LSU Student Dental Plan

Deductible

 $50 Plan Year Maximum (3 per family/$150 maximum deductible per family). Applies to Class B.

Benefit Year Maximum

 $1,000 per plan year (applies to class A & B)

Carryover Benefit

 Included (*) See chart below

Class A -- Preventive Services

***Deductible Waived***
 		Class A-100% Covered
Waiting Period: None
Routine exams (1 per 6 months)
Prophylaxis (1 per 6 months)
Bitewing X-rays (max 4 films; 1 per 12 months)
Fluoride to age 16 (1 per 12 months)
Full mouth X-ray (1 per 24 months)

Class B -- Basic Services


 Class B-20% (Student Responsibility)
Waiting Period: None
Sealants to age 16 (permanent molars, 1 per 36 months)
Fillings
Simple extractions

Class C -- Major Services


 Class C-50% (Student Responsibility)
Waiting Period: 12 Months
Endodontics (root canals)

Reimbursements

 In-Network: Fee Schedule
Non-Network: 90th Percentile
Dental Rates
Annual Fall Spring / Summer Three Payment Nine Payment Summer
08/14/08 - 08/13/09 08/14/08 - 01/05/09 01/06/09 - 08/13/09 08/14/08 - 08/13/09 08/14/08 - 08/13/09 06/05/09 - 08/13/09
Student $215.76 $107.88 $107.88 $71.92 $23.98 $53.94
Student +1 $431.76 $215.88 $215.88 $143.92 $47.98 $107.94
Student + Family $767.52 $383.76 $383.76 $255.84 $85.30 $191.88
Carryover Benefit Rider (flyer)
Base Plan
Annual Maximum 		Threshold
Limit 		Carryover
Amount 		Carryover Account
Maximum 		Total Potential
Annual Maximum
$1,000
 $500 $250 $1,000 $2,000

(*) Carryover Benefit: If an Insured submits Qualifying Claims for Covered Expenses during a benefit year and, in that benefit year, receives benefits that are less than their group’s Threshold Limit, the Insured will be credited a Carryover Benefit. Carryover Benefits will be accrued and stored in the Insured’s Carryover Account to be used in the next benefit year. If, in the next benefit year, an Insured reaches his or her Policy Year Maximum Benefit, we will pay a benefit from the Insured’s Carryover Account up to the amount stored in the Insured’s Carryover Account. The accrued Carryover Benefits stored in the Carryover Account may not be greater than the Carryover Account Maximum.

Disclaimer: This information is for illustrative purposes only. This document does not amend or alter the coverage provided by the actual insurance policies and contracts. Please see the Master Policy for specific policy information and exclusions.