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Benefit summary

Benefit summary of the ExxonMobil Dental Plan

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 $50
Family $150
Annual Dental Maximum: $2,000 per covered person

Covered services

Preventive Services: 100% (no deductible and charges not applied to annual dental maximum)
  • Oral examinations (limited to four times each calendar year)
  • Bitewing X-rays (limited to four times each calendar year)
  • Periapical X-rays
  • Prophylaxis and/or Periodontal cleanings (up to four cleanings per calendar year)
  • Fluoride applications (limited to four times each calendar year)
  • Full mouth or panoramic X-rays* (limited to once in any three consecutive years)
  • Tooth sealants applied to a permanent molar (limit to one application per tooth
    in any three consecutive years)
  • Space maintainers (limited to deciduous teeth whether primary or baby teeth and
  • Treatment for children under age 19)
  • Occlusal night guards (limited to one appliance in any two calendar-year period)
  • Problem focused exam and X-rays (if no other treatment that day)
 

General Services: 80% after deductible
  • Fillings
  • Extractions
  • General anesthetics if medically necessary according to Aetna guidelines 
  • Injected antibiotics (in conjunction with treatment of a covered dental expense) if medically necessary according to Aetna guidelines
  • Oral surgery
  • Pre-surgery oral exams
  • Periodontics (treatment of gums)
  • Endodontics (root canals)
  • Denture and bridge repairs
 
Major Services: 50% after deductible
  • Original bridges and dentures
  • Replacement of unserviceable bridges and dentures
  • Crown and gold restorations
  • Dental implant
  • Inlays / Onlays
 
Orthodontic Services:** 50% (no deductible)
  • Orthodontia lifetime maximum
$2,000 per covered person
* Limitation does not apply to orthodontic treatment.
** Orthodontia benefits are paid based on treatment plan, not payment schedule
 


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

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