three times each calendar year).
  • Diagnostic full-mouth or panoramic x-rays* (limited to once in any three consecutive years).
  • Space maintainers and their insertion (limited to treatment for a covered dependent under age 14).
  • Tooth sealants applied to a permanent molar (limited to one application per tooth in any three consecutive years).

* Limitation does not apply to orthodontia treatment

orange square Emergency Treatment

The Plan also pays 100% of reasonable and customary covered charges for diagnostic x-rays and examination charges for emergency office visits. However, if you incur charges for emergency treatment on a day when you receive other dental services, such as a routine checkup or an extraction, the emergency examination charges will not be covered.

Example:
Suppose you see your dentist for an emergency toothache. Your dentist gives you an emergency examination, takes x-rays, and asks you to return for treatment at a later time. These costs are 100% reimbursable by the Plan. Suppose, however, your dentist also does an extraction in addition to the x-rays. The only covered expenses are the x-rays (at 100%) and the extraction (at 80%). If your dentist bills you for the emergency exam, the Plan will not reimburse you for it because the cost of such an exam is normally included in the cost of an extraction.

orange square General Services

After you meet an annual deductible of $50 per person (maximum of $150 per family), the Plan pays 80%, or as otherwise specified, of covered charges for the following services:

  • Care and treatment involving tooth extractions, fractures, and dislocations of the jaw, and cutting procedures in the oral cavity.
  • Following comprehensive periodontal therapy, a total of up to 5 cleanings (treatments) will be covered in a calendar year. The cleanings can be either all periodontal or some combination of periodontal and prophylaxis, provided that of the five total cleanings, no more than three are for prophylaxis in a calendar year. The first three cleanings, whether periodontal or prophylaxis, are covered at 100% of covered charges and the additional fourth and fifth cleanings are covered at 80% of covered charges. Periodontal treatments will be covered each calendar year, without additional periodontal therapy, if a continuing need is determined through the clinical evaluation of the dentist.
  • Root canals and other endodontic treatment.
  • General anesthetic and its administration in connection with oral surgery, periodontics, fractures, and dislocations.
  • Injection of antibiotics in conjunction with treatment of a covered dental expense.
  • Fillings, other than gold fillings. (For gold fillings, see Major Services below.)
  • Repair and rebasing existing dentures or fixed bridges. (Replacing such dentures and fixed bridges is described under Major Services below.)
  • Addition of teeth to existing denture or fixed bridge if required by loss of natural teeth.
  • Occlusal guards for the treatment of bruxism, limited to one appliance in any two calendar-year period.
  • Pre-surgery oral exams.

orange square Major Services

After you meet the annual deductible of $50 per person (maximum of $150 per family), the plan pays 50% of covered charges for these services:

  • Full or partial dentures or fixed bridges or implants and their initial insertion. Note dental implants are subject to the alternative course of treatment provision. (See page 27 for information). Replacement of existing devices can only be covered if such device cannot be made serviceable and is more than five years old. The Plan does not cover charges for adjusting dentures or bridges within six months of installation. Such follow-up visits are normally included in initial charges.
  • Gold fillings and permanent crowns — or their replacement — necessary for restoration of tooth structure broken down by decay, injury or severe attrition.

Separate charges for temporary fillings and crowns are not covered. If you are charged for both temporary and permanent crowns or dentures, only the charge for the permanent crown or denture is covered.

orange square Orthodontic Services

The Plan pays 50% of covered charges with no deductible up to the orthodontic lifetime limit of $2,000 per person for orthodontic services and supplies to correct malposed teeth if insertion of the first appliance occurs while the person is covered under the Plan. (See Orthodontia Lifetime Maximum on page 24 for more information.)

If a former Mobil employee enrolls when first eligible, orthodontic services and supplies will be covered even if the insertion of the first appliance occurs prior to becoming a covered person.

The following tool shows how benefits are paid from the ExxonMobil Dental Plan and reimbursements are made from your Health Care Flexible Spending Account. Monthly reimbursements are based on your treatment plan (number of months braces are on the teeth), not your payment schedule. The orthodontia lifetime maximum benefit is $2,000 per covered person.

Go to
www.exxonmobil.com/Family-English/HR/Files/CALCULATOR_ORTHO2008_091907.xls
for the Orthodontia FSA Expenses Calculator.