How To Understand The Octomontain Dental Plan

Transcription

1 ExxonMobil Dental Plan Summary Plan Description 201

2 About Dental - Information Sources - Introduction - Plan at a Glance Eligibility and Enrollment Dental PPO Covered Expenses Exclusions Payments Claims Continuation Coverage Administrative and ERISA Information Key Terms Benefit Summary ExxonMobil Dental Plan SPD As of January 2015 About The Dental Plan This summary plan description (SPD) is a summary of the ExxonMobil Dental Plan. It does not contain all the Plan details. In determining your specific benefits, the full provisions of the formal documents, as they exist now or as they may exist in the future, always govern. You may obtain copies of these documents by making a written request to the Administrator-Benefits. Exxon Mobil Corporation reserves the right to change benefits in any way or terminate any benefit at any time. The Dental Plan is self-insured. There is no insurance company to collect premiums or underwrite coverage. Instead, contributions from you and ExxonMobil pay all benefits. Prior claims experience and forecasted expenses are used to determine the amount of money needed to pay future benefits. These options are governed by federal laws, not by state insurance laws. Notice: The Dental Plan is an excepted benefit under PPACA and is not minimum essential coverage. Since it is not minimum essential coverage, you may not treat it as required coverage when filing your U.S. Federal Income Tax return. Applicability to represented employees is governed by collective bargaining agreements and any local bargaining requirements. Information Sources When you need information, you may contact: Claims and Dental Preferred Provider Organization (PPO) Administrator Provides claim payment information, Aetna Dental PPO provider and claim forms. Phone Numbers: Address: Aetna Member Services OR (international, call collect) Monday - Friday 8:00 a.m. to 6:00 p.m. (Central Time), except certain holidays Automated Voice Response - 24 hours a day, 7 days a week Aetna P. O. Box Lexington, KY

3 2 Benefits Administration Customer Service Representatives can provide specialized assistance. References to Benefits Administration throughout this SPD refer to either ExxonMobil Benefits Administration or ExxonMobil Benefits Service Center as listed below. Depending on your status (employee, retiree, or survivor), you should contact the appropriate service center. Employees can enroll/change benefits on the ExxonMobil Me HR Intranet site through Employee Direct Access (EDA) when a change in status occurs. Enrollment forms are also available through ExxonMobil Benefits Administration for those without access to EDA. Phone Numbers: Address: Employees call: ExxonMobil Benefits Administration/Health Plan Services Monday - Friday 8:00 a.m. to 3:00 p.m. (Central Time), except certain holidays (toll free outside Houston) (fax) ExxonMobil Benefits Administration ExxonMobil BA BSC USBA 4300 Dacoma or "BH1" Houston, TX Retirees and Survivors call: ExxonMobil Benefits Service Center Monday Friday 8:00 a.m. to 6:00 p.m. (Eastern Time), except certain holidays Toll-Free: or 800-TDD-TDD4 ( ) for hearing impaired ExxonMobil Benefits Service Center PO Box Dallas, TX ExxonMobil Sponsored Sites Access to plan-related information including claim forms for employees, retirees, survivors, and their family members. ExxonMobil Me, the Human Resources Intranet Site can be accessed at work by employees. ExxonMobil Family, the Human Resources Internet Site can be accessed from home by everyone at Retiree Online Community Internet Site can be accessed from home by retirees and survivors only at ExxonMobil Benefits Service Center at Xerox Internet Site can be accessed from home by everyone at Aetna does not render dental services or treatments. Neither the Plan nor Aetna is responsible for the services that are delivered by providers participating in the Aetna Dental PPO and those providers are solely responsible for the dental services they deliver. Providers are not the agents nor employees of the Plan or Aetna.

4 3 Introduction The ExxonMobil Dental Plan (the Plan) encourages good dental health by paying, within plan limits, for 100% of the cost of preventive services and part of the cost of other general and major services, including orthodontia. The Plan offers you the opportunity to use the Aetna Dental PPO Network, a voluntary PPO. Because participating dentists and dental specialists have agreed to provide their services at negotiated rates, you will save money and maximize your annual Plan benefits when you choose to receive care from a participating dentist. ExxonMobil's dental plan is described in detail in this SPD. These tools help you find specific information quickly and easily: Plan at a Glance, a quick user's guide highlighting plan basics. Charts and tables throughout this SPD provide information, examples, highlights of plan provisions, etc. References to sources of additional information. Key Terms containing definitions of some words and terms used in this SPD. Terms are underlined and linked for easy identification. A careful reading of this SPD will help you understand how the Plan works so you can make the best use of the Plan provisions.

5 4 Plan at a Glance Enrolling You may enroll yourself and your eligible family members within your first 60 days of employment or within 60 days of a subsequent change in status or at Annual Enrollment. See page 7. The Dental PPO You can visit any dentist but save when you choose a dentist who participates in the Aetna Dental PPO network. The negotiated rates for the dentist's services are always within reasonable and customary (R&C) limits and generally lower than rates charged by non-network dentists which helps you maximize your annual plan benefit by paying less out of pocket for covered services. See page 16. Covered and Excluded Expenses The Plan provides benefits for many, but not all, preventive, general, major and orthodontic services. See pages and Payments You and the Plan share the costs for covered treatments and services. You pay a deductible before the Plan begins paying for certain benefits. For each covered person, the Plan pays up to $2,000 each calendar year for covered dental expenses (other than preventive and orthodontic services) and up to a $2,000 lifetime maximum benefit for covered orthodontic expenses. See page 24. Claims Dental PPO providers file claims for you. You are responsible for ensuring that claims for non-network care are filed. See page 29. Consolidated Omnibus Budget Reconciliation Act 1985 (COBRA) You and your family members who lose eligibility may continue dental coverage for a limited time in certain circumstances. See page 33. Administrative and ERISA Information This Plan is subject to rules of the federal government, including the Employee Retirement Income Security Act of 1974, (ERISA) as amended, not state insurance laws. See page 39. Key Terms This is an alphabetized list of words and phrases, with their definitions, used in this SPD. See page 45. Benefit Summary A brief summary of benefits. See page 52.

6 About Dental Eligibility and Enrollment - Eligible Family Members - Suspended Retiree - Special Eligibility Rules - Classes of Coverage - Double Coverage - How to Enroll - Changing Your Coverage - Changes in Status - Changes During the Year - Other Changes That May Affect Your Coverage - When Coverage Ends - Loss of Eligibility Dental PPO Covered Expenses Exclusions Payments Claims Continuation Coverage Administrative and ERISA Information Key Terms Benefit Summary Eligibility and Enrollment Q. What are the Plan's eligibility requirements? A. Most U.S. dollar payroll regular employees of Exxon Mobil Corporation and participating affiliates are eligible for this Plan. Generally, you are eligible if: You are a regular employee. You are an extended part-time employee. You are a trainee as described in the Key Terms section You are a retiree. You are a survivor, which means an eligible family member of a deceased regular or extended part-time employee or retiree. You are not eligible if: You participate in any other employer dental plan to which ExxonMobil contributes. You fail to make any required contribution toward the cost of the Plan. You fail to comply with general administrative requirements including but not limited to enrollment requirements. You lost eligibility as described under the Loss of Eligibility section on page 14. Eligible Family Members You may also elect coverage for your eligible family members including: Your spouse. When you enroll your spouse for coverage, you may be required to provide proof that you are legally married. Your child(ren) under age 26. Coverage ends at the end of the month in which they reach age 26. If your situation involves a family member other than your biological or legally adopted child, call Benefits Administration. Your totally and continuously disabled child(ren) who is incapable of selfsustaining employment by reason of mental or physical disability, that occurred prior to otherwise losing eligibility and meets the Internal Revenue Service's definition of a dependent. A child or spouse of a Medicare-eligible retiree enrolled in the ExxonMobil Medicare Supplement Plan, as long as that spouse or child is not eligible for Medicare. Refer to Key Terms for definitions of eligible family members, child, suspended retiree, spouse, and Qualified Medical Child Support Order.

7 6 Suspended Retiree A person who becomes a retiree due to incapacity within the meaning of the ExxonMobil Disability Plan and who begins long-term disability benefits under that plan, but whose benefits stop because the person is no longer incapacitated is considered a suspended retiree and is not eligible for coverage until the earlier of the date the person: Reaches age 55, or Begins his or her retirement benefit under the ExxonMobil Pension Plan, at which time the person is again considered a retiree and may enroll. The family members of a deceased suspended retiree will be eligible for coverage under this Plan only after the occurrence of the earlier of the following: The date the suspended retiree would have attained age 55, or The date a survivor begins receiving a benefit due to the suspended retiree's accrued benefit from the ExxonMobil Pension Plan. Special Eligibility Rules A person who otherwise is not a spouse but who, as a dependent of a former Mobil employee who participated in or received benefits under a Mobil-sponsored plan or program prior to March 1, 2000, is considered an eligible dependent as long as that person's eligibility for coverage as a dependent under a Mobil-sponsored plan would have continued. Classes of Coverage You can choose coverage as an: Employee or retiree only; Employee or retiree and spouse; Employee or retiree and child(ren). There are also classes of coverage for extended part-time employees, surviving spouses and family members of deceased employees and retirees and employees on certain types of leaves of absence. For employees on an approved leave of absence, their contribution rate will change from the employee contribution rate to the Leave of Absence contribution rate as shown in the table on the next page.

