2018 Bonitas Medical Scheme Dental Benefit Table

Bonitas Medical Scheme Dental Benefit Table

                                                                                                                   2018


PRIMARY DENTAL BENEFIT TABLE 2018
BONSAVE DENTAL BENEFIT TABLE 2018
STANDARD / STANDARD SELECT DENTAL BENEFIT TABLE 2018
BONCOM DENTAL BENEFIT TABLE 2018

Dental benefits are paid at the Bonitas Dental Tariff (BDT). Hospitalisation and certain specialised dentistry procedures and
treatment must be pre-authorised*. Procedures and treatment not pre-authorised will not attract a benefit, with the exception
of crown and bridge procedures where a 20% penalty will apply if authorisation is applied for after the treatment has been
done. Failure to pre-authorise orthodontic treatment will result in a payment ONLY from date of authorisation for the
remaining months of treatment, provided that the treatment is clinically indicated. Penalties do not apply to emergency
hospital admission.

Co-payments are levied for Orthodontics on the Standard and Standard Select option

Benefits payable on the Primary option is subject to a Designated Service Provider arrangement with the DENIS Dental
Network.

Dentures* must be pre-authorised on the Primary, BonSave, Standard, Standard Select and BonCom options.

Co-payments are levied on the Hospital account on the Primary, BonSave, Standard and Standard Select options.

Members on the Standard Select option must use a hospital within the Bonitas Hospital Network. Should a member on
the Standard Select option make use of a non-network hospital, a 30% co-payment will be applicable on the hospital
account.

Dental benefits are subject to managed care protocols and managed care interventions which may include the requirement
of treatment plans and/or radiographs prior to benefit application. Scheme Exclusions apply to dental benefits. In the event
of a dispute, the registered rules of the scheme prevail.

BonCom option**
The dental benefits of the BonCom option will be paid from the member’s available savings and/or threshold limit. The dental
benefits as published below will apply, subject to DENIS managed care protocols and managed care interventions which
include pre-authorisation where necessary. Pre-authorisation is required for crowns, orthodontics, implants, periodontics,
hospital and IV/conscious sedation. Co-payments are not applicable to maxillo-facial surgery and hospitalisation.

Please note that Medscheme will be responsible for the payment of all dental claims on the BonCom option.




                                                                                                                           1
STANDARD/
                                                   PRIMARY                  BONSAVE                STANDARD                  BONCOM
                                                                                                    SELECT

                                              Two annual check-        Two annual check-       Two annual check-       Once in 6 months
                                              ups per beneficiary      ups per beneficiary     ups per beneficiary
                                              (once in 6 months).      (once in 6 months).     (once in 6 months).

                                              Benefit is subject to    Benefit is subject to   Benefit is subject to   Benefit is subject to
                         Consultations
                                              managed care             managed care            managed care            managed care
                                              protocols.               protocols.              protocols.              protocols.

                                              Covered at the BDT.      Covered at the BDT.     Covered at the BDT.     Covered at the
                                                                                                                       BDT**.

                                              Benefit is subject to    Benefit is subject to   Benefit is subject to   Benefit is subject to
                                              managed care             managed care            managed care            managed care
                                              protocols.               protocols.              protocols.              protocols.
                         X-rays: Intra-oral

                                              Covered at the BDT.      Covered at the BDT.     Covered at the BDT.     Covered at the
                                                                                                                       BDT**.
CONSERVATIVE DENTISTRY




                                              One per beneficiary      One per beneficiary     One per beneficiary     One per beneficiary
                                              in a 3-year period.      in a 3-year period.     in a 3-year period.     in a 3-year period.

                                              Benefit is subject to    Benefit is subject to   Benefit is subject to   Benefit is subject to
                                              managed care             managed care            managed care            managed care
                                              protocols.               protocols.              protocols.              protocols.

                         X-rays: Extra-oral                                                    Additional benefit      Additional benefit
                                                                                               may be considered       may be considered
                                                                                               where specialised       where specialised
                                                                                               dental treatment is     dental treatment is
                                                                                               required.               required.

                                              Covered at the BDT.      Covered at the BDT.     Covered at the BDT.     Covered at the
                                                                                                                       BDT**.

                                              Two annual scale         Two annual scale        Two annual scale      Once in 6 months
                                              and polish               and polish treatments   and polish treatments
                                              treatments per           per beneficiary (once   per beneficiary (once
                                              beneficiary (once in 6   in 6 months).           in 6 months).
                                              months).
                         Oral Hygiene

                                              Benefit is subject to    Benefit is subject to   Benefit is subject to   Benefit is subject to
                                              managed care             managed care            managed care            managed care
                                              protocols.               protocols.              protocols.              protocols.




                                                                                                                                               2
STANDARD/
                                              PRIMARY                   BONSAVE                   STANDARD                     BONCOM
                                                                                                   SELECT

                                        Covered at the BDT.        Covered at the BDT.        Covered at the BDT.        Covered at the
                                                                                                                         BDT**.

                                        Benefit for fissure        Benefit for fissure        Benefit for fissure        Benefit for fissure
                                        sealants is limited to     sealants is limited to     sealants is limited to     sealants is limited to
                                        beneficiaries younger      beneficiaries younger      beneficiaries younger      beneficiaries younger
                                        than 16 years of age.      than 16 years of age.      than 16 years of age.      than 16 years of age.

                                        Benefit for fluoride is    Benefit for fluoride is    Benefit for fluoride is    Benefit for fluoride is
                                        limited to                 limited to                 limited to                 limited to
                                        beneficiaries from         beneficiaries from         beneficiaries from         beneficiaries from
                         Oral Hygiene   age 5 and younger          age 5 and younger          age 5 and younger          age 5 and younger
                         (continue)     than 16 years of age.      than 16 years of age.      than 16 years of age.      than 16 years of age.

                                        Scheme                     Scheme                     Scheme                     Scheme
                                        Exclusions:                Exclusions:                Exclusions:                Exclusions:
                                        • Oral hygiene             • Oral hygiene             • Oral hygiene             • Oral hygiene
                                          instructions               instructions               instructions               instructions
CONSERVATIVE DENTISTRY




                                        • Oral hygiene             • Oral hygiene             • Oral hygiene             • Oral hygiene
                                          evaluation                 evaluation                 evaluation                 evaluation
                                        • Professionally           • Professionally           • Professionally           • Professionally
                                          applied fluoride for       applied fluoride for       applied fluoride for       applied fluoride for
                                          beneficiaries 16           beneficiaries 16           beneficiaries 16           beneficiaries 16
                                          years and older            years and older            years and older            years and older
                                        • Dental bleaching         • Dental bleaching         • Dental bleaching         • Dental bleaching

                                        Benefit for fillings are   Benefit for fillings are   Benefit for fillings are   Benefit for fillings are
                                        granted once per           granted once per           granted once per           granted once per
                                        tooth in 365 days.         tooth in 365 days.         tooth in 365 days.         tooth in 365 days.

                                        Benefit for re-            Benefit for re-            Benefit for re-            Benefit for re-
                                        treatment of a tooth       treatment of a tooth       treatment of a tooth       treatment of a tooth
                                        is subject to              is subject to              is subject to              is subject to
                                        managed care               managed care               managed care               managed care
                                        protocols.                 protocols.                 protocols.                 protocols.
                         Fillings
                                        Covered at the BDT.        Covered at the BDT.        Covered at the BDT.        Covered at the
                                                                                                                         BDT**.

                                        A treatment plan and       A treatment plan and       A treatment plan and       A treatment plan and
                                        X-rays may be              X-rays may be              X-rays may be              X-rays may be
                                        required for multiple      required for multiple      required for multiple      required for multiple
                                        fillings.                  fillings.                  fillings.                  fillings.




