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MAXICARE HEALTHCARE CORPORATION

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 I. IN-PATIENT BENEFITS 3. Anti-Nuclear Antibody, C-Reactive Protein, Lupus
 Room and Board Accommodation Cell Exam
 Use of Operating Room, Intensive Care Unit (ICU), 4. Arterial Blood Gas
Isolation Room (if prescribed by an attending accredited 5. Arthroscopic Procedures, Orthopedic
physician) and Recovery Rooms Arthroscopy
 Professional Fees of Attending Physicians, Surgeons, 6. Audiograms and Tympanograms
Anesthesiologist and Cardio-pulmonary clearance 7. Bone Densitometry Scan (Dexascan)
before surgery and cardiac monitoring during surgery 8. Bone Mineral Density Studies
 Standard nursing services
9. Cardiac Ambulatory Monitoring
 Medicines for in-patient use
10. Cardiac Stress Tests (Thallium and Dipyridamole
 Blood product transfusions and intravenous fluids,
Stress Tests)
including blood screening and cross matching
11. Computed Tomography (CT) Scans
 X-ray, laboratory examinations, diagnostic tests and
12. Diagnostic Angiogram: Cerebral, Coronary,
therapeutic procedures incidental to confinement
Mesentric, Flourescein Angiography
 Dressings, conventional casts (plaster of Paris) and
13. Diagnostic Radiographs or X-rays
sutures
i. Biliary Tract: Cholecystogram and
 Anesthesia and its administration
Cholangiogram
 Oxygen and its administration
ii. Chest, Ribs, Sternum and Clavicle
 Standard admission kit
iii. Digestive Tract: Plain film of the abdomen,
 All other items directly related in the medical
Barium Enema, Upper Gastro Intestinal (GI)
management of the patient, as deemed medically
Series, Small Bowel Series, Lower Gastro
necessary by the attending accredited physician
Intestinal Series
NOTE: Required to file Philhealth. Non-Philhealth iv. Face (including sinuses), Head and Neck
member will pay for the Philhealth portion. v. Urinary Tract: Kidney Ureter Bladder (KUB),
Pyelograms, Cystograms
vi. X-ray of the extremities and pelvis
II. OUT-PATIENT BENEFITS vii. X-ray of the Spine (cervical, thoracic, lumbo-
The following services shall be provided when medically sacral)
necessary: 14. Diagnostic Ultrasounds:
 Consultations during regular clinic hours, except for i. 2D-Echo with Doppler
medicines prescribed ii. Abdomen
 Eye, ear, nose and throat (EENT) treatment prescribed iii. Duplex Scan
by an accredited physician/specialist iv. Digestive and Urinary Systems
 Treatment for minor injuries such as lacerations, mild v. Ultrasound of the Lungs
burns, sprains and the like 15. Electro Encephalogram (EEG)
 Dressing, conventional casts (plaster of Paris) and 16. Electromyography & nerve conduction velocity
sutures studies
 X-ray, laboratory examinations, routine, diagnostic and 17. Endoscopic Procedures
therapeutic procedures prescribed by an accredited 18. Flourescein Angiography
physician/specialist, provided however that the cost of 19. Impedance Plethysmography
diagnostic and therapeutic procedures covered shall be 20. Lead Electrocardiogram
limited to the amount set forth under pertinent sections 21. Magnetic Resonance Angiography (MRA)
below. 22. Magnetic Resonance Imaging (MRI)
o Routine procedures to be covered at 100% of actual 23. Mammogram and Sonomammogram
cost and to be charged against MBL: 24. Microscopic Examinations
1. Blood Chemistries 25. Myelogram
2. Chest X-Ray 26. Nuclear Radioactive Isotope Scan
3. Complete Blood Count 27. Pap’s Smear
4. Fecalysis 28. Perfusion Scan
5. Urinalysis 29. Plasma Urinary Cortisol, Plasma Aldosterone
o Diagnostic procedures to be covered at 100% of 30. Polysomnograms (Sleep Recording)
actual cost and to be charged against MBL: 31. Pulmonary Function tests
1. 24-Hour Electro Encephalogram Monitoring 32. Radioisotope Scans and Function Studies:
2. Adrenocortical Function
 i. Cardiac  Speech therapy (for stroke patients only) shall be
ii. Gastrointestinal covered as charged but on reimbursement basis up to
iii. Liver Php10,000 per member per year. Consultations shall be
iv. Parathyroid, Bone, Pulmonary (Perfusion, part of the limit and treated as sessions for purposes of
Ventilation Lung Scans) determining coverage
v. Renal
vi. Thyroid Scans  Tuberculin test up to Php600 per member per year
vii. Total Body Scans
33. Radionuclide Ventriculography III. SALIENT FEATURES
34. Surface Electromyography (SEMG)
35. Thallium Scintigraphy PLAN TYPE R&B MBL
36. Treadmill Stress Test (TMST) Platinum Plus Large Private Php 200,000
Platinum Regular Private 150,000