8 7 Leave of Absence Contribution Rate begins Type of Leave Immediately No later than after 6 months Military (voluntary) Civic Affairs Health / Dependent Care Education Personal X X X X No later than after 12 months X Each class of coverage described in this section has its own contribution rate. Employees contribute to the Dental Plan through monthly deductions from their pay on a pre-tax or after-tax basis. Retirees and survivors receiving monthly benefit checks from ExxonMobil pay by deductions from these checks on an after-tax basis. Other retirees or survivors and participants with continuation coverage pay by check or by monthly draft on their bank account. Double Coverage No one can be covered more than once in the Dental Plan. You and your spouse cannot both enroll as employees (or retirees) and elect coverage for each other as eligible family members. If you and your spouse work for the company or are both retirees you may both be eligible for coverage. Each of you can be covered as an individual employee (or retiree), or one of you can be covered as the employee (or retiree) and the other can be an eligible family member. Also, if you have children, each child can only be covered by one of you. In addition a marriage between two ExxonMobil employees does not allow enrollment or cancellation in any of the ExxonMobil health plans if either employee is then making contributions on a pre-tax basis. In order to change your coverage you need to wait until you experience a change in status that allows coverage changes or Annual Enrollment. How to Enroll As a newly hired employee, if you enroll in the Dental Plan within 30 days of your start date, coverage begins the first day of employment. If you enroll between 31 and 60 days of your date of hire, coverage will be effective the first day of the month following receipt of the forms by Benefits Administration. If you are eligible for the ExxonMobil Pre-Tax Spending Plan, you will be enrolled to pay your monthly contributions on a pre-tax basis unless you annually decline this feature. Your monthly pre-tax contributions and class of coverage must remain in effect for the entire plan year, unless you experience a change in status. (See Annual Enrollment and Changing Your Coverage sections.) You can enroll eligible family members only if you are enrolled in this Plan. You can enroll in the Plan using Employee Direct Access (EDA) available on the ExxonMobil Me HR Intranet site. Enrollment forms are also available from Benefits Administration for those individuals who do not have access to EDA. You may be requested to provide documents at some future date to prove that the family members you enrolled were eligible (e.g., marriage certificate, birth certificate). If you fail to provide such requested documents within 90 days of the request, coverage for the family members will be canceled the first of the following month and you may be subject to discipline up to and including termination of employment for falsifying company records.

9 8 Under the Children's Health Insurance Program (CHIP) Reauthorization Act of 2009 you may change your Plan election for yourself and any eligible family members within 60 days of either (1) termination of Medicaid or CHIP coverage due to loss of eligibility, or (2) becoming eligible for a state premium assistance program under Medicaid or CHIP coverage. In either case, coverage is effective the first of the month following receipt of the forms by Benefits Administration. Annual Enrollment Each year, usually during the fall, ExxonMobil offers an annual enrollment period. During this time, you can switch from your current option to another available option. This is also the time to make changes to coverage by adding or deleting family members. Family members may be added or deleted for any reason but they must be deleted if they are no longer eligible. Changes elected during annual enrollment take effect the first of the following year. Employees are automatically enrolled in the Pre-Tax Spending Plan to pay monthly contributions on a pre-tax basis unless this feature is declined each time. This choice is only available during the annual enrollment period or with a change in status. If you pay your monthly contributions on an after-tax basis and would like to continue making contributions on an after-tax basis for the following year, you must elect to do so during each Annual Enrollment and after each change in status. Otherwise, your contributions will be switched to a pre-tax basis beginning the first day of the following year. As a retiree, you will pay your contributions on an after-tax basis via payroll deduction (if eligible), check, or bank draft Changing Your Coverage An employee may add a family member effective the first day of a month if required contributions are made on a pre-tax basis and adding the family member does not change the coverage level. If you are enrolled on an after-tax basis, you may add an eligible family member to your existing option effective the first of the following month following receipt of your written election by Benefits Administration. To make a change to your coverage you may also wait until Annual Enrollment or until you experience one of the following Changes in Status.

10 9 Changes in Status This section explains which events are considered changes in status and what changes you may make as a result. If you have a change in status, you must complete your change within 60 days. If you do not complete your change within 60 days, changes to your coverage may be limited. If you fail to remove an ineligible family member within 60 days of the event that causes the person to be no longer eligible, (e.g., divorce) you must continue to pay the same pre-tax contribution for coverage even though you have removed that ineligible person. The only exception is death of an eligible family member. Your pre-tax contribution for coverage will remain the same until you have another change in status or the first of the plan year following the next annual enrollment period. Your election made due to a change in status cannot be changed after the form is received by Benefits Administration or the transaction is completed in EDA if it changes your pre-tax elections. If you make a mistake in EDA, call Benefits Administration at immediately or no later than the same day or first work day following the day on which the mistake was made. The following is a quick reference guide to the Changes in Status discussed in more detail after the table. Changes During the Year - Medical/Dental/Vision (Health Plans) Marriage If this event occurs... Divorce - Employee enrolled in Dental Plan Divorce - Employee loses coverage under spouse's dental plan Gain a family member through birth, adoption or placement for adoption or guardianship Death of a spouse or other eligible dependent. Other loss of family member's eligibility (e.g. sole managing conservatorship of grandchild ends) You lose eligibility because of a change in your employment status, e.g., regular to non-regular You gain eligibility because of a change in your employment status, e.g. nonregular to regular Termination of Employment by spouse or other family member or other change in their employment status (e.g., change from full-time to part-time) triggering loss of eligibility under spouse's or family member's plan in which you or they were enrolled You may... Enroll yourself and spouse and any new eligible family members. Change your level of coverage. You must drop coverage for your former spouse but you may not drop coverage for yourself or other covered eligible family members. Enroll yourself and other family members that might have lost eligibility for spouse's dental plans. Enroll any eligible family members. Change your level of coverage. You may not drop coverage for yourself or other covered eligible family members. Change your level of coverage. You may not drop coverage for yourself or other eligible family members. Your Dental Plan participation will automatically be termed at the end of the month. Enroll yourself or any eligible family members in the Dental Plan. Enroll yourself and other eligible family members that may have lost eligibility under the spouse's or family member's plan in the Dental Plan.

11 If this event occurs... Your former spouse is ordered to provide coverage to your children through a QMCSO Commencement of Employment by spouse or other family member or other change in their employment status (e.g., change from part-time to full-time) triggering eligibility under another employer's plan Change in worksite or residence affecting eligibility to participate in the elected Dental Plan Judgment, decree or other court order requiring you to cover a family member. (Begin a QMCSO) Termination of employment and rehire within 30 days or retroactive reinstatement ordered by court Termination of employment and rehire after 30 days You are covered under your spouse's dental plan and plan changes coverage to a lesser coverage level with a higher deductible mid-year You begin a leave of absence You return from a leave of absence of more than 30 days (paid or unpaid). You may... End the family member's coverage, change level of coverage and terminate their participation in the Dental Plan. End other family member's coverage and terminate their participation in the Dental Plan if the employee represents that they have or will obtain coverage under the other employer plan. You may also cancel coverage for yourself, if health care coverage is obtained through your spouse s employer plan. You may not drop coverage for yourself or other eligible family members. Change your Dental Plan level of coverage. Dental Plan coverage is reinstated. Enroll in the Dental Plan as a new hire. Enroll yourself and eligible family members in the Dental Plan. Call Benefits Administration Call Benefits Administration Changes will only be allowed if the medical/dental/vision enrollment form is received within 60 days of the event by the Benefits Administration Office or the change is made in EDA within 30 days. Unless otherwise noted, the effective date will be the first of the month after the forms are received or the transaction is completed in EDA. Birth, Adoption or Placement for Adoption If you gain a family member through birth, adoption, or placement for adoption you may add the new eligible family member to your current coverage. You may also enroll yourself, your spouse, and all eligible children. Coverage is effective on the date of birth, adoption or placement for adoption. You must add the new family member within 60 days even if you already have family coverage. See the Changing your Coverage section for additional circumstances in which changes can be made. If you enroll your new family member between 31 and 60 days from the birth or adoption and your coverage level changes, you will pay the cost difference on a posttax basis until the end of the month in which the forms are received by Benefits Administration. Beginning the first day of the following month your deduction will be on a pre-tax basis. Sole Legal Guardianship or Sole Managing Conservatorship If you (or your spouse, separately or together) become the sole court appointed legal guardian or sole managing conservator of a child and the child meets all other requirements of the definition of an eligible family member, you have 60 days from the date the judgment is signed to enroll the child for coverage. You must provide a copy of the court document signed by a judge appointing you (or your spouse separately or together) guardian or sole managing conservator.

12 11 Marriage If you are enrolled in the Dental Plan, you can enroll your new spouse and his or her eligible family members (your stepchildren) for coverage. If you are not already enrolled for coverage, you can sign up for dental coverage for yourself, your new spouse, and your stepchildren. If you gain coverage under your spouse's dental plan, you can cancel your coverage. You must make these changes within 60 days following the date of your marriage or wait until Annual Enrollment or another change in status. Death of a Spouse If you lose coverage under your spouse's dental plan, you can sign up for Dental Plan coverage for yourself and your eligible family members. You must make these changes within 60 days following the date you lose coverage or wait until Annual Enrollment or another change in status. If you and your family members are enrolled in the ExxonMobil Dental Plan, any stepchildren will cease to be eligible upon your spouse's death unless you are their court appointed guardian or sole managing conservator. When a Child is No Longer Eligible If an enrolled family member is no longer an eligible family member, coverage continues through the end of the month in which they cease to be eligible. In some cases, continuation coverage under COBRA may be available. (See page 33 for more details about COBRA.) You must notify and provide the appropriate forms to Benefits Administration as soon as a family member is no longer eligible. If you fail to notify and provide the appropriate forms to Benefits Administration within 60 days, the family member will not be entitled to elect COBRA. While we have an administrative process to remove dependents reaching the maximum eligibility age, you remain responsible for ensuring that the dependent is removed from coverage. If you fail to ensure that a family member is removed in a timely manner, there may be consequences for falsifying company records. Divorce In the case of divorce, your former spouse and any stepchildren are eligible for coverage only through the end of the month in which the divorce is final. You must notify and provide any requested documents to Benefits Administration as soon as your divorce is final. If you fail to notify and provide the appropriate forms to Benefits Administration within 60 days, the former spouse and family member will not be entitled to elect COBRA. There may also be consequences for falsifying company records. Please see the Continuation Coverage section of this SPD. You may not make a change to your coverage if you and your spouse become legally separated because there is no impact on eligibility. If you lose coverage under your spouse's dental plan because of divorce, you can sign up for dental coverage for yourself and your eligible family members. You must enroll within 60 days following the date you lose coverage under your spouse's plan or wait until Annual Enrollment or another change in status. Leave of Absence If you are on an approved leave of absence, you can continue coverage by making required contributions directly to the Dental Plan by check. If you chose not to continue your coverage while on leave, your coverage ends on the last day of the month in which your leave began and you will be required to pay for the entire month's contributions. If you fail to make required contributions while on leave, coverage will end.