                                                                                                                                                  3
STANDARD/
                                            PRIMARY                  BONSAVE                 STANDARD                  BONCOM
                                                                                              SELECT

                                       Scheme                   Scheme                 Scheme                 Scheme
                                       Exclusions:              Exclusions:            Exclusions:            Exclusions:
                                       • Fillings to restore    • Fillings to restore  • Fillings to restore  • Fillings to restore
                                         teeth damaged due        teeth damaged due      teeth damaged due      teeth damaged due
                                         to toothbrush            to toothbrush          to toothbrush          to toothbrush
                                         abrasion, attrition,     abrasion, attrition,   abrasion, attrition,   abrasion, attrition,
                                         erosion and              erosion and            erosion and            erosion and
                                         fluorosis                fluorosis              fluorosis              fluorosis
                         Fillings      • Resin bonding for      • Resin bonding for    • Resin bonding for    • Resin bonding for
                         (continue)      restorations that        restorations that      restorations that      restorations that
                                         are charged as a         are charged as a       are charged as a       are charged as a
                                         separate procedure       separate procedure     separate procedure     separate procedure
                                         to the restoration       to the restoration     to the restoration     to the restoration
                                       • The polishing of       • The polishing of     • The polishing of     • The polishing of
                                         restorations             restorations           restorations           restorations
                                       • Gold foil              • Gold foil            • Gold foil            • Gold foil
                                         restorations             restorations           restorations           restorations
CONSERVATIVE DENTISTRY




                                       • Ozone therapy          • Ozone therapy        • Ozone therapy        • Ozone therapy

                                       Benefit is subject to    Benefit is subject to    Benefit is subject to   Benefit is subject to
                                       managed care             managed care             managed care            managed care
                                       protocols.               protocols.               protocols.              protocols.

                                       Benefit for root canal   Benefit for root canal
                                       includes all teeth       includes all teeth
                                       except primary teeth     except primary teeth
                                       and permanent            and permanent
                                       molars.                  molars.

                                       Covered at the BDT.      Covered at the BDT.      Covered at the BDT.     Covered at the
                         Root Canal
                                                                                                                 BDT**.
                         Therapy and
                         Extractions
                                       Scheme                   Scheme                   Scheme                  Scheme
                                       Exclusions:              Exclusions:              Exclusions:             Exclusions:
                                       • Direct and indirect    • Direct and indirect    • Root canal therapy    • Root canal therapy
                                         pulp capping             pulp capping             on primary (milk)       on primary (milk)
                                         procedures               procedures               teeth                   teeth
                                       • Root canal therapy     • Root canal therapy     • Root canal therapy    • Root canal therapy
                                         on wisdom teeth          on wisdom teeth          on wisdom teeth         on wisdom teeth
                                         (third molars)           (third molars)           (third molars)          (third molars)
                                       • Direct and indirect    • Direct and indirect    • Direct and indirect   • Direct and indirect
                                         pulp capping             pulp capping             pulp capping            pulp capping
                                         procedures               procedures               procedures              procedures




                                                                                                                                         4
STANDARD/
                                                   PRIMARY                  BONSAVE                  STANDARD                    BONCOM
                                                                                                      SELECT

                                             Pre-authorisation is      Pre-authorisation is      Pre-authorisation is      Pre-authorisation is
                                             required.                 required.                 required.                 required.

                                             One set of plastic        One set of plastic        One set of plastic        One set of plastic
                                             dentures (an upper        dentures (an upper        dentures (an upper        dentures (an upper
                                             and a lower) per          and a lower) per          and a lower) per          and a lower) per
                                             beneficiary in a 4-       beneficiary in a 4-       beneficiary in a 4-       beneficiary in a 4-
                                             year period.              year period.              year period.              year period.

                                             Benefit is subject to     Benefit is subject to     Benefit is subject to      Benefit is subject to
                                             managed care              managed care              managed care              managed care
                                             protocols.                protocols.                protocols.                protocols.

                                             Covered at the BDT.       Covered at the BDT.       Covered at the BDT.       Covered at the
                                                                                                                           BDT**.

                                             Benefit is not            Benefit is not            Benefit is not            Benefit is not
                                             available for the         available for the         available for the         available for the
CONSERVATIVE DENTISTRY




                                             clinical fee of denture   clinical fee of denture   clinical fee of denture   clinical fee of denture
                                             repairs, denture tooth    repairs, denture tooth    repairs, denture tooth    repairs, denture tooth
                                             replacements and          replacements and          replacements and          replacements and
                         Plastic Dentures*
                                             the addition of a soft    the addition of a soft    the addition of a soft    the addition of a soft
                         and
                                             base to new               base to new               base to new               base to new
                         Associated
                                             dentures; the             dentures; the             dentures; the             dentures; the
                         Laboratory Costs
                                             laboratory fee will be    laboratory fee will be    laboratory fee will be    laboratory fee will be
                                             covered.                  covered.                  covered.                  covered.

                                             Benefit is not            Benefit is not            Benefit is not            Benefit is not
                                             available for the         available for the         available for the         available for the
                                             laboratory fee of         laboratory fee of         laboratory fee of         laboratory fee of
                                             mouthguards; the          mouthguards; the          mouthguards; the          mouthguards; the
                                             clinical fee will be      clinical fee will be      clinical fee will be      clinical fee will be
                                             covered.                  covered.                  covered.                  covered.

                                             Scheme                    Scheme                    Scheme                    Scheme
                                             Exclusions:               Exclusions:               Exclusions:               Exclusions:
                                             • Diagnostic              • Diagnostic              • Diagnostic              • Diagnostic
                                               dentures and              dentures and              dentures and              dentures and
                                               associated                associated                associated                associated
                                               laboratory costs          laboratory costs          laboratory costs          laboratory costs
                                             • Snoring appliances      • Snoring appliances      • Snoring appliances      • Snoring appliances
                                               and associated            and associated            and associated            and associated
                                               laboratory costs          laboratory costs          laboratory costs          laboratory costs
                                             • High impact acrylic     • High impact acrylic     • High impact acrylic     • High impact acrylic




                                                                                                                                                    5
STANDARD/
                                                  PRIMARY                 BONSAVE                STANDARD                  BONCOM
                                                                                                  SELECT

                                             • The cost of gold,     • The cost of gold,     • The cost of gold,       The cost of gold,
CONSERVATIVE DENTISTRY




                                               precious metal,         precious metal,         precious metal,         precious metal,
                                               semi-precious           semi-precious           semi-precious           semi-precious
                         Plastic Dentures*     metal and platinum      metal and platinum      metal and platinum      metal and platinum
                         and                   foil                    foil                    foil                    foil
                         Associated          • Laboratory delivery   • Laboratory delivery   • Laboratory delivery   • Laboratory delivery
                         Laboratory Costs      fees                    fees                    fees                    fees
                         (continue)          • Provisional           • Provisional           • Provisional           • Provisional
                                               dentures and            dentures and            dentures and            dentures and
                                               associated              associated              associated              associated
                                               laboratory costs        laboratory costs        laboratory costs        laboratory costs


                                             No benefit              No benefit              Pre-authorisation is    Pre-authorisation is
                                                                                             required.               required.

                                                                                             One partial frame (an   Two partial frames
                                                                                             upper or a lower) per   (an upper and a
                                                                                             beneficiary in a 5-     lower) per beneficiary
                                                                                             year period.            in a 5-year period.

                                                                                             Benefit is subject to   Benefit is subject to
                                                                                             managed care            managed care
                                                                                             protocols.              protocols.
SPECIALISED DENTISTRY




                                                                                             Covered at the BDT.     Covered at the BDT.
                         Partial Metal
                         Frame Dentures*                                                     Scheme                  Scheme
                         and Associated                                                      Exclusions:             Exclusions:
                         Laboratory Costs                                                    • The metal base to     • The metal base to
                                                                                               full dentures and       full dentures and
                                                                                               associated              associated
                                                                                               laboratory costs        laboratory costs
                                                                                             • High impact acrylic   • High impact acrylic
                                                                                             • The cost of gold,     • The cost of gold,
                                                                                               precious metal,         precious metal,
                                                                                               semi-precious           semi-precious
                                                                                               metal and platinum      metal and platinum
                                                                                               foil                    foil
                                                                                             • Laboratory delivery   • Laboratory delivery
                                                                                               fees                    fees




                                                                                                                                             6
STANDARD/
                                                    PRIMARY        BONSAVE       STANDARD                  BONCOM
                                                                                  SELECT

                                               No benefit     No benefit     Pre-authorisation is    Pre-authorisation is
                                                                             required.               required.

                                                                             One crown per family Three crowns per
                                                                             per year.            family per year.

                                                                             Benefit is subject to   Benefit is subject to
                                                                             managed care            managed care
                                                                             protocols.              protocols.

                                                                             Covered at the BDT.     Covered at the BDT.

