Noblesville Schools Medical Plan 43 Section 1: Covered Health Care Services • The dental damage is severe enough that first contact with a Physician or dentist happened within 72 hours of the accident. (You may request this time period be longer if you do so within 60 days of the Injury and if extenuating circumstances exist due to the severity of the Injury.) Please note that dental damage that happens as a result of normal activities of daily living or extraordinary use of the teeth is not considered an accidental Injury. Benefits are not available for repairs to teeth that are damaged as a result of such activities. Dental services to repair damage caused by accidental Injury must follow these time-frames: • Treatment is started within three months of the accident, or if not a Covered Person at the time of the accident, within the first three months of coverage under the Plan, unless extenuating circumstances exist (such as prolonged hospitalization or the presence of fixation wires from fracture care). • Treatment must be completed within 12 months of the accident, or if not a Covered Person at the time of the accident, within the first 12 months of coverage under the Plan. Benefits for treatment of accidental Injury are limited to the following: • Emergency exam. • Diagnostic X-rays. • Endodontic (root canal) treatment. • Temporary splinting of teeth. • Prefabricated post and core. • Simple minimal restorative procedures (fillings). • Extractions. • Post-traumatic crowns if such are the only clinically acceptable treatment. • Replacement of lost teeth due to Injury with implant, dentures or bridges. Diabetes Services Diabetes Self-Management and Training/Diabetic Eye Exams/Foot Care Outpatient self-management training for the treatment of diabetes, education and medical nutrition therapy services. Services must be ordered by a Physician and provided by appropriately licensed or registered health care professionals. Benefits also include medical eye exams (dilated retinal exams) and preventive foot care for diabetes. Diabetic Self-Management Items Insulin pumps and supplies and continuous glucose monitors for the management and treatment of diabetes, based upon your medical needs. An insulin pump is subject to all the conditions of coverage stated under Durable Medical Equipment (DME), Orthotics and Supplies. Benefits for blood glucose meters, including continuous glucose monitors, insulin syringes with needles, blood glucose and urine test strips, ketone test strips and tablets and lancets and lancet devices may be available through the outpatient prescription drug plan. Durable Medical Equipment (DME), Orthotics and Supplies Benefits are provided for DME and certain orthotics and supplies. If more than one item can meet your functional needs, Benefits are available only for the item that meets the minimum specifications for your needs. If you purchase an item that exceeds these minimum specifications, the Plan will pay only the