13 12 If the company should make any payment on your behalf to continue your coverage while you are on leave and you decide not to return to work, you will be required to reimburse the company for required contributions. If you are on an approved leave of absence and the Leave of Absence contribution rate begins, you may continue your coverage by making your required contribution. If you were on a leave that meets the requirements of the Family and Medical Leave Act of 1993 (FMLA) or the Uniformed Services Employment and Reemployment Rights Act (USERRA) and your coverage ended, re-enrollment is subject to FMLA or USERRA requirements. For more information, call Benefits Administration. Change in Coverage Costs or Significant Curtailment If the cost for coverage charged to you significantly increases or decreases during a plan year, you may be able to make a corresponding prospective change in your election, including the cancellation of your election. This provision also applies to a significant increase in the dental deductible or co-payment. If the cost of coverage under your spouse's dental plan significantly increases or there is a significant curtailment of coverage that permits revocation of coverage during a plan year and you drop that coverage, you will be able to sign up for dental coverage for yourself and any eligible family members. You must enroll within 60 days following the date you lose coverage under your spouse's plan or wait until Annual Enrollment or another change in status. Coverage due to a change in status will be effective as of the first of the month following your completion of the enrollment, or in the case of Annual Enrollment, the first of the following year. Addition or Improvement of Options If a new plan option is added or if benefits under an existing option are significantly improved during a plan year, you may be able to cancel your current election in order to make an election for coverage under the new or improved option. Loss of Option If the plan is discontinued, you will be able to elect either to receive coverage under another plan option providing similar coverage or to drop dental coverage altogether if no similar option is available. IMPORTANT REMINDER: If you pay your contributions on a pre-tax basis and you experience any of the events mentioned previously, or if you are newly eligible as a result of a change or loss of coverage under your spouse's dental plan, it is your responsibility to complete your change within 60 days of experiencing the event. If you miss the 60-day period, you will not be able to make changes until Annual Enrollment or until you experience another Changes in Status.

14 13 Other Changes That May Affect Your Coverage If You are a Retiree Not Yet Eligible for Medicare If you are a retiree not eligible for Medicare, you and your family members who are not eligible for Medicare can continue to participate in the Plan. When you (as a retiree) or a covered family member become eligible for Medicare, Medicare will become the primary plan and benefits will be coordinated. If You are an Extended Part-Time Employee If you terminate employment as an extended part-time employee, you are not eligible to continue to participate in the Plan. You may be eligible to elect continuation coverage for yourself and your eligible family members under COBRA provisions. See page 33 for details. If You Work Beyond When You Become Eligible for Medicare If you continue to work for ExxonMobil, although you are eligible for Medicare, your ExxonMobil coverage remains in effect for you and eligible family members and the Plan is your primary plan. If You or Your Covered Family Members Become Medicare Eligible for any Reason When a retiree or a covered eligible family member become eligible for Medicare, benefits will be coordinated with Medicare. If You Die If you die while enrolled, your covered eligible family members can continue coverage. Their eligibility continues with the company contributions for a specified amount of time: If you have 15 or more years of benefit service at the time of your death, eligibility continues until your spouse remarries or dies. If you have less than 15 years of benefit service, eligibility continues for twice your length of Benefit Service or until the spouse remarries or dies, whichever occurs first. Children of deceased employees or retirees may continue participation as long as they are an eligible family member. If your surviving spouse remarries, eligibility for your children also ends. Special rules may apply to family members of individuals who become retirees due to disability. (See Continued Coverage for suspended retirees on page 33). Eligible family members of deceased extended part-time employees are not eligible to continue to participate in the Plan. These family members may be eligible to elect continuation coverage under COBRA provisions. (See page 33 for details).

15 14 If You Become a Suspended Retiree If you are a retiree and you would otherwise lose coverage because you have become a suspended retiree under the ExxonMobil Disability Plan (see page 6 for details), you may continue coverage for yourself and your family members who were eligible for plan participation before you became a suspended retiree for either 12 or 18 months. Coverage continues for 12 months from the date coverage would otherwise end if you received transition benefits under the ExxonMobil Disability Plan. However, if you did not receive transition benefits under the ExxonMobil Disability Plan, coverage continues for 18 months from the date coverage would otherwise end. The cost of this continued coverage is 102% of the combined participant and company contributions. When Coverage Ends Coverage for you and/or your family members ends on the earliest of the following dates: OR The last day of the month in which: You terminate employment (except as a retiree or due to disability); You elect not to participate; A family member ceases to be eligible (for example, a child reaches age 26); or A retiree becomes a suspended retiree (see page 6). You are no longer eligible for benefits under this Plan (e.g., employment classification changes from "regular employee" to "nonregular employee" or from non-represented to represented where you are no longer eligible for this Plan); You do not make your required contribution; A Qualified Medical Child Support Order is no longer in effect for a covered family member; The date: You die; The Plan ends; Your employer discontinues participation in the Plan; You enrolled an ineligible family member and in the opinion of the Administrator-Benefits, the enrollment was a result of fraud or a misrepresentation of a material fact. You are responsible for ending coverage with Benefits Administration when your enrolled spouse or family member is no longer eligible for coverage. If you do not complete your change within 60 days, any contributions you make for ineligible family members will not be refunded. Loss of Eligibility Everyone in your family may lose eligibility for plan coverage, and you may be subject to disciplinary action up to and including termination of employment if you commit fraud against the Plan, for instance, by filing claims for benefits to which you are not entitled. Coverage may also be terminated if you refuse to repay amounts erroneously paid by the Plan on your behalf or which you recover from a third party. Your participation may be terminated if you fail to comply with the terms of the Plan and its administrative requirements. You may also lose eligibility if you enroll persons who are not eligible, for instance, by covering children who do not meet the eligibility requirements or do not cancel coverage for family members at the time they are no longer eligible, e.g. divorced spouse.

16 15 Extended Benefits at Termination You are entitled to extended coverage for as much as a year if you are terminated due to disability with fewer than 15 years of service. This coverage is provided at no cost to you. This is considered a portion of the COBRA continuation period. In order to assure coverage beyond this extension period, you must elect COBRA upon termination of employment. Several conditions must be met: The disability must exist when your employment terminates. The extension lasts only as long as the disability continues, but no longer than 12 months. This extension applies only to the employee who is terminated because of a disability. Continuation coverage for eligible family members may be available through COBRA.

17 About Dental Eligibility and Enrollment Dental PPO - Using the Dental PPO - To Find a Dental PPO Provider - Pre-determination of Benefits Covered Expenses Exclusions Payments Claims Continuation Coverage Administrative and ERISA Information Key Terms Benefit Summary Dental PPO Q1. Are my out-of-pocket costs different if I use a network dentist versus a non-network dentist? A1. When you use a network dentist, you save money because these participating providers have agreed to provide their services at negotiated rates that are generally less than the rates charged by nonnetwork dentists. Q2. Are my benefits different if I use a network dentist versus a nonnetwork dentist? A2. The percent of eligible charges that the Plan pays is the same whether you use network or non-network providers. However, you may be responsible for charges above the reasonable and customary (R&C) limit for non-network providers (see Reasonable and Customary Limits on page 26). Using the Dental PPO Using the Dental PPO is completely voluntary. The Dental PPO provides access to a network of dentists and dental specialists who have met Aetna's standards for licensing, academics and service. Dental PPO providers' charges are always within reasonable and customary limits. (See page 26.) There are several advantages to using network providers: The discounts offered by network dentists generally lower your out-of-pocket costs and allow you to cover more dental services for the annual benefit maximum. Network dentists submit claims for you, so you do not have to complete claim forms. Negotiated rates are within reasonable and customary limits, so you will not have to pay charges above the limits. However, the alternative course of treatment rules noted on page 27 apply. To receive the benefit of negotiated rates, use network dentists and present your Aetna Dental PPO ID card.

18 17 To Find a Dental PPO Provider: Check DocFind ( on Aetna's Web site for the most up-to-date list of dental PPO providers. The site is updated three times a week. Call Aetna Member Services for help with locating a PPO provider or to request a printed listing of providers. Confirm with Aetna Member Services and/or the dentist's office whether the dentist participates in the network before the appointment, since network participation may change. If you or your covered family members need to see a dentist while away from home, you can go to any licensed dentist. However, you may access the Aetna Web site or contact Aetna Member Services to see if there is a network dentist in the area. Pre-determination of Benefits You are encouraged to submit a pre-determination of benefits before you begin any complicated or expensive dental procedure to avoid unexpected expenses. Generally, Aetna will tell you what benefits will be paid for the proposed treatment. However, if a less expensive alternative course of treatment is available, Aetna will advise you of the alternative course of treatment and tell you what benefits will be paid. If you decide to have the more expensive proposed treatment, the Plan pays benefits based on the cost of the alternative course of treatment. Here is how the pre-determination process works: Indicate on a claim form (or in a letter) that you are seeking a predetermination of benefits. Give the form to your dentist. The dentist describes the suggested course of treatment, itemizing specific services and charges. In some cases medical information, including x-rays, may also be needed. The dentist submits the information to Aetna, which determines the Plan benefits for the services outlined and notifies both you and the dentist. This gives you a chance to discuss the work and charges with your dentist before the work is performed. If a lower cost alternative course of treatment would be medically appropriate, you might decide to proceed with the original treatment, or you might opt for the alternative course of treatment. That is a matter for you and your dentist to decide. Plan benefits are based on the actual work done or on the Plan's requirements relating to alternative course of treatment, not on the pre-determination. (See Alternative Course of Treatment on page 27). Note: A pre-determination is processed much like a claim. Plan accordingly and allow sufficient time for that process to take place.

19 About Dental Eligibility and Enrollment Dental PPO Covered Expenses - Preventive Services - Emergency Treatment - General Services - Major Services - Orthodontic Services Exclusions Payments Covered Expenses Q. What types of dental services are covered by the Plan? A. The Plan divides dental services into four categories: Preventive Services General Services Major Services Orthodontic Services 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). Claims Continuation Coverage Administrative and ERISA Information Key Terms Benefit Summary 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: Medically necessary Performed or prescribed by a dentist or physician, and Not excluded under this Plan. 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 implant post is inserted. The implant crown is considered incurred on the date it is placed on the implant post.

