Dental Benefits and Rules

General Information
TopMed provides a comprehensive set of Dental Benefits, payable from your Major Medical Benefit (where applicable) on the Traditional Option, Savings and Professional Options (See Summary of Benefits for the benefits and limitations provided per option).

Benefits are payable at 80% of the TopMed Tariff on the TopMed Traditional Option and 75% of the TT in respect of the Savings and Professional Options, which is applicable to all your Dental Benefits, including hospitalisation (where clinically approved). Should your dentist charge above the TT, you will be liable for the applicable co-payment as well as the difference between the TT and the fees that your dentist charges. However, it is your right to negotiate this difference with your dentist, to minimise your out-of-pocket payment.

Benefits payable
For information on the benefits provided refer to the Summary of Benefits per option, which will outline the benefits provided per option.

Conservative Dentistry
The benefits provided as part of your Conservative Dentistry are highlighted in the Summary of Benefits.

Specialised Dentistry and Hospitalisation
The provision of Specialised Dentistry and Hospitalisation benefits are based on clinical criteria, subject to obtaining pre-authorisation (PAR) from TopMed, prior to treatment being received.

If no PAR is obtained or if a PAR is obtained late, no benefits will be paid by TopMed . Refer to page 12 for additional information on obtaining pre-authorisation.

As part of the pre-authorisation process please be advised that treatment plans/tooth numbers/x-rays etc will be required for certain Specialised Dentistry benefits. In addition, all requests for hospitalisation will require letters of motivation together with the relevant radiographs from your dentist before any procedures will be authorised.

Call 0860 00 21 58 to obtain a PAR.
Dental Claims
All dental claims must be submitted to TopMed
PO Box 1462
Durban
4000

When submitting a claim, please ensure the following details are clearly visible:

• Your membership number
• The dentist's details and practice registration number
• The correct dependant code (see your membership card)
• The treatment date

Exclusions applicable to Basic and Specialised Dentistry

The following treatment is not covered. The member is liable for the total cost of these procedures:

• Altered cast technique
• Additive partial denture
• Alveolar ridge augmentation – total (by bone graft)
• Alveolar ridge augmentation – total (by all plastic material)
• Alveolar ridge augmentation – one to two tooth sites
• Alveolar ridge augmentation – three across 3 or more tooth sites
• Apicectomy – anteriors/posterior (including retrograde filling)
• Appointment not kept/30min
• Behaviour management
• Bone regeneration – part of a flap operation
• Bone regeneration – at a single site
• Caries susceptibility test
• Cost of bone regenerative/repair material
• Cost of suture material
• Cost of Mineral Trioxide
• Cost of prescribed toothpastes, mouthwashes (e.g.
Corsodyl) and ointments
• Connector bar – implant supported
• Carve restoration to accommodate existing claps or rest
• Clinical claim lengthening
• Coping Metal
• Cost of ceramic block
• Custom abutment
• Clasp or rest – stainless steel
• Connector Bar
• Crown ¾ cast metal/porcelain/ceramic
• Diagnostic denture
• Enamel micro abrasion
• External bleaching – per arch
• Electrognathographic recording without/with computer analysis
• Emergency crown
• Fabrication of computer generated ceramic restoration
• Gold foil class I-V
• Home bleaching – instructions and applicator
• Home bleaching – subsequent visit
• Internal bleaching – per tooth
• Internal bleaching – each additional visit
• Interim, partial or complete denture
• Inlay - Metal
• Inlay - porcelain
• Inlay - resin
• Inlay/on-lay retainer – metal or porcelain – two surface
• Inlay/on-lay retainer – metal or porcelain – three surface
• Inlay/on lay retainer – metal or porcelain – four or more surface
• Locks and milled rest
• Metal base to complete denture
• Microbiological studies
• Nutritional and Tobacco counselling
• Occlusal/mouth guards
• Ortho Tx-fixed lingual appliance – one arch
• Ortho Tx-fixed lingual appliance – one arch, moderate
• Ortho Tx-fixed lingual appliance – one arch severe
• Ortho Tx – fixed lingual appliance – both arches, Class 1 mild
• Ortho Tx – fixed lingual appliance – both arches, Class 1 moderate
• Ortho Tx – fixed lingual appliance – both arches, Class 1 severe
• Ortho Tx – fixed lingual appliance – both arches, Class 1 severe w/complications
• Ortho Tx – fixed lingual appliance – both arches, Class 2/3 mild
• Ortho Tx – fixed lingual appliance – both arches, Class 2/3 moderate
• Ortho Tx – fixed lingual appliance – both arches, Class 2/3 severe
• Oral and/or facial image (Digital/conventional)
• Over, partial or complete denture
• Orthognathic (jaw corrections) surgery and the related hospital cost
• Occlusion analysis mounted
• Ozone therapy
• Pantographic recording
• Pedicle flapped graft
• Partial denture – cast metal framework with resign denture base
• Pulp test
• Pulp cap - direct
• Precision attachment
• Provisional crown
• Polishing – complete dentition
• Re-burnishing and polishing of restorations – complete dentition.
• Remount crown or bridge for prosthetics
• Removal of gross calculus
• Retainer cast metal (Maryland type retainer)
• Prefabricated abutment
• Prefabricated metal or resin crown
• Repair of implant supported prosthesis
• Repair of implant abutment
• Surgical removal of implant
• Stress breaker
• Snoring appliances
• Supply of bleaching materials
• Special report
• Sedative filling
• Sinus lift procedures
• Soft base to denture
• Therapeutic drug injection
• Topical application of fluoride - adult
• Topical application of fluoride - adult
• Veneer – resin (chair side/lab/porcelain)