Dental services ALERT! Dentists and other dental providers are not included in the UMP provider network, even if they are listed in the Regence provider directory. The plan does not cover most dental services. For example, dental implants, orthodontic services, and treatment for damage to teeth or gums caused by biting, chewing, grinding, or any combination of these are not covered. However, your PEBB dental plan may cover these services. Refer to your dental plan’s COC, found on the HCA website at hca.wa.gov/erb, for more information. What is covered by the plan The plan covers oral surgery and other dental services under the medical benefit when they are considered medical. Oral surgery and dental services are considered medical if the condition being diagnosed and treated is either one which is not connected to the teeth and/or gums or is related to a disease or illness that affects the whole body. These medical services may be performed by a dentist or medical professional provider. You can find examples of these medical services in the Regence Medical Policy Administrative Guidelines to Determine Dental vs Medical Services by visiting the UMP Policies that affect your care webpage (see Directory for link). You pay 20 percent of the allowed amount for covered dental services unless otherwise stated, and the provider may balance bill you. Note: UMP is not affiliated with the Uniform Dental Plan (UDP). If you are enrolled in UDP, contact UDP for information about services covered under your dental plan. Visit the HCA website at hca.wa.gov/erb and select “Contact” to find UDP contact information. Fluoride treatment Under certain circumstances, the plan may cover fluoride supplements (see the “Preventive care” benefit) at the preventive rate. The application of fluoride varnish may be covered for infants and children starting at the age when primary teeth come in (primary teeth eruption) in primary care practices for prevention of tooth decay (dental caries or cavities). Coverage of fluoride treatment depends on the network status of the medical provider as described in the “Finding a health care provider” section. Health care providers, such as your child’s medical PCP, may apply fluoride varnish. General anesthesia during a dental procedure General anesthesia performed during a dental procedure is covered only when: • It is provided by an anesthesiologist; and • The charges are covered by the plan (see below). Dental procedures General anesthesia may be performed in a dental office for covered procedures and is paid at the standard rate. Dental procedures that are performed in a hospital or ambulatory surgery center are covered only when the member: • Is under age 8 with a dental condition that cannot be safely and effectively treated in a dental office; or • Has a dental condition that cannot be safely and effectively treated in a dental office because of a physical or developmental disability; or • Has a medical condition that would put the member at undue risk if the procedure were performed in a dental office. 44 2024 UMP Classic (PEBB) Certificate of Coverage