20 19 Preventive Services To encourage good oral health and improve overall health of participants, the Plan pays 100% of covered charges for the following preventive services with no deductible and these expenses are not applied to the annual dental maximum: Diagnostic oral examinations Prophylaxis and/or Periodontal cleanings (up to four cleanings per calendar year) Diagnostic supplementary (bite-wing) X-rays (limited to four times each calendar year). Periapical X-rays Diagnostic full-mouth or panoramic X-rays* (limited to once in any three consecutive years). Topical stannous fluoride application (limited to four times each calendar year). Space maintainers and their insertion (limited to deciduous teeth whether primary or baby teeth and treatment for a covered family member under age 19). Tooth sealants applied to a permanent molar (limited to one application per tooth in any three consecutive years). Occlusal (night) guards for the treatment of bruxism (limited to one appliance every other year). * Limitation does not apply to orthodontia treatment Emergency Treatment The Plan also pays 100% of reasonable and customary covered charges for diagnostic x-rays and examination charges for problem focused limited oral exams. If you incur charges for urgent treatment on a day when you receive other dental services, such as a routine checkup or an extraction, the problem focus limited oral examination charges will 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. If your dentist does an extraction in addition to the x-rays and emergency examination, these services are covered by the Plan, even if incurred on the same day. The emergency examination and x-rays would be covered at 100% and the extraction at 80%.

21 20 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. 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. Pre-surgery oral exams. 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. 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. 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. (See Orthodontia Lifetime Maximum on page 25 for more information.)

22 21 When an employee is first eligible and enrolls in the Plan, orthodontic services and supplies will be covered even if the insertion of the first appliance occurs prior to becoming a covered person. In addition to traditional orthodontia treatments, the Plan provides coverage for Invisalign however benefits are payable only for charges up to the reasonable and customary amount for similar services and supplies in the area. This means that you are responsible for the excess amount. As with other orthodontic treatments, these charges are subject to your orthodontia lifetime maximum. The tool referenced below shows how benefits are paid from the ExxonMobil Dental Plan and reimbursements are made from your Health Care Flexible Spending Account. Refer to the Pre-Tax Spending Plan Summary Plan Description when using Pre-Tax Plan for orthodontia reimbursement. 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. NOTE: If you are paying your orthodontic services in full up front, contact Aetna member services for claim handling guidelines for your Health Care Flexible Spending Account. The orthodontia calculator does not calculate correctly if orthodontia services are paid in full upfront. Go to English/HR/Files/CALCULATOR_ORTHO2008_ xls for the Orthodontia FSA Expenses Calculator.

23 About Dental Eligibility and Enrollment Dental PPO Covered Expenses Exclusions Payments Claims Continuation Coverage Administrative and ERISA Information Key Terms Benefit Summary Exclusions Q. Are there expenses which are not covered by the Plan? A. Although the Plan covers many types of dental treatments and services, it does not cover all of them. No benefits are payable under the Plan for any charge incurred for: Treatment by a person other than a dentist or physician, except for services performed by a licensed dental or medical professional under the direction of a dentist or physician. Services not incident to and for the diagnosis or treatment of a condition, disease or injury while a covered person. Cosmetic services or supplies, except necessary reconstructive expenses in connection with treatment of an accidental injury which begins within 90 days after the accidental injury is sustained. Treatment covered by workers' compensation or similar law. Professional services rendered by the patient. Treatment of any condition with personally specialized or individually designed services. For example, if you want a denture designed with a gap that resembles a gap that existed in the natural teeth the denture is replacing, the charge for creating that gap, or for personalizing the denture, is not covered. Facings on crowns behind the second bicuspid. Training in or supplies used for dietary counseling, oral hygiene or plaque control. Procedures, restorations, and appliances to increase vertical dimension, to restore occlusion and to repair attrition including, but not limited to, treatment of Temporomandibular Joint Disorder (TMJ/TMD).

24 23 Services or supplies which are experimental according to accepted standards of dental practice. Post-operative procedures or examinations for which an additional or separate charge is made. Follow-up adjustments of dentures, fixed bridges, or implants within six months of initial insertion for which an additional and separate charge is made. Temporary crowns or dentures, prior to installation of permanent devices, for which an additional and separate charge is made. Treatment of any condition, disease or injury, including otherwise covered dental expenses, if the person would not be required to pay charges had the person not been covered under this Plan, including services provided in a hospital operated by the United States or any of its agencies. Any charge for a service or supply not listed as a covered expense.

25 About Dental Eligibility and Enrollment Dental PPO Covered Expenses Exclusions Payments - Annual Maximum - Deductibles - Percentage Co-payments - Orthodontia Lifetime Maximum - Adjustments to Billed Charges Claims Continuation Coverage Administrative and ERISA Information Key Terms Benefit Summary Payments Q. How are payments determined? A. The Plan helps you and your family members with dental expenses. You and the Plan share costs for covered treatment and services. You pay a percentage co-payment for most covered expenses. You must satisfy an annual deductible before the Plan starts paying on covered non-preventive services. The Plan also has an annual maximum and a lifetime orthodontia maximum amount. Once the maximum lifetime benefit maximum has been paid, no other benefits will be paid under any circumstances. Once the Plan has paid charges for covered expenses up to the maximum, you are responsible for all charges above the maximum. See Adjustments to Billed Charges on page 26 for other factors that may affect reimbursement. This section explains some of the terms and provisions you need to know to use the Plan to your best advantage. Annual Maximum The annual maximum is $2,000, which is the amount of benefits payable under the Plan for covered dental expenses (other than preventive and orthodontic services) each calendar year for each covered person. This annual maximum benefit is determined after you pay any necessary deductibles and co-payments. Orthodontic expenses have a separate lifetime limit of $2,000. Once the annual maximum benefit has been paid, no other benefits are available under any circumstances. You are responsible for all charges above the annual maximum benefit. Example: You have had several dental procedures totaling $1,800 between January 1st and July 31st. You have $200 remaining until you reach the annual maximum. On September 2nd, you have a dental procedure performed, and the cost to the Plan is $300. Since the annual maximum is $2,000, the Plan will pay only $200 of the charge. You are responsible for $100, and no benefits are available for dental services performed for the remainder of the calendar year. However, beginning January 1st of the following year, a new annual maximum benefit will be available to pay charges for covered expenses incurred during that calendar year.

26 25 Deductibles The deductible is the amount of covered expenses you must pay each calendar year before the Plan begins sharing the cost. You do not pay a deductible for preventive or orthodontic services. An annual deductible must be met for general and major services. A $50 deductible applies to each covered person. Once deductibles for your family reach $150, your family has satisfied the deductible requirements for the year. The deductible does not include any amounts above the reasonable and customary limits (see Reasonable and Customary Limits section on page 26). Percentage Co-payments The co-payment is the percentage of the cost of covered dental treatment or services that you pay. You pay a 20% co-payment for general services and a 50% co-payment for major and orthodontic services. Orthodontia Lifetime Maximum The Plan pays up to $2,000 for covered orthodontic expenses for the lifetime of each covered person. This is in addition to the annual maximum benefit for other types of dental care.

27 26 Adjustments to Billed Charges When providers submit charges for payment, the following factors affect the amount that will be considered eligible for reimbursement. References to these limitations may appear on your explanation of benefits. Contact Aetna Member Services for more information. A pre-determination of benefits is strongly recommended before you incur any major or unusual expenses. Reasonable and Customary Limits Allowable amounts for services are determined by reasonable and customary (R&C) limits. The Plan's claims administrator determines R&C limits. These limits are based on data obtained from the Prevailing Healthcare Charges System owned by FAIR Health. R&C limits for services are set at the 90th percentile of the range of charges for a particular procedure in the same geographic area(s). R&C limits apply only to non-network providers and services. If any non-network provider charges a fee that exceeds the R&C limit, you are responsible for the excess amount. The amount above the R&C limit does not apply toward your annual deductible or your percentage co-payments. To find out if a proposed charge is within R&C limits, contact Aetna Member Services. PPO provider negotiated rates are always within R&C limits. Example: Assume that the R&C charge in your area for a tooth filling is $120, your non-network dentist charges $140 to fill your tooth, and the network dentist's negotiated charge is $100. Network Non-Network Tooth filling $100 $140 Covered amount $100 $120 You pay 20%* of covered amount $ 20 $ 24 You pay amount over R&C Your total cost $ 20 $ 44 *After deductible has been satisfied. The summary on page 52 provides an overview of the ExxonMobil Dental Plan. More detailed explanations of the expenses covered under each category (preventive, general, major, and orthodontic) and expenses not covered are provided beginning on pages of this SPD.

28 27 Alternative Course of Treatment In situations where an alternative course of treatment would provide professionally adequate (based on American Dental Association guidelines) results at a lower cost, the lower-cost treatment is considered the covered expense. The alternative course of treatment is determined either at the time a predetermination is made or when the claim is processed. Reimbursement and subsequent repairs, replacement, or servicing is based on that alternative course of treatment. Use the Plan's pre-determination of benefits feature to avoid unexpected expenses. If you incur a service that is eligible for an alternative course of treatment without a pre-determination or you choose not to use the alternative course of treatment identified during a pre-determination, you will be responsible for the following: Any reasonable and customary charges that you may incur while using a non- PPO provider. The difference in cost between the alternative course of treatment and the treatment performed. Your co-payment based on the alternative course of treatment, if your deductible has been met. Example: Assume that you have one or more missing teeth and you would like them replaced with an initial bridge. Dental bridges bridge the gap created by one or more missing teeth. Your provider is a Dental PPO network provider and the submitted charge is $2000 for an initial bridge. When you submit your treatment plan for a predetermination of benefits, Aetna determines that a medically necessary, cost-effective alternative course of treatment is available a partial denture that costs $1000. The table below shows the cost you would pay if you choose to proceed with an initial dental bridge instead of a partial denture. Also, the table shows the cost if you use a non-network provider who charges $3,000. For this example: A claim is submitted for an initial bridge on teeth numbers 8-10, with tooth 9 as the missing tooth which will be replaced with a porcelain bridge (pontic). For this example, an alternate benefit of a partial denture is approved. The negotiated fee for the alternate course of treatment of a partial denture is $ For the Nonnetwork example the reasonable and customary amount is $1,000 for the partial denture. A B C D E F G Dental Bridge Network $ 2,000 Non- Network $ 3,000 R&C limit $ 2,000 $ 0 Cost in excess of R&C limit (A- B) *After deductible has been satisfied. Covered amountcost of partial denture $ 1,000 Cost in excess of the covered amount (B-D) Your copayment 50%* of covered amount (D*.5) Your total cost (C+E+F) $ 1,000 $ 500 $ 1,500 $ 2,000 $ 1,000 $ 1,000 $ 1,000 $ 500 $ 2,500 Note: When an alternative course of treatment is applied, reimbursement for the other missing teeth in the arch related to the initial bridge are subject to the alternative course of treatment benefit for the partial denture.