                                                                             Benefits for crowns     Benefits for crowns
                                                                             will be granted once    will be granted once
                                                                             per tooth in a 5-year   per tooth in a 5-year
                                                                             period.                 period.
                        Crown & Bridge*
SPECIALISED DENTISTRY




                        and Associated
                                                                             A treatment plan and    A treatment plan and
                        Laboratory Costs
                                                                             X-rays may be           X-rays may be
                                                                             requested.              requested.
                        A bridge comprises
                        two or more crown
                                                                             Scheme                  Scheme
                        units. Each crown is
                                                                             Exclusions:             Exclusions:
                        payable from the
                                                                             • Crowns or crown       • Crowns or crown
                        available Crown &
                                                                               retainers on            retainers on
                        Bridge benefit.
                                                                               wisdom teeth (third     wisdom teeth (third
                                                                               molars)                 molars)
                                                                             • Pontics on second     • Pontics on second
                                                                               molars where the        molars where the
                                                                               third molar is a        third molar is a
                                                                               retainer                retainer
                                                                             • Crown and bridge      • Crown and bridge
                                                                               procedures for          procedures for
                                                                               cosmetic reasons        cosmetic reasons
                                                                               and associated          and associated
                                                                               laboratory costs        laboratory costs
                                                                             • Occlusal              • Occlusal
                                                                               rehabilitations and     rehabilitations and
                                                                               associated              associated
                                                                               laboratory costs        laboratory costs




                                                                                                                             7
STANDARD/
                                                PRIMARY        BONSAVE       STANDARD                  BONCOM
                                                                              SELECT

                                                                         • Provisional crowns    • Provisional crowns
                                                                           and associated          and associated
                                                                           laboratory costs        laboratory costs
                                                                         • Porcelain veneers     • Porcelain veneers
                                                                           and inlays and          and inlays and
                                                                           associated              associated
                                                                           laboratory costs        laboratory costs
                                                                         • Emergency crowns      • Emergency crowns
                                                                           that are not placed     that are not placed
                        Crown & Bridge*                                    for the immediate       for the immediate
                        and Associated                                     protection in tooth     protection in tooth
                        Laboratory Costs                                   injury and              injury and
                        (continue)                                         associated              associated
                                                                           laboratory costs.       laboratory costs.
                                                                         • The cost of gold,     • The cost of gold,
                                                                           precious metal,         precious metal,
                                                                           semi-precious           semi-precious
                                                                           metal and platinum      metal and platinum
                                                                           foil                    foil
SPECIALISED DENTISTRY




                                                                         • Laboratory delivery   • Laboratory delivery
                                                                           fees                    fees



                                           No benefit     No benefit     No benefit              Pre-authorisation is
                                                                                                 required.

                                                                                                 Two implants per
                                                                                                 beneficiary in a
                                                                                                 5-year period.

                                                                                                 Benefit is subject to
                                                                                                 managed care
                                                                                                 protocols.
                        Implants* and
                        Associated                                                               Covered at the
                        Laboratory Costs                                                         BDT**.

                                                                                                 Cost of implant
                                                                                                 components is
                                                                                                 limited to R2 490
                                                                                                 per implant.




                                                                                                                         8
STANDARD/
                                                 PRIMARY        BONSAVE       STANDARD                   BONCOM
                                                                               SELECT

                                            No benefit     No benefit     No benefit               Scheme
                                                                                                   Exclusions:
                                                                                                   • Implants on
                                                                                                     wisdom teeth (third
                                                                                                     molars)
                        Implants* and
                                                                                                   • Dolder bars and
                        Associated
                                                                                                     associated
                        Laboratory Costs
                                                                                                     abutments on
                        (continue)
                                                                                                     implants including
                                                                                                     the associated
                                                                                                     laboratory costs
                                                                                                   • Laboratory delivery
                                                                                                     fees

                                            No benefit     No benefit     Pre-authorisation is     Pre-authorisation is
                                                                          required.                required.

                                                                          Benefit is subject to    Benefit is subject to
SPECIALISED DENTISTRY




                                                                          managed care             managed care
                                                                          protocols.               protocols.

                                                                          Orthodontic              Orthodontic
                                                                          treatment is granted     treatment is granted
                                                                          once per beneficiary     once per beneficiary
                                                                          per lifetime.            per lifetime.

                                                                          On pre-authorisation,    On pre-authorisation,
                                                                          cases will be            cases will be
                        Orthodontics* and                                 clinically assessed by   clinically assessed by
                        Associated                                        using an orthodontic     using an orthodontic
                        Laboratory Costs                                  needs analysis.          needs analysis.
                                                                          Benefit allocation is    Benefit allocation is
                                                                          subject to the           subject to the
                                                                          outcome of the           outcome of the
                                                                          needs analysis and       needs analysis and
                                                                          funding can be           funding can be
                                                                          granted up to 80% of     granted up to 100%
                                                                          BDT.                     of BDT.

                                                                          Benefit for              Benefit for
                                                                          orthodontic treatment    orthodontic treatment
                                                                          will be granted where    will be granted where
                                                                          function is impaired     function is impaired.




                                                                                                                           9
STANDARD/
                                            PRIMARY   BONSAVE       STANDARD                    BONCOM
                                                                     SELECT

                                                                Benefit will not be       Benefit will not be
                                                                granted where             granted where
                                                                orthodontic treatment     orthodontic treatment
                                                                is required for           is required for
                                                                cosmetic reasons.         cosmetic reasons.

                                                                The associated            The associated
                                                                laboratory costs will     laboratory costs will
                                                                also not be covered.      also not be covered.

                                                                Only one family           Only one family
                                                                member may                member may
                                                                commence                  commence
                                                                orthodontic treatment     orthodontic treatment
                                                                in a calendar year.       in a calendar year.

                                                                Benefit for fixed         Benefit for fixed
                                                                comprehensive             comprehensive
                                                                treatment is limited to   treatment is limited to
SPECIALISED DENTISTRY




                                                                individuals from age      individuals from age
                                                                9 and younger than        9 and younger than
                        Orthodontics* and                       18 years of age.          18 years of age.
                        Associated
                        Laboratory Costs                        Scheme                 Scheme
                        (continue)                              Exclusions:            Exclusions:
                                                                • Orthognathic (jaw    • Orthognathic (jaw
                                                                  correction) and        correction) and
                                                                  other orthodontic      other orthodontic
                                                                  related surgery and    related surgery and
                                                                  any related hospital   any related hospital
                                                                  and laboratory         and laboratory
                                                                  costs                  costs
                                                                • Orthodontic re-      • Orthodontic re-
                                                                  treatment and any      treatment and any
                                                                  related laboratory     related laboratory
                                                                  costs                  costs
                                                                • Invisible retainer   • Invisible retainer
                                                                  material               material
                                                                • Laboratory delivery • Laboratory delivery
                                                                  fees                   fees




                                                                                                              10
STANDARD/
                                              PRIMARY                 BONSAVE                STANDARD                  BONCOM
                                                                                              SELECT

                                         No benefit              No benefit              Pre-authorisation is    Pre-authorisation is
                                                                                         required.               required.

                                                                                         Benefit is subject to   Benefit is subject to
                                                                                         managed care            managed care
                                                                                         protocols.              protocols.

                                                                                         Covered at the BDT.     Covered at the
                                                                                                                 BDT**.

                                                                                         Benefit is limited to   Benefit is limited to
                                                                                         conservative, non-      conservative, non-
                                                                                         surgical therapy only   surgical therapy only
                                                                                         and will only be        and will only be
                                                                                         applied to members      applied to members
                                                                                         who are registered      who are registered
                        Periodontics*                                                    on the Periodontal      on the Periodontal
                                                                                         Programme.              Programme.
SPECIALISED DENTISTRY




                                                                                         Scheme                  Scheme
                                                                                         Exclusions:             Exclusions:
                                                                                         • Surgical              • Surgical
                                                                                           periodontics which      periodontics which
                                                                                           includes                includes
                                                                                           gingivectomies,         gingivectomies,
                                                                                           periodontal flap        periodontal flap
                                                                                           surgery tissue          surgery tissue
                                                                                           grafting and the        grafting and the
                                                                                           hemisection of a        hemisection of a
                                                                                           tooth                   tooth
                                                                                         • Perio chip            • Perio chip
                                                                                           placement               placement


                                         Surgery in the dental   Surgery in the dental   Surgery in the dental   Surgery in the dental
                                         chair: Benefit is       chair: Benefit is       chair: Benefit is       chair: Benefit is
                                         subject to managed      subject to managed      subject to managed      subject to managed
                                         care protocols.         care protocols.         care protocols.         care protocols.
                                         Covered at the BDT.     Covered at the BDT.     Covered at the BDT.     Covered at the
                        Maxillo-facial
                                                                                                                 BDT**.
                        Surgery
                        and Oral
                                         Temporo-mandibular      Temporo-mandibular      Temporo-mandibular      Temporo-mandibular
                        Pathology
                                         joint (TMJ) therapy:    joint (TMJ) therapy:    joint (TMJ) therapy:    joint (TMJ) therapy:
                                         Benefit is limited to   Benefit is limited to   Benefit is limited to   Benefit is limited to
                                         non-surgical            non-surgical            non-surgical            non-surgical
                                         intervention            intervention            intervention            intervention
                                         /treatments.            /treatments.            /treatments.            /treatments.