 Therapeutic procedures shall be covered at 100% of Gold Regular Private 100,000
actual cost and to be charged against MBL up to twelve Silver Semi-Private 60,000
(12) sessions per member per year R&B – Room and Board Accommodation (room category)
o Dialysis MBL – Maximum Benefit Limit (limit per illness per year)
o Intravenous Chemotherapy
o Therapeutic Radiology IV. PREVENTIVE CARE
1. Brachytherapy  Passive and active vaccines for treatment of tetanus
2. Cobalt and animal bites shall be covered up to Php18,000 per
3. Linear Accelerator Therapy member per year
4. Radioactive Cesium  Periodic monitoring of health problems
5. Radioactive Iodine  Health education and counseling on diets and exercise
o Physical therapy / Occupational therapy (shared limit)  Health habits & family planning counseling
excluding subspecialties such as cardiac
rehabilitation, pulmonary rehabilitation and the like. V. EMERGENCY CARE
(Therapy of one (1) body area shall be considered as  Accredited Hospital
one (1) session.) o Doctor’s services
o Emergency Room fees
 Minor surgery not requiring confinement prescribed by o Medicines used for immediate relief and during
an accredited physician/specialist treatment
o Oxygen, intravenous fluids and blood products
 Eye laser therapy for retinal tear, retinal hole, retinal o Dressings, conventional casts (plaster of Paris) and
detachment & glaucoma prescribed by an accredited sutures
physician/specialist up to Php10,000 per eye per o X-rays, laboratory, diagnostic examinations and other
member per year. Eye correction such as Lasik, PRK medical services related to the emergency treatment
and the like are not covered. of the patient
 Non-Accredited Hospitals
 Electrocauterization of skin lesions such as plantar o Within the Philippines
warts, flat warts, periungual warts, filiform warts and Maxicare shall reimburse up to 80% of the actual
molluscum contagiosum, in any part of the body, except hospital bills and 80% of the professional fees based
genital warts and condyloma acuminata, prescribed by on Maxicare rates incurred during the first twenty-four
an Accredited Physician/Specialist shall be covered up (24) hours of treatment up to Php 30,000 per
to Php1,000 per member per year. availment per member.
o Areas without accredited hospitals within the
 Sclerotherapy for varicose veins (except medicines and Philippines
for cosmetic purposes) as prescribed by an accredited Maxicare shall reimburse 100% of the total hospital
physician up to Php5,000 per leg per member per year bills and Professional fees based on Maxicare rates.
to be availed through accredited vascular surgeons o Outside the Philippines
Maxicare shall reimburse 100% actual costs up to
 Allergy testing / allergy screening and other related Php30,000 per availment per member.
examinations prescribed by an accredited physician up
to Php2,500 per member per year
 Ambulance Service from a non-accredited Hospital to an accredited Hospital
Maxicare will cover road ambulance service for transfers (on reimbursement basis).
from an accredited hospital to another accredited Note: it is very important that you call the Maxicare Hotline within
hospital up to MBL and Php2,500 per conduction if it is 24 hours in order for Customer Care to arrange a transfer from
the non-accredited hospital to the accredited hospital.
 Initial treatment of animal bites shall be covered for the first twenty-four (24) hours from the time of bite subject to MBL.

VI. ADDITIONAL BENEFITS Positron Emission Tomography, etc. shall be covered

 Life coverage with Accidental Death & Dismemberment up to Php 5,000 per procedure per member per year.
up to Php25,000  Transurethral Microwave Therapy of Prostate covered
 Motor vehicular accidents shall be covered up to MBL. up to Php25,000 per member per year
 Scoliosis including necessary procedures, except
physical therapy sessions, shall be covered up to VII. ANNUAL CHECK-UP (ACU)
Php20,000 per member per year. Physical Therapy
sessions shall form part of the Physical therapy Basic 5 Routine; Clinic-based: (Applicable to all Plan
/Occupational therapy limits.
type)
 Congenital illness, except physical therapy sessions
and developmental disorders, shall be covered up to
Php20,000 per member per year. Physical Therapy  History and Physical Exam
sessions shall form part of the Physical therapy  CBC (Complete Blood Count)
/Occupational therapy limits.  Routine Urinalysis
 Congenital hernia shall be covered up to MBL.  Routine Fecalysis
 Consultations for Chronic Dermatoses shall be covered  Chest X-ray (PA and Lateral)
up to MBL.