29 28 Note: When an alternative course of treatment is applied, reimbursement for the other missing teeth in the arch related to the initial bridge are subject to the alternative course of treatment benefit for the partial denture. Recovery of Overpayment If you or your beneficiary receives a distribution of any amount from the Plan to which you are not entitled, you or your beneficiary will be required to repay the amount of the overpayment to ExxonMobil or the Plan. The plan administrator may make reasonable arrangements with you for repayment.

30 About Dental Eligibility and Enrollment Dental PPO Covered Expenses Exclusions Payments Claims Q. When must claims be filed? A. All dental claims must be filed within two years from the date services were received. 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 32. Claims - Claims for Non-Network Provider Care - Explanation of Benefits - Claim Denial and Reconsideration - Claims Outside the United States - Right of Reimbursement and Subrogation - Coordination of Benefits - Coverage of a Child - Retirees Covered by Two Plans - Medical Claims for Dental Work Continuation Coverage Administrative and ERISA Information Key Terms Benefit Summary Aetna Dental PPO Network providers should file all claims directly with Aetna. 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 ExxonMobil Me, or ExxonMobil Family Web sites for yourself and/or each eligible family member 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 a non-network provider: Most dentists expect payment in full for services at the time the work is done 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 will 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.

31 30 You can view your EOBs online by signing up for Aetna Navigator TM. Just go to the Aetna Navigator Web site at 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 that includes a copy of the tooth chart clearly identifying the tooth number (s) and indicate if the provider is using a USA standard tooth number or a different tooth identification standard. 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 service. Right of Reimbursement and Subrogation If your claim results from an accident or other injury that may be the fault of another party, the Plan will be subrogated to your (or your covered family member's) right of recovery against any party. In addition, you must reimburse any amount paid by the Plan that you recover from any responsible party. The Plan does not require reimbursement from any voluntary medical payments coverage you may carry under your motor vehicle or homeowner's insurance. The Plan will seek reimbursement/ subrogation from coverage you may carry for uninsured/underinsured motorists. The Plan's right to subrogation and reimbursement also constitute an "equitable lien" against any payments by any responsible party made or payable to you, your covered family members, or anyone acting on your behalf, now or in the future, regardless of how the payments are characterized. For example, injury, illness or disability related payments that you receive for expenses such as past medical expenses, future medical expenses, attorneys' fees and expenses, or other costs or compensation, up to the full amount of all benefits paid by the Plan, must first be used to repay the Plan before any money goes to you. This creates a priority recovery right in favor of the Plan and is not subject to any application of a "make-whole" or "common fund" rule under local or other law. By accepting benefits from the Plan you are agreeing to this arrangement. The Plan's right to do this is called its right to impose an equitable lien or constructive trust. You are required to promptly notify the Plan of any occurrence that may give rise to the Plan's reimbursement/subrogation rights and to cooperate with the Plan (or its representative) to secure these rights. Please refer to the Plan's master documents for additional information on the Plan's reimbursement/subrogation rights. 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 family member 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.

32 31 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 Child When a 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 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 Dental Plan obtains a full-time job in which the retiree is covered by the new employer's dental plan, that plan becomes the primary plan and the Dental 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 or your family member become entitled to Medicare, Medicare is assumed to be the primary plan except in the following circumstances: Medicare is secondary for Medicare-eligible employees and their family members who are covered by the Plan through their current employment or the current employment of a spouse. Medicare is secondary for employees and their family members 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 their family members 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 employment of the employee or family member. 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.

33 32 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. If an accident occurs, claims are payable as medical expenses, but claims are not coordinated with the ExxonMobil Dental 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 54 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 participate in the EMMP Aetna Select option or the EMMSP, your claim needs to be filed with the dental plan rather than the medical plan. If you are an employee who participates in the ExxonMobil Pre-Tax Spending Plan Health Care Flexible Spending Account (HCFSA), Aetna will automatically process any eligible expenses remaining from your dental claim and send you the spending account reimbursement, if you have elected HCFSA automatic reimbursement. This means that, in most cases, you will not need to file a separate pre-tax claim form.

34 About Dental Eligibility and Enrollment Dental PPO Covered Expenses Exclusions Payments Claims Continuation Coverage - Continuation Coverage Rights Under COBRA - What is COBRA Coverage? Administrative and ERISA Information Key Terms Benefit Summary Continuation Coverage Q1. Can coverage be continued after eligibility in this Plan ends? A1. Yes. The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) entitles you and your covered family members to extend medical benefits beyond the date your coverage would normally end. Q2. What notification time limits must I comply with to begin COBRA for my spouse or my family member? A2. You are responsible for ending coverage with Benefits Administration when your spouse or family member is no longer eligible for coverage. This must be done as soon as possible. In order to be eligible for COBRA, you must notify and provide the appropriate forms to Benefits Administration within 60 days of the event which caused the person to lose eligibility. Continuation Coverage Rights Under COBRA Introduction You are required to be given the information in this section because you are covered under a group health plan (the Plan). This section contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan under certain circumstances when coverage would otherwise end. This section generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. The right to COBRA coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA coverage can become available to you when you would otherwise lose your group health coverage under the Plan. It can also become available to your spouse and children, if they are covered under the Plan when they would otherwise lose their group health coverage. This section does not fully describe COBRA coverage or other rights under the Plan. For additional information about your rights and obligations under the Plan and under federal law, you should review this SPD or contact ExxonMobil Benefits Administration at the telephone numbers or address listed under Benefits Administration on page 37. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse s plan), even if that plan generally doesn t accept late enrollees.

35 34 Determination of Benefits Administration Entity to Contact: IMPORTANT: "Benefits Administration" references throughout this notice change depending on your status. Unless specifically stated otherwise, you should refer to the correct Benefits Administration entity using the list below. If your status is not listed, call ExxonMobil Benefits Administration/Health Plan Services for assistance. Current ExxonMobil and XTO Employees or their covered family members should use EDA or contact ExxonMobil Benefits Administration/ Health Plan Services; Exxon, ExxonMobil, Mobil, XTO or Superior Oil Retirees, or their Survivors, or their covered family members contact ExxonMobil Benefits Service Center; and Former Exxon, Exxon Mobil or XTO Employees and Exxon and ExxonMobil Retirees (who retired before October 1, 2005) and their Survivors or covered family members, who have elected and are participating through COBRA, contact to ExxonMobil COBRA Administration.. What is COBRA Coverage? COBRA coverage is a continuation of plan coverage when coverage would otherwise end because of a life event known as a "qualifying event." Specific qualifying events are listed later in this section. If a specific qualifying event occurs and any required notice of that event is properly provided to Benefits Administration, COBRA coverage must be offered to each person losing coverage who is a "qualified beneficiary." You, your spouse, and your children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Certain newborns, newly adopted children, and alternate recipients under QMCSOs may also be qualified beneficiaries. This is discussed in more detail in separate paragraphs below. Under the Plan, qualified beneficiaries who elect COBRA coverage must pay the entire cost of COBRA coverage. Who is entitled to elect COBRA? If you are an employee, you will be entitled to elect COBRA, if you lose your coverage under the Plan because either one of the following qualifying events happen: Your hours of employment are reduced; or Your employment ends for any reason other than your gross misconduct. If you are the spouse of an employee, you will be entitled to elect COBRA if you lose coverage under the Plan because any of the following qualifying events happen: Your spouse dies; Your spouse's hours of employment are reduced; Your spouse s employment ends for any reason other than his or her gross misconduct; You become divorced from your spouse. Also, if your spouse (the employee) reduces or eliminates your group health coverage in anticipation of a divorce, and a divorce later occurs, then the divorce may be considered a qualifying event for you even though your coverage was reduced or eliminated before the divorce. A person enrolled as the employee s child will be entitled to elect COBRA if he or she loses coverage under the Plan because any of the following qualifying events happen: The parent-employee or parent-retiree dies; The parent-employee's hours of employment are reduced; The parent-employee's employment ends for any reason other than his or her gross misconduct; or The child stops being eligible for coverage under the Plan as a child. When is COBRA Coverage Available? When the qualifying event is the end of employment or reduction of hours of employment or death of the employee, the Plan will offer COBRA coverage to qualified beneficiaries. You need to notify Benefits Administration of any other qualifying events.

36 35 You Must Give Notice of Some Qualifying Events For the other qualifying events (divorce of the employee and spouse or a child losing eligibility for coverage), a COBRA election will be available to you only if you notify and provide the appropriate forms to the Benefits Administration entity within 60 days after the later of (1) the date of the qualifying event or (2) the date on which the qualified beneficiary loses (or would lose) coverage under the terms of the Plan as a result of the qualifying event. In providing this notice, you must notify the correct Benefits Administration entity based on your status and follow the procedures outlined in the below section. If these procedures are not followed or if the wrong entity is notified during the 60-day notice period, THEN ALL QUALIFIED BENEFICIARIES WILL LOSE THEIR RIGHT TO ELECT COBRA. See page 37 for the listing of Benefits Administration entities. Notices of qualifying events from current employees must be made by logging onto Employee Direct Access (EDA) located on the ExxonMobil Me HR Intranet site. Forms are also available from ExxonMobil Benefits Administration/ Health Plan Services for those individuals who do not have access to EDA. Notices of these qualifying events from retirees and survivors must be made via the ExxonMobil Benefits Web or by calling the ExxonMobil Benefits Service Center. Notice is not effective until either EDA or the ExxonMobil Benefits Web change is made or the properly completed form is received. Election of COBRA Each qualified beneficiary will have an independent right to elect COBRA. Covered employees and spouses (if the spouse is a qualified beneficiary) may elect COBRA on behalf of all qualified beneficiaries, and parents may elect COBRA on behalf of their children. Any qualified beneficiary for whom COBRA is not elected within the 60- day election period specified in the Plan s COBRA election notice WILL LOSE HIS OR HER RIGHT TO ELECT COBRA. How long does COBRA coverage last? COBRA coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the covered employee s divorce or a child's losing eligibility as a child, COBRA coverage under the Plan can last for up to a total of 36 months. When the qualifying event is the end of employment or the reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA coverage under the Plan for qualified beneficiaries (other than the employee) who lose coverage as a result of the qualifying event can last until up to 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA coverage for his spouse and children who lost coverage as a result of his termination can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). This COBRA coverage period is available only if the covered employee becomes entitled to Medicare within 18 months BEFORE termination or reduction of hours. Otherwise, when the qualifying event is the end of employment or reduction of the employee's hours of employment, COBRA coverage under the Plan generally can last for only up to a total of 18 months. The COBRA coverage periods described above are maximum coverage periods. COBRA coverage can end before the end of the maximum coverage periods described in this notice for several reasons. There are two ways (described in the following paragraphs) in which the period of COBRA coverage resulting from a termination of employment or reduction of hours can be extended. Disability Extension of 18-month Period of Continuation Coverage If a qualified beneficiary is determined by the Social Security Administration to be disabled and you notify the correct Benefits Administration entity, in a timely fashion, all of your qualified beneficiaries in your family may be entitled to receive up to an additional 11 months of COBRA coverage, for a total maximum of 29 months. This extension is available only for qualified beneficiaries who are receiving COBRA coverage because of a qualifying event that was the covered employee s termination of employment or reduction of hours. The disability must have started at some time before the 61st day after the covered employee s termination of employment or reduction of hours and must last at least until the end of the period of COBRA coverage that would be available without the disability extension (generally 18 months, as described above).