                                                                                                                                     11
STANDARD/
                                              PRIMARY                  BONSAVE                 STANDARD                  BONCOM
                                                                                                SELECT

                                         Oral pathology           Oral pathology           Oral pathology           Oral pathology
                                         procedures (cysts        procedures (cysts        procedures (cysts        procedures (cysts
                                         and biopsies, the        and biopsies, the        and biopsies, the        and biopsies, the
                                         surgical treatment of    surgical treatment of    surgical treatment of    surgical treatment of
                                         tumours of the jaw       tumours of the jaw       tumours of the jaw       tumours of the jaw
                                         and soft tissue          and soft tissue          and soft tissue          and soft tissue
                                         tumours):                tumours):                tumours):                tumours):
                                         Claims will only be      Claims will only be      Claims will only be      Claims will only be
                                         covered if supported     covered if supported     covered if supported     covered if supported
                                         by a laboratory report   by a laboratory report   by a laboratory report   by a laboratory report
                                         that confirms            that confirms            that confirms            that confirms
                                         diagnosis.               diagnosis.               diagnosis.               diagnosis.

                                         Scheme                   Scheme                   Scheme                   Scheme
                                         Exclusions:              Exclusions:              Exclusions:              Exclusions:
                                         • Orthognathic (jaw      • Orthognathic (jaw      • Orthognathic (jaw      • Orthognathic (jaw
                                           correction) surgery      correction) surgery      correction) surgery      correction) surgery
                                         • Sinus lifts            • Sinus lifts            • Sinus lifts            • Sinus lifts
                                         • Bone                   • Bone                   • Bone                   • Bone
SPECIALISED DENTISTRY




                                           augmentations            augmentations            augmentations            augmentations
                                         • Bone and tissue        • Bone and tissue        • Bone and tissue        • Bone and tissue
                        Maxillo-facial
                                           regeneration             regeneration             regeneration             regeneration
                        Surgery
                                           procedures               procedures               procedures               procedures
                        and Oral
                                         • The cost of bone       • The cost of bone       • The cost of bone       • The cost of bone
                        Pathology
                                           regeneration             regeneration             regeneration             regeneration
                        (continue)
                                           material                 material                 material                 material
                                         • The auto-              • The auto-              • The auto-              • The auto-
                                           transplantation of       transplantation of       transplantation of       transplantation of
                                           teeth                    teeth                    teeth                    teeth
                                         • The closure of an      • The closure of an      • The closure of an      • The closure of an
                                           oral-antral opening      oral-antral opening      oral-antral opening      oral-antral opening
                                           (currently code          (currently code          (currently code          (currently code
                                           8909) when               8909) when               8909) when               8909) when
                                           claimed during the       claimed during the       claimed during the       claimed during the
                                           same visit with          same visit with          same visit with          same visit with
                                           impacted teeth           impacted teeth           impacted teeth           impacted teeth
                                           (currently codes         (currently codes         (currently codes         (currently codes
                                           8941, 8943 and           8941, 8943 and           8941, 8943 and           8941, 8943 and
                                           8945)                    8945)                    8945)                    8945)

                                         Surgery in hospital:     Surgery in hospital:     Surgery in hospital:     Surgery in hospital:
                                         • See                    • See                    • See                    • See
                                           Hospitalisation*         Hospitalisation*         Hospitalisation*         Hospitalisation*
                                           below                    below                    below                    below




                                                                                                                                           12
STANDARD/
                                                          PRIMARY                  BONSAVE                 STANDARD                  BONCOM
                                                                                                            SELECT

                                                     Pre-authorisation is     Pre-authorisation is     Pre-authorisation is     Pre-authorisation is
                                                     required.                required.                required.                required.

                                                     Admission protocols      Admission protocols      Admission protocols      Admission protocols
                                                     apply.                   apply.                   apply.                   apply.

                                                     A co-payment of          A co-payment of          A co-payment of
                                                     R3 000 per hospital      R3 000 per hospital      R3 000 per hospital
                                                     admission applies.       admission applies.       admission applies.

                                                     General anaesthetic      General anaesthetic      General anaesthetic      General anaesthetic
                                                     benefits are available   benefits are available   benefits are available   benefits are available
                                                     for children under the   for children under the   for children under the   for children under the
                                                     age of 5 years for       age of 5 years for       age of 5 years for       age of 5 years for
                                                     extensive dental         extensive dental         extensive dental         extensive dental
                                                     treatment.               treatment.               treatment.               treatment.
HOSPITALISATION AND ANAESTHETICS




                                                     General anaesthetic      General anaesthetic      General anaesthetic      General anaesthetic
                                                     benefits are available   benefits are available   benefits are available   benefits are available
                                                     for the removal of       for the removal of       for the removal of       for the removal of
                                                     impacted teeth.          impacted teeth.          impacted teeth.          impacted teeth.
                                                     Benefit is subject to    Benefit is subject to    Benefit is subject to    Benefit is subject to
                                   Hospitalisation
                                                     managed care             managed care             managed care             managed care
                                   (General
                                                     protocols.               protocols.               protocols.               protocols.
                                   Anaesthetic)*
                                                     The hospital and         The hospital and         The hospital and         The hospital and
                                                     anaesthetist claims      anaesthetist claims      anaesthetist claims      anaesthetist claims
                                                     for the procedures       for the procedures       for the procedures       for the procedures
                                                     listed below will not    listed below will not    listed below will not    listed below will not
                                                     be covered when          be covered when          be covered when          be covered when
                                                     performed under          performed under          performed under          performed under
                                                     general anaesthesia.     general anaesthesia.     general anaesthesia.     general anaesthesia.
                                                     The payment              The payment              The payment              The payment
                                                     of the dental            of the dental            of the dental            of the dental
                                                     procedure will be        procedure will be        procedure will be        procedure will be
                                                     dependent on             dependent on             dependent on             dependent on
                                                     available benefits,      available benefits,      available benefits,      available benefits,
                                                     and payable at BDT:      and payable at BDT:      and payable at BDT:      and payable at
                                                     • Apicectomies           • Apicectomies           • Apicectomies           BDT**:
                                                     • Dentectomies           • Dentectomies           • Dentectomies           • Apicectomies
                                                     • Frenectomies           • Frenectomies           • Frenectomies           • Dentectomies
                                                     • Implantology and       • Implantology and       • Implantology and       • Frenectomies
                                                        associated surgical      associated surgical      associated surgical   • Implantology and
                                                        procedures               procedures               procedures               associated surgical
                                                                                                                                   procedures




                                                                                                                                                    13
STANDARD/
                                                            PRIMARY                   BONSAVE                   STANDARD                     BONCOM
                                                                                                                 SELECT

                                                      • Conservative             • Conservative             • Conservative             • Conservative
                                                        dental treatment           dental treatment           dental treatment           dental treatment
                                                        (fillings, extractions     (fillings, extractions     (fillings, extractions     (fillings, extractions
                                                        and root canal             and root canal             and root canal             and root canal
                                                        therapy) for adults        therapy) for adults        therapy) for adults        therapy) for adults
                                                      • Professional             • Professional             • Professional             • Professional
                                                        oral hygiene               oral hygiene               oral hygiene               oral hygiene
                                                        procedures                 procedures                 procedures                 procedures
                                                      • Surgical tooth           • Surgical tooth           • Surgical tooth           • Surgical tooth
                                                        exposures for              exposures for              exposures for              exposures for
                                                        orthodontic                orthodontic                orthodontic                orthodontic
                                                        reasons                    reasons                    reasons                    reasons

