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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 one time per calendar year) Periapical X-rays Prophylaxis and/or Periodontal cleanings (up to four cleanings per calendar year) Fluoride applications (limited to 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; one per quadrant allowed) 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)

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 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; one per quadrant allowed)
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 Debridement (once per lifetime)

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

Covered services

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