37 36 The disability extension is only available if you notify Benefits Administration in writing of the Social Security Administration s determination of disability within 60 days after the latest of: The date of the Social Security Administration s disability determination The date of the covered employee s termination or reduction of hours; and The date on which the qualified beneficiary loses (or would lose) coverage under the terms of the Plan as a result of the covered employee s termination of employment or reduction of hours. You must also provide this notice within 18 months after the covered employee s termination of employment or reduction of hours in order to be entitled to a disability extension, and you must notify the correct Benefits Administration entity at least 30 days before the end of the 18-month period. See the last page of this notice for the listing of Benefits Administration entities. If these procedures are not followed or if the notice to the correct Benefits Administration entity is not provided during the 60-day notice period and within 18 months after the covered employee s termination of employment or reduction of hours, THEN THERE WILL BE NO DISABILITY EXTENSION OF COBRA COVERAGE. See page 37 for the listing of Benefits Administration entities. Second Qualifying Event Extension of COBRA Coverage If your family experiences another qualifying event while receiving 18 months of COBRA coverage as a result of the covered employee s termination of employment or reduction of hours (including COBRA coverage during disability extension as described above), the covered spouse and children in your family can get up to 18 additional months of COBRA coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the correct Benefits Administration entity. This extension may be available to the spouse and any child receiving continuation coverage if the employee or former employee dies, gets divorced, or if the covered child stops being eligible under the Plan as a child. This extension is available only if the qualifying event would have caused the spouse or child to lose coverage under the Plan had the first qualifying event not occurred. This extension is not available under the Plan when a covered employee becomes entitled to Medicare after his or her termination of employment or reduction of hours. This extension due to a second qualifying event is available only if you notify the correct Benefits Administration entity within 60 days of the date of the second qualifying event. See the last page of this notice for the listing of Benefits Administration entities. If these procedures are not followed or if the notice to the correct Benefits Administration entity is not provided during the 60 day notice period and within 18 months after the covered employee's termination of employment or reduction of hours, THEN THERE WILL BE NO EXTENSION OF COBRA COVERAGE. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse s plan) through what is called a special enrollment period. Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at More Information About Individuals Who May Be Qualified Beneficiaries Children born to or placed for adoption with the covered employee during COBRA coverage period A child born to, adopted by, or placed for adoption with a covered employee during a period of COBRA coverage is considered to be a qualified beneficiary provided that, if the covered employee is a qualified beneficiary, the covered employee has elected COBRA coverage for himself or herself. The child's COBRA coverage begins when the child is enrolled in the Plan, whether through special enrollment or open enrollment, and it lasts for as long as COBRA coverage lasts for other family members of the employee. To be enrolled in the Plan, the child must satisfy the otherwiseapplicable Plan eligibility requirements (for example, regarding age).

38 37 Alternate recipients under QMCSOs A child of the covered employee who is receiving benefits under the Plan pursuant to a qualified medical child support order (QMCSO) received by Exxon Mobil Corporation during the covered employee's period of employment with Exxon Mobil Corporation is entitled to the same rights to elect COBRA as an eligible child of the covered employee. Cost of COBRA Coverage A person who elects continuation coverage may be required to pay the group rate premium for continuation coverage plus a 2% administration fee, if applicable, or 102% of cost to the Plan to maintain the coverage, unless the person is entitled to extended coverage due to disability. If the person becomes entitled to such extended coverage, the person may be required to contribute up to 150% of contributions after the initial 18-month's coverage until coverage ends. A person who elects continuation coverage must pay the required contributions within 45 days from the date coverage is elected, retroactively to the date benefits terminated under the Plan. If You Have Questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor s Employee Benefits Security Administration (EBSA) in your area or visit (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA s website.) For more information about the Marketplace, visit Keep Your Plan Informed of Address Changes In order to protect your family's rights, you should keep the correct Benefits Administration entity informed of any changes in your address as well as the addresses of family members. You should also keep a copy, for your records, of any notices you send to Benefits Administration. Benefits Administration: The following sets out the contact numbers based on your status under the ExxonMobil Dental Plan. FAILURE TO NOTIFY THE CORRECT ENTITY COULD RESULT IN YOUR LOSS OF COBRA RIGHTS. If your status is not listed, call ExxonMobil Benefits Administration/Health Plan Services for assistance or contact them at [email protected].

39 38 ExxonMobil Dental Plan Contact Information Phone Numbers: Address: Employees and their covered family members: ExxonMobil Benefits Administration/Health Plan Services Monday - Friday except certain holidays 8:00 a.m. to 3:00 p.m. (U.S. Central Time) (toll free outside Houston) ExxonMobil Benefits Administration ATTN: Health Plan Services ExxonMobil BA BSC USBA 4300 Dacoma BH-1 Houston, TX Retirees, their survivors and covered family members: ExxonMobil Benefits Service Center ExxonMobil Benefits Service Center Monday Friday except certain holidays P.O. Box :00 a.m. to 6:00 p.m. (U.S. Eastern Time) Totowa, NJ (toll free) 800-TDD-TDD4 ( ) for the hearing impaired Former employees and retirees (who retired before October 1, 2005), their survivors and family members who have elected and are participating through COBRA: ExxonMobil COBRA Administration Monday - Friday except certain holidays 8:00 a.m. to 7:00 p.m. (U.S. Central Time) Benefits Continuation Services, Dept. 166 ADP National Accounts Services ExxonMobil COBRA Administration (800) (toll free) P O Box 2968 Alpharetta, GA Fax: (770)

40 About Dental Eligibility and Enrollment Dental PPO Covered Expenses Exclusions Payments Claims Continuation Coverage Administrative and ERISA Information - Basic Plan Information - Benefit Claims Procedures - No Implied Promises - Future of the Plan - Your Rights Under ERISA Key Terms Benefit Summary Administrative and ERISA Information Q. What other information do I need to know about the Plan? A. This section contains technical information about the Plan and identifies its administrator. It also contains a summary of your rights with respect to the Plan and instructions about how you can submit an appeal if your claim for benefits is denied. The formal name of the Plan is the ExxonMobil Dental Plan. Plan Sponsor and Participating Affiliates The ExxonMobil Dental Plan is sponsored by: Exxon Mobil Corporation 5959 Las Colinas Blvd Irving, Texas All of Exxon Mobil Corporation's divisions and most of the major U.S. affiliates participate in the ExxonMobil Dental Plan. A complete list of participating affiliates is available from the Administrator-Benefits upon written request. Certain employees covered by collective bargaining agreements do not participate in the plan. Basic Plan Information Plan Administrator The Plan Administrator for the ExxonMobil Dental Plan is the Administrator-Benefits. The Administrator-Benefits is the Manager-Global Benefits Design, Exxon Mobil Corporation. You may contact the Administrator-Benefits at the following address. Legal process may be served upon the Administrator-Benefits c/o Exxon Mobil Corporation by serving the Corporation's Registered Agent for Service of Process, Corporation Service Company (CSC). Administrator-Benefits P.O. Box 2283 Houston, Texas For Service of Legal Process: Corporation Service Co. 211 East 7 th Street, Suite 620 Austin, Texas

41 40 Claims Administrator The claims administrator, Aetna, provides information about claims payment, providers participating in the Dental PPO, and benefit pre-determinations. Claims Fiduciary and Appeals The claims fiduciary is the person to whom all appeals are filed. The claims fiduciary is Aetna for dental mandatory appeals and the Administrator-Benefits for voluntary appeals. You may contact the claims fiduciary as follows: For Mandatory Appeals: Aetna P. O. Box Lexington, KY For Voluntary Appeals: Administrator-Benefits ExxonMobil Dental Plan P.O. Box 2283 Houston, Texas Type of Plan The ExxonMobil Dental Plan is a welfare plan under ERISA providing dental benefits. Plan Numbers The ExxonMobil Dental Plan is identified with government agencies under two numbers: the Employer Identification Number (EIN), , and the Plan Number (PN), 555. Plan Year The plan year is the calendar year. Plan Funding Benefits are funded through employee and employer contributions. Benefit Claims Procedures Filing a Claim You or your provider must file a claim in writing to Aetna Member Services. Aetna is responsible for determining and informing you of your entitlement to a benefit and any amounts payable to you. Claims for benefits where the Plan provisions do not require approval before dental care is obtained are the most common claims filed under the ExxonMobil Dental Plan. These claims are made after care is received. Aetna will review your claim and respond within a designated response time, usually 30 days after receiving your claim. If Aetna needs additional time (an extension) to decide on your claim because of special circumstances, you will be notified within the claim response period. An additional 15 days is all that is allowed. If an extension is necessary due to incomplete information, you must provide the additional information within 45 days from the date of receipt of the extension notice. If you have a question or a problem with a plan benefit, contact Aetna Member Services.