                                                      Scheme                     Scheme                     Scheme                     Scheme
                                                      Exclusions:                Exclusions:                Exclusions:                Exclusions:
                                    Hospitalisation
                                                      • Where the only           • Where the only           • Where the only           • Where the only
HOSPITALISATION AND ANAESTHETICS




                                    (General
                                                        reason for                 reason for                 reason for                 reason for
                                    Anaesthetic)*
                                                        admission to               admission to               admission to               admission to
                                    (continue)
                                                        hospital is dental         hospital is dental         hospital is dental         hospital is dental
                                                        fear and anxiety           fear and anxiety           fear and anxiety           fear and anxiety
                                                      • Multiple hospital        • Multiple hospital        • Multiple hospital        • Multiple hospital
                                                        admissions                 admissions                 admissions                 admissions
                                                      • Where the only           • Where the only           • Where the only           • Where the only
                                                        reason for the             reason for the             reason for the             reason for the
                                                        admission request          admission request          admission request          admission request
                                                        is for a sterile           is for a sterile           is for a sterile           is for a sterile
                                                        facility                   facility                   facility                   facility
                                                      • The cost of dental       • The cost of dental       • The cost of dental       • The cost of dental
                                                        materials for              materials for              materials for              materials for
                                                        procedures                 procedures                 procedures                 procedures
                                                        performed under            performed under            performed under            performed under
                                                        general                    general                    general                    general
                                                        anaesthesia                anaesthesia                anaesthesia                anaesthesia

                                                      Benefit is subject to      Benefit is subject to      Benefit is subject to      Benefit is subject to
                                                      managed care               managed care               managed care               managed care
                                                      protocols.                 protocols.                 protocols.                 protocols.

                                                      Covered at the BDT.        Covered at the BDT.        Covered at the BDT.        Covered at the
                                   Laughing Gas in                                                                                     BDT**.
                                   Dental Rooms




                                                                                                                                                             14
STANDARD/
                                                              PRIMARY                BONSAVE                STANDARD                  BONCOM
                                                                                                             SELECT

                                                        Pre-authorisation is    Pre-authorisation is    Pre-authorisation is    Pre-authorisation is
 HOSPITALISATION AND ANAESTHETICS




                                                        required.               required.               required.               required.

                                                        Benefit is subject to   Benefit is subject to   Benefit is subject to   Benefit is subject to
                                                        managed care            managed care            managed care            managed care
                                                        protocols.              protocols.              protocols.              protocols.
                                    IV/Conscious
                                                        Covered at the BDT.     Covered at the BDT.     Covered at the BDT.     Covered at the
                                    Sedation in
                                                                                                                                BDT**.
                                    Rooms*

                                                        Benefit is limited to   Benefit is limited to   Benefit is limited to   Benefit is limited to
                                                        extensive dental        extensive dental        extensive dental        extensive dental
                                                        treatment.              treatment.              treatment.              treatment.




Additional Scheme Exclusions:
                              •     Electrognathographic recordings, pantographic recordings and other such electronic analyses
                              •     Nutritional and tobacco counseling
                              •     Caries susceptibility and microbiological tests
                              •     Fissure sealants on patients 16 years and older
                              •     Pulp tests
                              •     Cost of Mineral Trioxide
                              •     Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments
                              •     Appointment not kept
                              •     Special report
                              •     Dental testimony including dento-legal fees
                              •     Treatment plan completed (currently code 8120)
                              •     Enamel microabrasion
                              •     Behaviour management
                              •     Intramuscular or subcutaneous injection
                              •     Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures




                                                                                                                                                        15
BONCLASSIC DENTAL BENEFIT TABLE 2018

Dental benefits are paid at the Bonitas Dental Tariff (BDT) subject to the available financial limit. Hospitalisation and certain
specialised dentistry procedures must be pre-authorised*. Procedures and treatment not pre-authorised will not attract a
benefit, with the exception of crown and bridge procedures where a 20% penalty will apply if authorisation is applied for
after the treatment has been done. Failure to pre-authorise orthodontic treatment will result in a payment ONLY from date
of authorisation for the remaining months of treatment, provided that the treatment is clinically indicated. Penalties do not
apply to emergency hospital admission.

Co-payments are levied on the Hospital account on the BonClassic option.

Dentures* must be pre-authorised on the BonClassic option.

Dental benefits are subject to managed care protocols and managed care interventions which may include the requirement
of treatment plans and/or radiographs prior to benefit application. Scheme Exclusions apply to dental benefits. In the event
of a dispute, the rules of the scheme prevail.


                                                                                        BONCLASSIC
                                                                Conservative Dentistry – Limit of R4 450 per family per year
                                                                Specialised Dentistry – Limit of R5 350 per family per year

                                                 Two annual check-ups per beneficiary (once in 6 months).

                            Consultations        Benefit is subject to managed care protocols.

                                                 Covered at the BDT.

                                                 Benefit is subject to managed care protocols.
                            X-rays: Intra-oral
   CONSERVATIVE DENTISTRY




                                                 Covered at the BDT.

                                                 One per beneficiary in a 3-year period.

                                                 Benefit is subject to managed care protocols.
                            X-rays: Extra-oral

                                                 Additional benefit may be considered where specialised dental treatment is required.
                                                 Covered at the BDT.

                                                 Two annual scale and polish treatments per beneficiary (once in 6 months).

                                                 Benefit is subject to managed care protocols.

                            Oral Hygiene         Benefit for fissure sealants is limited to beneficiaries younger than 16 years of age.

                                                 Benefit for fluoride is limited to beneficiaries from age 5 and younger than 16 years of age.

                                                 Covered at the BDT.




                                                                                                                                             16
BONCLASSIC
                                                         Conservative Dentistry – Limit of R4 450 per family per year
                                                         Specialised Dentistry – Limit of R5 350 per family per year

                                          Scheme Exclusions:
                                          • Oral hygiene instructions
                         Oral Hygiene
                                          • Oral hygiene evaluation
                         (continue)
                                          • Professionally applied fluoride for beneficiaries 16 years and older
                                          • Dental bleaching

                                          Benefit for fillings are granted once per tooth in 365 days.

                                          Benefit for re-treatment of a tooth is subject to managed care protocols.
                                          Covered at the BDT.

                                          A treatment plan and X-rays may be required for multiple fillings.

                         Fillings         Scheme Exclusions:
                                          • Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and
                                            fluorosis
                                          • Resin bonding for restorations that are charged as a separate procedure to the
                                            restoration
CONSERVATIVE DENTISTRY




                                          • The polishing of restorations
                                          • Gold foil restorations
                                          • Ozone therapy

                                          Benefit is subject to managed care protocols.
                                          Covered at the BDT.
                          Root Canal
                          Therapy and     Scheme Exclusions:
                          Extractions     • Root canal therapy on primary (milk) teeth
                                          • Root canal therapy on wisdom teeth (third molars)
                                          • Direct and indirect pulp capping procedures

                                          Pre-authorisation is required.

                                          One set of plastic dentures (an upper and a lower) per beneficiary in a 4-year period.
                                          Benefit is subject to managed care protocols.

                          Plastic         Covered at the BDT.
                          Dentures* and
                          Associated      Please note:
                          Laboratory      • Benefit for plastic dentures and associated laboratory costs is payable from the
                          Costs               available Conservative Dentistry limit.
                                          • Benefit is not available for the clinical fee of denture repairs, denture tooth
                                              replacements and the addition of a soft base to new dentures; the laboratory fee will
                                              be covered.
                                          • Benefit is not available for the laboratory fee of mouthguards; the clinical fee will be
                                              covered.




                                                                                                                                       17
BONCLASSIC
                                                              Conservative Dentistry – Limit of R4 450 per family per year
                                                              Specialised Dentistry – Limit of R5 350 per family per year

                                               Scheme Exclusions:
CONSERVATIVE




                           Plastic
                                               • Diagnostic dentures and associated laboratory costs
  DENTISTRY




                           Dentures* and
                                               • Snoring appliances and associated laboratory costs
                           Associated
                                               • High impact acrylic
                           Laboratory
                           Costs               • The cost of gold, precious metal, semi-precious metal and platinum foil
                                               • Laboratory delivery fees
                           (continue)
                                               • Provisional dentures and associated laboratory costs

                                               Pre-authorisation is required.

