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. Accidental injuries To receive coverage for repair of an accidental injury to natural teeth, the injury must be evaluated, and a treatment plan developed and finalized within 30 days of the injury. The actual treatment may extend beyond 30 days if your provider determines upon the initial assessment that treatment should start later or continue longer. Treatment must be completed by the end of the calendar year following the accident. The plan does not cover treatment after UMP coverage ends. Example: You have an accident on March 12, 2024, resulting in injuries that are covered by the plan. Your treatment plan must be finalized no later than April 11, 2024. All related treatment must be completed by December 31, 2025 (the calendar year following the accident). The plan does not cover treatment that: • Was not included in the treatment plan developed within the first 30 days following the accident; • Extends past the end of the calendar year following the accident; or • Extends past the end of your enrollment in the plan. Diabetes care supplies TIP: If a health plan other than UMP is your primary payer, claims for diabetes care supplies may be paid differently (see page 121). Medical Insulin pumps and pump supplies are covered as durable medical equipment (DME). See page 53 for coverage of insulin pumps and related supplies. 2024 UMP Plus–UW Medicine ACN (PEBB) Certificate of Coverage 49