42 41 Denied Claims If your claim for benefits is denied completely or partially, you, your beneficiary, or designated representative will receive written notice of the decision. The notice will describe: The specific reason(s) for the denial. The process for requesting an appeal. Filing a Mandatory Appeal If your claim is denied, you, your beneficiary, or your designated representative may file an appeal to Aetna. The written appeal should include the reasons why you believe the benefit should be paid and information that supports, or is relevant to, your claim (written comments, documents, records, etc). The written appeal may also include a request for reasonable access to, and copies of, all documents, records, and other information relevant to your claim. You must submit your written appeal within 180 days from the date of the denial notice. The review will take into account all comments, documents, records, and other information submitted relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination. Aetna will respond to the appeal within 60 days. If Aetna needs additional time to decide on your claim because of special circumstances, you will be notified within the claim response period. However, an extension may be requested, but the law stipulates that no additional time must be allowed. If the appeal is denied, you will receive written notice of the decision. The notice will set forth: The specific reason(s) for the denial and the plan provisions upon which the denial is based. A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim. A statement of the voluntary appeal procedure and your right to obtain information about such procedure or a description of the voluntary appeal procedure. A statement of your right to bring an action under section 502(a) of the Employee Retirement Income Security Act (ERISA). Statute of Limitations After you have received the response to the mandatory appeal, you may bring an action under section 502(a) of ERISA. Such action must be filed within one year of the date on which your mandatory appeal was decided. The statute of limitations or other defense based on timeliness is suspended during the time that a voluntary appeal is pending. Filing a Voluntary Appeal If your mandatory appeal is denied, you may submit a voluntary appeal to the Administrator-Benefits within 30 days of the denial of your mandatory appeal along with the new information pertinent to the claim. You will be notified within 15 days after your request was received whether or not the information was considered new information. If it is determined that there is new relevant information, a decision will be made within 60 days after the Administrator-Benefits receives your request for a voluntary appeal. If it is determined that there is no new information pertinent to your claim, your voluntary appeal will not be considered. If it is determined that there is new relevant information, a decision will be made within 60 days of the date the Administrator-Benefits receives your request for a voluntary appeal. Authority of Administrator-Benefits The Administrator-Benefits (and those to whom the Administrator-Benefits has delegated authority) has the full and final discretionary authority to determine eligibility for benefits, to construe and interpret the terms of the Dental Plan in its application to any participant or beneficiary, and to decide any and all claim appeals.

43 42 No Implied Promises Nothing in this SPD says or implies that participation in the ExxonMobil Dental Plan is a guarantee of continued employment with the company. Future of the Plan ExxonMobil expects to continue the Plan. However, ExxonMobil has the right to change, suspend, withdraw, amend, modify or terminate the Plan or any of its provisions at any time and for any reason. A change may also be made to required contributions and future eligibility for coverage, and may apply to those who retired in the past, as well as those who retire in the future. If any material changes are made in the future, you will be notified. For health plans, certain rules apply regarding what happens when a plan is changed, terminated or merged. Expenses incurred before the effective date of a plan change or termination will not be affected. Expenses incurred after a plan is terminated will not be covered. If the Plan cannot pay all of the incurred claims and plan expenses as of the date the Plan is changed or terminated, ExxonMobil will make sufficient contributions to the Plan to make up the difference. If all claims and expenses are paid and there's still money in ExxonMobil's book reserve established for the purpose of making contributions toward the cost of employees' health care coverage, ExxonMobil will determine what to do with the excess amount in view of the purposes of the Plans. Your Rights Under ERISA As a participant in the ExxonMobil Dental Plan, you have certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that as a plan participant, you shall be entitled to: Receive Information About Your Plan and Benefits Examine, without charge, at the office of the Administrator-Benefits and at other specified locations, such as worksites and union halls, all documents governing the Dental Plan, including collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Dental Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. Obtain, upon written request to the Administrator-Benefits, copies of documents governing the operation of the Dental Plan, including collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The administrator may require a reasonable charge for the copies. Receive a summary of the Dental Plan's annual financial report. The Administrator-Benefits is required by law to furnish each participant with a copy of this summary annual report. Prudent Actions by Dental Plan Fiduciaries In addition to creating rights for Dental Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Dental Plan, called "fiduciaries" of the Dental Plan, have a duty to do so prudently and in the interest of you and other Dental Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a plan benefit or exercising your rights under ERISA.

44 43 Enforce Your Rights If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision, without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Dental Plan documents or the latest summary annual report from the Dental Plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Administrator-Benefits to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim and an appeal for benefits, which are denied or ignored, in whole or in part, you may file suit in a federal court. Such lawsuit must be filed in the United States District Court for the Southern District of Texas, Houston, Texas, or in the United States District Court for the federal judicial district where the employee currently works. If a retiree or terminee, the suit must be filed in the last location worked prior to termination of employment. Beneficiaries must also file in the same federal judicial district that the employee or retiree would be required to file. Any such lawsuit must be brought within one year of the date on which an appeal was denied. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

45 44 Assistance with Your Questions If you have any questions about your Dental Plan, you should contact Aetna Member Services via the telephone number on your ID card, or call Benefits Administration. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Administrator-Benefits, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.

46 About Dental Eligibility and Enrollment Dental PPO Covered Expenses Exclusions Payments Claims Continuation Coverage Administrative and ERISA Information Key Terms Benefit Summary Key Terms In this section, you will find both General Terms pertaining to the Dental Plan and Common Dental Terms. General Terms Barred Employee An employee who is covered by a collective bargaining agreement except to the extent participation in the Dental Plan is provided under such agreement. Benefit Service Generally, all the time from the first day of employment until you leave the company's employment. Excluded are: unauthorized absences; leaves of absence of over 30 days (except military leaves or leave under the Federal Family and Medical Leave Act); certain absences from which you do not return; periods when you work as a non-regular employee, as a special agreement person, in a service station, car wash, or car-care center operations; or when you are covered by a contract that requires the company to contribute to a different benefit program, unless a special authorization credits the service. Change in Status Life or work event that allows you to make changes to your elections during the plan year and outside of the annual enrollment period. Child A person age 26 who is: A natural or legally adopted child of a regular employee or retiree; A grandchild, niece, nephew, cousin, or other child related by blood or marriage over whom a regular employee, retiree, or the spouse of a regular employee or retiree (separately or together) is the sole court appointed legal guardian or sole managing conservator; A child for whom the regular employee or retiree has assumed a legal obligation for support immediately prior to the child's adoption by the regular employee or retiree; or A stepchild of a regular employee or retiree. Child does not include a foster child. Claims Administrator/Processor Aetna, or affiliates, for claims.

47 Covered Charges Charges by a dentist or physician for services and supplies required for dental care and treatment. Charges in excess of the reasonable and customary charge made for similar services and supplies by dentists or physicians in the same area are not covered. Where alternative services or supplies are customarily available for such treatment, reimbursement will be based on the least expensive service or supply resulting in professionally adequate treatment. 46 Eligible Employees Most U.S. dollar-paid employees of Exxon Mobil Corporation and participating affiliates are eligible. Full-time employees not hired on a temporary basis (also called "regular employees") are eligible. Extended part-time employees, as classified on the employer's books and records, are also eligible. The following are not eligible to participate in the Plan: leased employees as defined in the Internal Revenue Code, barred employees, or special agreement persons as defined in the plan document. Generally, specialagreement persons are persons paid by the company on a commission basis, persons working for an unaffiliated company that provides services to the company, and persons working for the company pursuant to a contract that excludes coverage of benefits.

48 47 Eligible Family Members Eligible family members are generally your: Spouse. A child who is described in any one of the following paragraphs (1) through (3): (1) has not reached the end of the month during which age 26 is attained; or (2) is totally and continuously disabled and incapable of self-sustaining employment by reason of mental or physical disability, provided the child: (a) meets the Internal Revenue Service's definition of a dependent and (b) either (i) was, or would have been, covered as an eligible family member under this Plan immediately prior to the birthday on which the child's eligibility would have otherwise ceased, or (ii) was covered as an eligible family member under a predecessor plan which provided for coverage of disability, if the disability occurred prior to the birthday on which the child's eligibility under that plan would have otherwise ceased, the child continued to be considered eligible for coverage because of such disability and the child had not lost eligibility under the predecessor plan; and (c) the child is disabled before such birthday and has remained continuously disabled, and (3) the child is recognized under a qualified medical child support order as having a right to coverage under this Plan. A child who was disabled by reason of a mental disability but who no longer meets the requirements of paragraph 2(a) above, ceases to be an eligible family member 300 days following the date on which the applicable requirement is not met. Please note: An eligible employee or retiree's parents are not eligible to be covered.

49 48 Extended Part-time Employee An employee who is classified as a non-regular employee, but who has been designated as an Extended Part-Time Employee under his or her employer's employment policies relating to flexible work arrangements. Medically Necessary A service or supply that is: Legal; Ordered by a dentist or physician; Reasonably required for the treatment or management of the condition for which it is ordered; and Commonly and customarily recognized by the United States dental community as appropriate in the treatment or management of the condition for which it is ordered. The Administrator-Benefits has the exclusive and final authority to determine if a service or supply is medically necessary as used in the Plan. In making this determination, the findings and assessments of the United States dental community and the experience and expertise of the claims administrator shall be considered along with evaluation from independent professionals. As used herein, the "United States dental community" shall include national dental associations, societies and organizations including, but not limited to, the American Dental Association. The Administrator-Benefits may apply different standards to different services or supplies in determining medical necessity. Additionally, the Administrator- Benefits may consider the Dental Clinical Policy Bulletins (CPBs) published by Aetna, the claims administrator. Dental CPBs are based on established, nationally accepted governmental and/or professional society recommendations, as well as other recognized sources. These Dental CPBs may be found on the Aetna Web site at or the Aetna NavigatorTM Web site at Predetermination A written pre-determination request will result in a detailed response as to whether a treatment or service is covered under the Dental Plan and whether the proposed cost is within reasonable and customary limits, thus ensuring all parties are aware of the financial consequences, providing all circumstances described in the request remain unchanged. Please note that a pre-determination, either verbal or written, is not a guarantee of payment, as claims are paid based on the actual services rendered and in accordance with Plan provisions. Qualified Medical Child Support Order A Qualified Medical Child Support Order (QMCSO) is a court decree under which a court order mandates health coverage for a child. A QMCSO must include, at a minimum: Name and address of the employee covered by the health plan. The name and address of each child for whom coverage is mandated. A reasonable description for the coverage to be provided. The time period of coverage. The name of each health plan to which the order applies. You may obtain, without charge, a copy of the Plan's procedures governing QMCSO determinations by written request to the Administrator-Benefits.

