90.04-31 Topical Fluoride Varnish Eff. 10/1/08 Therapeutic application
of topical fluoride varnish is covered for members under the age of twenty-one (21) with
moderate to high caries risk. MaineCare will cover application two (2) times per calendar
year. For members with high caries rates or new restoration within eighteen (18) months,
as are documented in the member’s
record, MaineCare will cover up to three (3) applications per calendar year. Coverage is allowable
for physicians with subspecialties of general or family practice, preventative medicine, pediatric,
or internal medicine.