                                               Two partial metal frames (an upper and a lower) per beneficiary in a 5-year period.
                           Partial Metal
                           Frame               Benefit is subject to managed care protocols.
                           Dentures* and
                           Associated          Covered at the BDT.
                           Laboratory          Scheme Exclusions:
                           Costs               • The metal base to full dentures and associated laboratory costs
                                               • High impact acrylic
                                               • The cost of gold, precious metal, semi-precious metal and platinum foil
                                               • Laboratory delivery fees
   SPECIALISED DENTISTRY




                                               Pre-authorisation is required.

                                               One crown per family per year.

                                               Benefit is subject to managed care protocols.
                           Crown &
                           Bridge* and
                                               Covered at the BDT.
                           Associated
                           Laboratory
                                               Benefits for crowns are granted once per tooth in a 5-year period.
                           Costs
                                               A treatment plan and X-rays may be requested.
                           A bridge
                           comprises two or
                                               Scheme Exclusions:
                           more crown
                                               • Crowns or crown retainers on wisdom teeth (third molars)
                           units. Each
                                               • Pontics on second molars where the third molar is a retainer
                           crown is payable
                                               • Crown and bridge procedures for cosmetic reasons and associated laboratory costs
                           from the
                                               • Occlusal rehabilitations and associated laboratory costs
                           available Crown
                                               • Provisional crowns and associated laboratory costs
                           & Bridge benefit.
                                               • Porcelain veneers and inlays and associated laboratory costs
                                               • Emergency crowns that are not placed for the immediate protection in tooth injury and
                                                  associated laboratory costs
                                               • The cost of gold, precious metal, semi-precious metal and platinum foil
                                               • Laboratory delivery fees



                                                                                                                                         18
BONCLASSIC
                                                        Conservative Dentistry – Limit of R4 450 per family per year
                                                        Specialised Dentistry – Limit of R5 350 per family per year

                        Implants* and    No benefit
                        Associated
                        Laboratory
                        Costs

                                         Pre-authorisation is required.

                                         Benefit is subject to managed care protocols.

                                         On pre-authorisation, cases will be clinically assessed by using an orthodontic needs
                                         analysis.

                                         Benefit allocation is subject to the outcome of the needs analysis and funding can be
                                         granted up to 100% of BDT.

                                         Benefit for orthodontic treatment will be granted where function is impaired.

                        Orthodontics*    Orthodontic treatment is granted once per beneficiary per lifetime.
                        and Associated
                        Laboratory       Benefit will not be granted where orthodontic treatment is required for cosmetic reasons.
                        Costs
                                         The associated laboratory costs will also not be covered.
SPECIALISED DENTISTRY




                                         Only one family member may commence orthodontic treatment in a calendar year.

                                         Benefit for fixed comprehensive treatment is limited to individuals from age 9 and younger
                                         than 18 years of age.
                                         Scheme Exclusions:
                                         • Orthognathic (jaw correction) and other orthodontic related surgery and any related
                                           Hospital cost including Associated Laboratory Costs
                                         • Orthodontic re-treatment and any related Laboratory costs
                                         • Invisible retainer material
                                         • Laboratory delivery fees

                                         Pre-authorisation is required.

                                         Benefit is subject to managed care protocols.

                                         Covered at the BDT.

                        Periodontics*    Benefit is limited to conservative, non-surgical therapy only and will only be applied to
                                         members who are registered on the Periodontal Programme.
                                         Scheme Exclusions:
                                         • Surgical periodontics which includes gingivectomies, periodontal flap surgery tissue
                                           grafting and the hemisection of a tooth
                                         • Perio chip placement

                                                                                                                                      19
BONCLASSIC
                                                         Conservative Dentistry – Limit of R4 450 per family per year
                                                         Specialised Dentistry – Limit of R5 350 per family per year

                                          Surgery in the dental chair:
                                          Benefit is subject to managed care protocols.
                                          Covered at the BDT.

                                          Temporo-mandibular joint (TMJ) therapy:
                                          Benefit is limited to non-surgical intervention/treatments.

                                          Oral pathology procedures (cysts and biopsies, the surgical treatment of tumours of the
                                          jaw and soft tissue tumours):
                                          Claims will only be covered if supported by a laboratory report that confirms diagnosis.
                        Maxillo-facial
                        Surgery and       Scheme Exclusions:
                        Oral Pathology    • Orthognathic (jaw correction) surgery
                                          • Sinus lifts
SPECIALISED DENTISTRY




                                          • Bone augmentations
                                          • Bone and tissue regeneration procedures
                                          • The cost of bone regeneration material
                                          • The auto-transplantation of teeth
                                          • The closure of an oral-antral opening (currently code 8909) when claimed during the
                                            same visit with impacted teeth (currently codes 8941, 8943 and 8945)

                                          Surgery in hospital:
                                          See Hospitalisation* below

                                          Pre-authorisation is required.

                                          Admission protocols apply.

                                          A co-payment of R3 000 per hospital admission applies.
                        Hospitalisation
                        (General
                                          General anaesthetic benefits are available for children under the age of 5 years for
                        Anaesthetic)*
                                          extensive dental treatment.

                                          General anaesthetic benefits are available for the removal of impacted teeth.

                                          Benefit is subject to managed care protocols.




                                                                                                                                     20
BONCLASSIC
                                                                  Conservative Dentistry – Limit of R4 450 per family per year
                                                                  Specialised Dentistry – Limit of R5 350 per family per year

                                                   The hospital and anaesthetist claims for the procedures listed below will not be covered
                                                   when performed under general anaesthesia. The payment of the dental procedure will be
                                                   dependent on available benefits, and payable at BDT:
                                                   • Apicectomies
         SPECIALISED DENTISTRY




                                                   • Dentectomies
                                                   • Frenectomies
                                 Hospitalisation   • Implantology and associated surgical procedures
                                 (General          • Conservative dental treatment (fillings, extractions and root canal therapy) for adults
                                 Anaesthetic)*     • Professional oral hygiene procedures
                                 (continue)        • Surgical tooth exposures for orthodontic reasons


                                                   Scheme Exclusions:
                                                   • Where the only reason for admission to hospital is dental fear and anxiety
                                                   • Multiple hospital admissions
                                                   Where the only reason for the admission request is for a sterile facility The cost of dental
                                                   materials for procedures performed under general anaesthesia

                                 Laughing Gas      Benefit is subject to managed care protocols.
    HOSPITALISATION AND




                                 in Dental         Covered at the BDT.
                                 Rooms
       ANAESTHETICS




                                                   Pre-authorisation is required.
                                                   Benefit is subject to managed care protocols.
                                 IV/Conscious      Covered at the BDT.
                                 Sedation in       Benefit is limited to extensive dental treatment.
                                 Rooms*




Additional Scheme Exclusions:

•                Electrognathographic recordings, pantographic recordings and other such electronic analyses.
•                Nutritional and tobacco counseling
•                Caries susceptibility and microbiological tests
•                Pulp tests
•                Cost of Mineral Trioxide
•                Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments
•                Appointment not kept
•                Special report
•                Dental testimony including dento-legal fees
•                Treatment plan completed
•                Enamel microabrasion
•                Behaviour management
•                Intramuscular or subcutaneous injection
•                Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures


                                                                                                                                                  21
BONCAP DENTAL BENEFIT TABLE 2018

Dental benefits are managed by DENIS at the Bonitas Dental Tariff (BDT) and are subject to a DENIS Designated Service
Provider Network for conservative out of hospital services. If there is no Designated Service Provider in the member’s area,
the member needs to contact DENIS prior to treatment. This option does not provide benefits for any specialised dentistry,
with the exception of limited maxillo-facial dentistry. Dental benefits are subject to managed care protocols and managed
care interventions which may include the requirement of treatment plans and/or radiographs prior to benefit application.
Only the dental codes listed in the table below will be covered under this option except in the case of authorised
hospitalisation and authorised PMB events. In the event of a dispute, the registered rules of the scheme prevail.

Dentures* must be pre-authorised on BonCap option. A 20% penalty will apply if authorisation is applied for after the
treatment has been done.