50 49 Regular Employee An employee of a participating employer, whether or not the person is a director, who, as determined by the participating employer, regularly works a full-time schedule, and is not employed on a temporary basis. The definition includes a person who regularly works a full-time schedule but who, for a limited period of time, is approved for a part-time regular work arrangement under the participating employer s work rules relating to part-time work for regular employees. Retiree Generally, a person at least 55 years old who retires as a regular employee with 15 or more years of benefit service and who has not thereafter recommenced employment as a covered employee or a nonregular employee. Retiree status may also be attained by someone who is retired by the company and entitled to long-term disability benefits under the ExxonMobil Disability Plan after 15 or more years of benefit service, regardless of age. Employees who terminate while non-regular (including extended parttime employees) are not eligible for retiree status regardless of age or service. Special-Agreement Person Generally, a person paid on a commission or commission salary basis other than a person paid while employed by the Marketing Department of ExxonMobil; an employee providing service to a non-affiliated organization that pays the person's salary or wages; or an employee working pursuant to an agreement that specifically excludes the person from coverage for benefits. Spouse; Marriage All references to marriage shall mean a marriage that is legally recognized under the laws of the state or other jurisdiction in which the marriage takes place, consistent with U.S. federal tax law. All references to a spouse or a married person shall refer to individuals who have such a marriage. Survivor/Surviving Spouse A surviving unmarried spouse or child of a deceased ExxonMobil regular employee or retiree. Suspended Retiree A person who becomes a retiree due to incapacity within the meaning of the ExxonMobil Disability Plan and who begins long-term disability benefits under that plan, but whose benefits stop because the person is no longer incapacitated. A person remains a suspended retiree until the earlier of the date the person: Reaches age 55; or Begins his or her retirement benefit under the ExxonMobil Pension Plan, at which time the person is again considered a retiree. The family members of a deceased suspended retiree will be eligible for coverage under this Plan only after the occurrence of the earlier of the following: The date the suspended retiree would have attained age 55; or The date a survivor begins receiving a benefit due to the suspended retiree's accrued benefit from the ExxonMobil Pension Plan. Trainee An employee who is classified as a non-regular employee, but who has been characterized as a Trainee and has graduated from high school.

51 50 Common Dental Terms Abutment Terminal tooth or root that retains or supports a bridge or a fixed or removable prosthesis. Appliance A device used to provide function or therapeutic (healing) effect. An appliance may be fixed or removable. Attrition The wearing away of a tooth's enamel. Bite-wing Dental x-ray showing approximately the coronal (crown) halves of the upper and lower jaw. Crown A tooth shaped cover placed over a tooth that is badly damaged or decayed, may also be referred to as a cap. Decay The destruction or decomposition of a tooth as a result of bacterial action. Dentist A person acting within the scope of his or her license and holding the degree of Doctor of Dental Surgery (DDS). Denture A device replacing missing teeth. Fixed Bridge A prosthesis replacing one or more teeth that is cemented in place in the mouth. It consists of one or more pontics held in place by one or more retainers on abutment teeth. Fluoride A solution of fluoride applied topically to teeth to prevent dental decay. Full-Mouth X-Ray An X-ray of every tooth, from crown to root to supporting structures, mostly using bitewing X-rays (with film inside the mouth). Implant A prosthetic device placed in the jaw to which a tooth or denture may be anchored. Impression A negative reproduction of a given area. Occlusal Night Guard A dental instrument that protects the teeth from damage done during sleep. The night guard may cover one or both rows of teeth and is fitted to each patient so that the teeth fit perfectly to limit the grinding and clenching during the night. Orthodontics The branch of dentistry primarily concerned with the detection, prevention, and correction of abnormalities in the positioning of the teeth in their relationship to the jaws. Panoramic X-Ray An X-ray of the entire mouth all teeth on both upper and lower jaws on a single X-ray (with film outside the mouth).

52 51 Partial Denture A prosthesis that replaces one or more, but less than all, of the natural teeth and associated structures and is supported by the teeth and/or the gums. It may be removable or fixed, on one side or two sides. Periapical An X-ray highlighting only one or two teeth at a time. A periapical X-ray looks similar to a bite-wing X-ray. However, it shows the entire length of each tooth, from crown to root. Periodontal Cleaning The removal of the bacterial plaque and calculus from supra gingival (above the gum line) and sub gingival (below the gum line) regions including scaling and root planing (removal of any remaining calculus and smoothing of irregular areas of the root surface). Physician A person acting within the scope of his or her license and holding the degree of Doctor of Medicine (M.D.). Pontic The part of a fixed bridge that is suspended between the abutments and which replaces a missing tooth or teeth. Prophylaxis The removal of tartar and stains from teeth through the cleaning of the teeth by a dentist or dental hygienist. Restoration Any inlay, crown, bridge, partial denture, or complete denture that restores or replaces loss of tooth structure, teeth, or oral tissue, which results in repair, restoration, or reformation of the shape, form, and function of part or all of a tooth or teeth. Root Canal Therapy Treatment of a tooth with damaged pulp, generally through complete removal of the pulp, sterilization of the pulp chamber and root canals, and filling the resulting space with sealing material. Scaling The removal of calculus (commonly called tartar) and plaque that attach to the tooth surfaces. Space Maintainers Designed to preserve the space created by the premature loss of a deciduous (baby) tooth in a child with deciduous or mixed dentition. They are used until normal eruption of the permanent tooth occurs or until it becomes practical to place a permanent prosthesis in place. Temporomandibular Joint Disorder (TMJ/TMD) Any myofascial pain dysfunction involving the temporomandibular joint connecting the skull and jawbone.

53 About Dental Eligibility and Enrollment Dental PPO Covered Expenses Exclusions Payments Claims Continuation Coverage Administrative and ERISA Information Key Terms Benefit Summary Benefit Summary 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 Family Annual Dental Maximum: $50 $150 $2,000 per covered person Covered Services Preventive Services: 100% (no deductible and charges not applied to annual dental maximum) Oral examinations* Bitewing X-rays* Periapical X-rays Prophylaxis and/or Periodontal cleanings (up to four cleanings per calendar year) Fluoride applications* 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 Injected antibiotics (in conjunction with treatment of a covered dental expense) Oral surgery (see page 54) 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

54 Orthodontic Services:*** 50% (no deductible) Orthodontia lifetime maximum $2,000 per covered person * Limited to four times each calendar year. ** Limitation does not apply to orthodontic treatment. *** Orthodontia benefits are paid based on treatment plan, not payment schedule. 53

55 54 Payment for the following oral surgery procedures is coordinated with the EMMP POS II option but not for the EMMP Aetna Select HMO option or the EMMSP: ADA Description Code D3428 Bone graft in conjunction with periradicular surgery per tooth, single site D3429 Bone graft in conjunction with periradicular surgery each additional contiguous tooth in same surgical site D3431 Biological materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery D3432 Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery D4210 Gingivectomy or Gingivoplasty 4 or more contiguous teeth or bounded teeth spaces per quadrant D4211 Gingivectomy or Gingivoplasty - 1 to 3 contiguous teeth or bounded teeth spaces per quadrant D4212 Gingivectomy or Gingivoplasty to allow access for restorative procedure, per tooth D4220 Gingival curettage D4240 Gingival flap procedure, including root planning, 4 or more contiguous teeth or bounded teeth spaces per quadrant D4241 Gingival flap procedure, including root planning, 1-3 teeth per quadrant D4245 Apically positioned flap D4260 Osseous surgery, including flap entry and closure, 4 or more teeth or bounded teeth spaces per quadrant D4263 Bone replacement graft-first site in quadrant D4264 Bone replacement graft-each additional site in quadrant D4265 Biological materials to aid in soft & osseous tissue regeneration D4266 Guided tissue regeneration-resorbable barrier, per site D4267 Guided tissue regeneration-non-resorbable barrier, per site (includes membrane removal) D4268 Surgical revision procedure, per tooth D4270 Pedicle soft graft-per graft D4273 Subepithelial connective tissue graft procedure, per tooth (includes donor site surgery) D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) D4277 Free soft tissue graft (including donor site surgery), first tooth or edentulous tooth position in a graft D4278 Free soft tissue graft (including donor site surgery), each additional contiguous tooth or edentulous tooth in a graft D4320 Provisional Splinting-Intracoronal D4321 Provisional Splinting-Extracoronal D6010 Surgical placement of implant body-endosteal implant D6011 Second stage implant surgery D6013 Surgical placement of mini implant D6040 Surgical placement: eposteal implant D6050 Surgical placement: transosteal implant D6052 Semi-precision attachment abutment D6101 Debridement of peri-implant defect and surface cleaning of exposed implant surfaces; including flap entry and closure D6102 Debridement of osseous contouring of a peri-implant defect; includes surface cleaning of exposed implant surfaces and flap entry and closure D6104 Bone graft at time of implant D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone/section of tooth

56 55 ADA Description Code D7220 Removal of impacted tooth, soft tissue D7230 Removal of impacted tooth, partially bony D7240 Removal of impacted tooth, completely bony D7241 Removal of impacted tooth, completely bony with unusual surgical complications D7250 Surgical removal of residual tooth roots (cutting procedure) D7260 Oroantral fistula closure D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) D7280 Surgical access of an unerupted tooth D7281 Surgical exposure of impacted unerupted teeth to aid eruption D7285 Biopsy of Oral Tissue-Hard D7286 Biopsy of Oral Tissue-Soft D7290 Surgical repositioning of the teeth D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report D7310 Alveoplasty in conjunction with extractions, per quadrant. (We consider this incidental to the extractions when performed at the same time as extractions and on 4 tooth sockets or less.) D7320 Alveoplasty not in conjunction with extractions, per quadrant D7340 Vestibuloplasty-ridge extension (secondary epithelialization) D7350 Vestibuloplasty,- ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue D7471 Removal of lateral exostosis, maxilla or mandible D7910 Suture, small wound-up to 5 cm D7911 Suture, complicated-up to 5 cm D7912 Suture, complicated-over 5 cm D7920 Skin graft (identify defect covered and graft location) D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or facial bonesautogenous or nonautogenous, by report. D7960 Frenulectomy D7970 Excision of hyperplastic tissue, per arch D7971 Excision of pericoronal gingival D7996 Implant-mandible for augmentation purposes (excluding alveolar ridge) D9219 Evaluation of deep sedation or general anesthesia D9220 Deep sedation/general anesthesia-first 30 minutes D9221 Deep sedation/general anesthesia-each additional 15 minutes D9241 Intravenous conscious sedation/analgesia-first 30 minutes D9242 Intravenous conscious sedation/analgesia- each additional 15 minutes For more information, please contact: Aetna Member Services: (800) or visit

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