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 one time per calendar year)
- Periapical X-rays
- Prophylaxis and/or Periodontal cleanings (up to four cleanings per calendar year)
- Fluoride applications (limited to one time for adults and two times for children under 16 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