There is no overall annual limit on BonCap for 2018. Access to a maxillo-facial specialist is ONLY on referral from a dentist
on the DENIS Designated Service Provider Network and authorised by DENIS. PMB treatment is the only treatment covered
in hospital on the BonCap option. All dental related PMB hospitalisation, must be pre-authorised* by DENIS. Emergencies
require authorisation within 48 hours of the first working day.

Please note that ALL dental claims (out-of-hospital dentistry, in-hospital PMB dentistry and related anaesthetics) will be
paid by Medscheme.


             BENEFIT                    CODE                          DENIS BENEFIT INFORMATION


 Consultation                        8101          One check-up per beneficiary per year.

 Specific Consultation               8104          One specific (emergency) consultation for pain and sepsis per
 (Emergency)                                       beneficiary per year.

 Intra-oral X-rays                   8107 and/or Four X-rays in total per beneficiary per year.
                                     8112

 Extra-oral X-rays                   8115          One per beneficiary in a lifetime.

 Polishing of Teeth                  8155          One polish OR one scaling and polishing per beneficiary per year.
 Scaling and Polishing               8159

 Fluoride Treatment                  8161 or       One treatment per year for beneficiaries under 16 years of age:
                                     8162             • 8161: 5 - 12 years of age; and
                                                      • 8162: 13 - 15 years of age

 Fissure Sealant                     8163          One per tooth in a 3-year period for beneficiaries younger than 16
                                                   years of age.

 Infection Control                   8109          One set per beneficiary per visit.
 Instrument Sterilisation            8110          (A Set: 8109 x 2, 8110 x 1 & 8145 x 1)
 Local Anaesthetic                   8145




                                                                                                                          22
BENEFIT          CODE                     DENIS BENEFIT INFORMATION


Inhalation Sedation       8141     Inhalation sedation limited to extensive dental treatment only.
(Laughing gas in dental   8143     • 8141 First 15 minutes
rooms)                             • 8143 Each additional 15 minutes


Emergency Root Canal      8131     Benefit for emergency treatment only.
Treatment                 8132     Please note: Root canal treatment on third molar is not covered.

Pulp Treatments           8307     Benefit for amputation of pulp of primary teeth.

Extractions               8201     Code 8201 is charged for the first extraction in a quadrant.
(Removal of teeth)        8202     Code 8202 is charged for each additional extraction in a quadrant.
                          8935     Treatment of septic sockets

Dental Fillings           8341     Benefit for 4 fillings per beneficiary per year.
                          8342     Benefit for fillings are granted once per tooth in 365 days.
                          8343     Benefit for re-treatment of a tooth is subject to managed care
                          8344     protocols.
                          8351
                          8352
                          8353
                          8354
                          8367
                          8368
                          8369
                          8370

Plastic Dentures*         8231     Pre-authorisation is required.
                          8232     One set of plastic dentures (an upper and a lower) per family in a 2-
                          8233     year period for beneficiaries 21 years and older. 20% co-payment
                          8234     applies.
                          8235     The appropriate laboratory codes will be covered. 20% co-payment
                          8236     applies.
                          8237
                          8238
                          8239
                          8240
                          8241

Denture Rebase            8259     Rebase of Denture once per family per year for beneficiaries 21
                                   years and older. 20% co-payment applies.
                                   The appropriate laboratory codes will be covered. 20% co-payment
                                   applies.

Denture Repairs           8263     Repairs to existing dentures twice per family per year for
                          8269     beneficiaries 21 years and older. 20% co-payment applies.
                          8271     The appropriate laboratory codes will be covered. 20% co-payment
                          8273     applies.



                                                                                                           23
BENEFIT                  CODE                          DENIS BENEFIT INFORMATION


    Maxillo-facial Surgery in                      Surgery in the dental chair – DENIS Designated Service Provider;
    dental chair*                                  access to a maxillo-facial specialist by DENIS pre-authorisation
                                                   ONLY.

                                     8937          Surgical removal of tooth.

                                     8213          Surgical removal of residual roots.
                                     8214
                                     8953

                                     8941          Surgical removal of impacted teeth.
                                     8943
                                     8945
                                                   Cover for PMB treatment.

                                                   Please note: No benefit for osseo-integrated implants and
                                                   orthognathic surgery.

    IV/Conscious Sedation in the     8144          Pre-authorisation from DENIS is required.
    rooms*                                         Benefit is limited to extensive dental treatment.

    Hospitalisation*                               No benefits for in hospital (general anaesthetic) dentistry, except for
    (General Anaesthetic)                          PMBs.
                                                   Subject to pre-authorisation.




Additional Scheme Exclusions:
•     Electrognathographic recordings, pantographic recordings and other such electronic analyses.
•     Nutritional and tobacco counseling
•     Caries susceptibility and microbiological tests
•     Pulp tests
•     Cost of Mineral Trioxide
•     Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments
•     Appointment not kept
•     Special report
•     Dental testimony including dento-legal fees
•     Treatment plan completed
•     Enamel microabrasion
•     Behaviour management
•     Intramuscular or subcutaneous injection
•     Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures




                                                                                                                             24
BONFIT DENTAL BENEFIT TABLE 2018
Dental benefits are managed by DENIS at the Bonitas Dental Tariff (BDT). This option does not provide benefits for
dentures and specialised dentistry, with the exception of limited maxillo-facial dentistry. Dental benefits are subject to
managed care protocols and managed care interventions which may include the requirement of treatment plans and/or
radiographs prior to benefit application.

PMB treatment is the only treatment covered in hospital on the BonFit option. All dental related PMB hospitalisation, must
be pre-authorised* by DENIS. Emergencies require authorisation within 48 hours of the first working day.

Dental benefits are subject to managed care protocols and managed care interventions which may include the requirement
of treatment plans and/or radiographs prior to benefit application. Scheme Exclusions apply to dental benefits. In the event
of a dispute, the rules of the scheme will prevail.


                                                                              BONITAS BONFIT OPTION


                                                Two annual check-ups per beneficiary (once in 6 months).

                           Consultations        Benefit is subject to managed care protocols.

                                                Covered at the BDT.

                                                Benefit is subject to managed care protocols.
                           X-rays: Intra-oral
                                                Covered at the BDT.
  CONSERVATIVE DENTISTRY




                                                One per beneficiary in a 3-year period.
                           X-rays: Extra-oral
                                                Benefit is subject to managed care protocols. Covered at the BDT.

                                                Two annual scale and polish treatments per beneficiary (once in 6 months).

                                                Benefit is subject to managed care protocols.

                                                Benefit for fissure sealants is limited to beneficiaries younger than 16 years of age.

                                                Benefit for fluoride is limited to beneficiaries from age 5 and younger than 16 years of
                                                age.
                           Oral Hygiene
                                                Covered at the BDT.

                                                Scheme Exclusions:
                                                • Oral hygiene instruction
                                                • Oral hygiene evaluation
                                                • Professionally applied fluoride for beneficiaries 13-years and older
                                                • Dental bleaching




                                                                                                                                           25
BONITAS BONFIT OPTION


                                                Benefit for fillings are granted once per tooth in 365 days.

                                                Benefit for re-treatment of a tooth is subject to managed care protocols.

                                                Covered at the BDT.

                                                A treatment plan and X-rays may be required for multiple fillings.
                         Fillings               Scheme Exclusions:
CONSERVATIVE DENTISTRY




                                                • Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and
                                                  fluorosis
                                                • Resin bonding for restorations that are charged as a separate procedure to the
                                                  restoration
                                                • The polishing of restorations
                                                • Gold foil restorations
                                                • Ozone therapy

                                                Benefit is subject to managed care protocols.

                                                Covered at the BDT.
                         Root Canal Therapy
                         and Extractions        Scheme Exclusions:
                                                • Root canal therapy on primary (milk) teeth
                                                • Root canal therapy on wisdom teeth (third molars)
                                                • Direct and indirect pulp capping procedures

                         Plastic Dentures and
                         associated             No benefit
                         Laboratory costs

                         Partial Metal Frame
                         Dentures and
                                                No benefit
                         Associated
SPECIALISED DENTISTRY




                         Laboratory Costs

                         Crown & Bridge and
                         Associated             No benefit
                         Laboratory Costs

                         Implants               No benefit

                         Orthodontics and
                         Associated             No benefit
                         Laboratory Costs

                         Periodontics           No benefit




                                                                                                                                         26
BONITAS BONFIT OPTION


                                                        Surgery in the dental chair:
                                                        Benefit is subject to managed care protocols.
                                                        Covered at the BDT.

                                                        Temporo-mandibular joint (TMJ) therapy:
                                                        Benefit is limited to non-surgical intervention/treatments.
       SPECIALISED DENTISTRY




                                                        Oral pathology procedures (cysts and biopsies, the surgical treatment of tumours of
                                                        the jaw and soft tissue tumours):
                               Maxillo-facial Surgery   Claims will only be covered if supported by a laboratory report that confirms diagnosis.
                               and Oral Pathology in
                               Rooms                    Scheme Exclusions:
                               (excluding removal of    • Orthognathic (jaw correction) surgery
                               impacted teeth under     • Sinus lifts
                               IV/conscious
                                                        • Bone augmentations
                               sedation)
                                                        • Bone and tissue regeneration procedures
                                                        • The cost of bone regeneration material
                                                        • The auto-transplantation of teeth
                                                        • The closure of an oral-antral opening (currently code 8909) when claimed during the
                                                          same visit with impacted teeth (currently codes 8941, 8943 and 8945) is a scheme
                                                          exclusion.

                                                        Surgery in hospital:
                                                        See Hospitalisation* below

                                                        No benefits for in hospital (general anaesthetic) dentistry, except for PMBs.
                               Hospitalisation
                               (General Anaesthetic)
                                                        Subject to pre-authorisation.
    HOSPITALISATION AND




                                                        Benefit is subject to managed care protocols.
       ANAESTHETICS




                               Laughing Gas in
                               Dental Rooms
                                                        Covered at the BDT.

                                                        Pre-authorisation is required.

                                                        Benefit is subject to managed care protocols.
                               IV/Conscious
                               Sedation in Rooms*
                                                        Covered at the BDT.

                                                        Benefit is limited to extensive dental treatment.




Additional Scheme Exclusions:

•              Electrognathographic recordings, pantographic recordings and other such electronic analyses
•              Nutritional and tobacco counseling
•              Caries susceptibility and microbiological tests
•              Fissure sealants on patients 16 years and older
                                                                                                                                                   27
•   Pulp tests
•   Cost of Mineral Trioxide
•   Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments
•   Appointment not kept
•   Special report
•   Dental testimony including dento-legal fees
•   Treatment plan completed (currently code 8120)
•   Enamel microabrasion
•   Behaviour management
•   Intramuscular or subcutaneous injection
•   Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures




                                                                                                                  28
BONCOMPLETE DENTAL BENEFIT TABLE 2018

Dental benefits are paid at the Bonitas Dental Tariff (BDT). Hospitalisation and certain specialised dentistry procedures and
treatment must be pre-authorised*. Procedures and treatment not pre-authorised will not attract a benefit, with the exception
of crown and bridge procedures where a 20% penalty will apply if authorisation is applied for after the treatment has been
done. Failure to pre-authorise orthodontic treatment will result in a payment ONLY from date of authorisation for the
remaining months of treatment, provided that the treatment is clinically indicated. Penalties do not apply to emergency
hospital admission.

Dentures* must be pre-authorised on BonComplete option.

Co-payments are levied on the Hospital account on the BonComplete option.

Dental benefits are subject to managed care protocols and managed care interventions which may include the requirement
of treatment plans and/or radiographs prior to benefit application. Scheme Exclusions apply to dental benefits. In the event
of a dispute, the rules of the scheme prevail.


                                                                                    BONCOMPLETE


                                                 Two annual check-ups per beneficiary (once in 6 months).

                            Consultations        Benefit is subject to managed care protocols.

                                                 Covered at the BDT.

                                                 Benefit is subject to managed care protocols.
                            X-rays: Intra-oral
                                                 Covered at the BDT.
   CONSERVATIVE DENTISTRY




                                                 One per beneficiary in a 3-year period.

                                                 Benefit is subject to managed care protocols.
                            X-rays: Extra-oral
                                                 Additional benefit may be considered where specialised dental treatment is required.

                                                 Covered at the BDT.

                                                 Two annual scale and polish treatments per beneficiary (once in 6 months).

                                                 Benefit is subject to managed care protocols.

                                                 Benefit for fissure sealants is limited to beneficiaries younger than 16 years of age.
                            Oral Hygiene
                                                 Benefit for fluoride is limited to beneficiaries from age 5 and younger than 16 years of
                                                 age.

                                                 Covered at the BDT.




                                                                                                                                            29
BONCOMPLETE


                                             Scheme Exclusions:
                         Oral Hygiene        • Oral hygiene instructions
                         (continue)          • Oral hygiene evaluation
                                             • Professionally applied fluoride for beneficiaries 16 years and older
                                             • Dental bleaching

                                             Benefit for fillings are granted once per tooth in 365 days.

                                             Benefit for re-treatment of a tooth is subject to managed care protocols.
                                             Covered at the BDT.

                                             A treatment plan and X-rays may be required for multiple fillings.

                         Fillings            Scheme Exclusions:
                         (continue)          • Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and
                                               fluorosis
                                             • Resin bonding for restorations that are charged as a separate procedure to the
CONSERVATIVE DENTISTRY




                                               restoration
                                             • The polishing of restorations
                                             • Gold foil restorations
                                             • Ozone therapy


                                             Benefit is subject to managed care protocols.

                         Root Canal          Covered at the BDT.
                         Therapy and
                         Extractions         Scheme Exclusions:
                                             • Root canal therapy on primary (milk) teeth
                                             • Root canal therapy on wisdom teeth (third molars)
                                             • Direct and indirect pulp capping procedures

                                             Pre-authorisation is required.

                                             One set of plastic dentures (an upper and a lower) per beneficiary in a 4-year period.

                                             Benefit is subject to managed care protocols.
                         Plastic Dentures*   Covered at the BDT.
                         and Associated
                         Laboratory costs    Benefit is not available for the clinical fee of denture repairs, denture tooth
                                             replacements and the addition of a soft base to new dentures; the laboratory fee will
                                             be covered.

                                             Benefit is not available for the laboratory fee of mouthguards; the clinical fee will be
                                             covered.




                                                                                                                                        30
BONCOMPLETE


                                                 Scheme Exclusions:
CONSERVATIVE




                                                 • Diagnostic dentures and associated laboratory costs
  DENTISTRY




                           Plastic Dentures*     • Snoring appliances and associated laboratory costs
                           and Associated
                                                 • High impact acrylic
                           Laboratory costs
                           (continue)            • The cost of gold, precious metal, semi-precious metal and platinum foil
                                                 • Laboratory delivery fees
                                                 • Provisional dentures and associated laboratory costs


                                                 Pre-authorisation is required.

                                                 One partial metal frames (an upper or a lower) per beneficiary in a 5-year period.

                                                 Benefit is subject to managed care protocols.
                           Partial Metal
                           Frame Dentures*
                           and Associated        Covered at the BDT.
                           Laboratory Costs      Scheme Exclusions:
                                                 • The metal base to full dentures and associated laboratory costs
                                                 • High impact acrylic
                                                 • The cost of gold, precious metal, semi-precious metal and platinum foil
                                                 • Laboratory delivery fees

                                                 Pre-authorisation is required.
   SPECIALISED DENTISTRY




                                                 One crown per family per year.

                                                 Benefit is subject to managed care protocols.
                                                 Covered at the BDT.

                                                 Benefits for crowns are granted once per tooth in a 5-year period.

                           Crown & Bridge*       A treatment plan and X-rays may be requested.
                           and Associated
                           Laboratory Costs
                                                 Scheme Exclusions:
                           A bridge comprises     • Crowns or crown retainers on wisdom teeth (third molars)
                           two or more crown      • Pontics on second molars where the third molar is a retainer
                           units. Each crown      • Crown and bridge procedures for cosmetic reasons and associated laboratory
                           is payable from the
                                                    costs
                           available Crown &
                           Bridge benefit.        • Occlusal rehabilitations and associated laboratory costs
                                                  • Provisional crowns and associated laboratory costs
                                                  • Porcelain veneers and inlays and associated laboratory costs
                                                  • Emergency crowns that are not placed for the immediate protection in tooth injury
                                                    and associated laboratory costs
                                                  • The cost of gold, precious metal, semi-precious metal and platinum foil
                                                  • Laboratory delivery fees




                                                                                                                                        31
Next part ... Cancel