 Additional Modalities and Procedures covered at 100%
of their actual cost up to MBL whether done in in-
patient or out-patient: The ACU however, may only be availed within
1. Angiography (gastrointestinal, brain, retinal and the contract period after (1) payment of at least six (6)
peripheral vascular) months worth of membership, and (2) must be a member
2. Coronary Angiogram of at least six (6) months starting from the effectivity date.
3. Cryosurgery
Member must notify Maxicare’s Customer Care
4. Gamma Knife Surgery
5. Hysterescopic Myoma Resection Department (CCD) at least one (1) month prior to
6. Hysterescopically-guided Dilation & Curettage preferred schedule. Any request for rescheduling or
7. Laparoscopy change of venue must be in writing and shall be allowed
8. Lithotripsy only once provided request was forwarded to CCD at
9. Percutaneous Ultrasonic Nephrolithomy least one (1) week prior to the original ACU schedule.
10. Conventional Hemmorhoidectomy Otherwise, ACU entitlement shall be forfeited
11. Scalpel Hemmorhoidectomy
 The following procedures shall be covered up to
Php5,000 per procedure per Member per year:
- Stapled Hemorrhoidectomy VIII. DENTAL CARE (OPTIONAL)
- Mammotome
- 4D Ultrasound except for maternity-related  Annual Oral/Dental Examinations & Consultation
cases  Emergency Dental Treatment
- Stapled Hemorrhoidectomy
 Annual Oral Prophylaxis
- Mammotome
- 4D Ultrasound except for maternity-related  Simple Tooth Extractions
cases  Restorative and Prosthodontic Treatment Planning
- Esophageal Manometry  Permanent fillings up to 2 fillings per year
- Intensified Modulated Radiotheraphy  Unlimited temporary fillings,as needed
- Botox which is not cosmetic in nature nor for  Desensitization of hypersensitive teeth – 2 per year
beautification purpose
 Simple adjustment of dentures
- Photodynamic Therapy
 Other medically necessary modalities are  Recementation of loose crowns, inlays or onlays
procedures/modalities that are not readily available in  Dental nutrition and dietary counseling
the major tertiary hospitals, costly relative to more  Dental Health Education
conventional procedures and relatively new or recently
introduced in the Philippines, such as but not limited to Note: Dental Benefit is optional for an additional fee of
Capsule Endoscopy, CT Pulmonary Angiography, Annual fee: P387, Semi-annual: P209, Quarterly P108
IX. VALUE ADDED FEATURES epidemics, required immunization and available
preventive measures
· Up to the minute travel supplier strike information
MAXICARE’S INTERNATIONAL EMERGENCY ASSIST
· Claims Assistance services
PROGRAM
TRAVEL GUARD
Maxicare has partnered with AIG Philippines Insurance, 24-Hour Alarm Center Number—Call Collect
Inc. Travel Guard Annual Business Travel insurance for
Philippines Tel No. (632) 878-1280
frequent travelers throughout the year under One Policy.
It provides benefits or losses caused of death or bodily
injured due to accidents while travelling overseas. It X. AVAILMENT PROCEDURES
covers the insured 24 hours a day, any place in the
world, on or off duty including while riding solely as a  Out-patient
passenger on a licensed commercial airline on regular, 1. To avail of consultations or treatment, go to any
scheduled or non-scheduled, special or chartered flight or Maxicare Accredited Clinics/Hospitals or Maxicare
on Military Airlift Command flight only while traveling on a Primary Care Centers (PCC).
bonafide business trip. 2. Member goes to the POS terminal in the
hospital/clinic (Billing/ER/Admitting section) or at the
This plan also covers travel incoveniences such as trip PCC.
curtailment, trip cancellation, loss of baggage, and 3. Hospital staff swipes the member’s swipe card. The
personal liability. Letter of Eligibility (LOE) will be given to the member
with his Maxicare card.
Benefits:
Please note that the LOE is valid only on the same
1. Medical Expense date that it was swiped. Availments made on
2. Emergency Medical Evacuation different dates will need an LOE per date.
3. Repatriation Expense
4. Personal Accident 4. Member proceeds to the Medical Coordinator’s clinic
and presents his LOE and Maxicare card for
Medical Assistance Services consultation.
· Medical Advice 5. If referred to an accredited specialist, secure LOE
· Physician/hospital/dental/vision referral and Referral Slip* from the Medical Coordinator/
· Emergency prescription replacement PCC.
· Shipment of medical records 6. Present Maxicare ID Card, LOE and Referral Slip to
· Qualified liaison for relaying medical info to Family accredited specialist to avail of consultation.
members 7. If member is requested to take a laboratory test,
· Inpatient and outpatient medical case management secure the Laboratory Slip* from the Medical
- Arrangement of appoinments with doctor Coordinator/ PCC.
- Arrangement of hospital admission 8. Proceed to the laboratory and present the laboratory
- Medical Monitoring slip with the LOE and avail of the test.
- Guarantee of medical expenses including 9. For follow-up consultations, follow steps 1-5 to
hospitalization secure LOE and referral slip/ laboratory slip from
-Review of medical expenses Maxicare Centers and/or Coordinator.
· Emergency Medical Evacuation
· Repatriation of Mortal Remains Note: Referral Slips and Laboratory Slips* are necessary
· Arrangement of compassionate visit in order for the doctor to know that Maxicare is to be
· Return travel arrangement for the minor children billed for the procedure. For queries and assistance,
please call Maxicare Hotline at 582-1900.
Travel Assistance Services
· Inoculation Information  In-patient
· Travel Information including visa/passport requirements
· Embassy or Consulate Referral 1. Secure an Admitting Order from a Maxicare
· Lost Luggage search, stolen luggage replacement Accredited Specialist.
· Lost passport/travel documents assistance 2. Coordinate with the admitting section and coordinator
· Emergency cash transfer assistance in the hospital for room reservation
· Emergency telephone interpretation assistance 3. If possible, call Maxicare at least 24 hours prior to
· Urgent message relay to family, friends or business admission for assistance in securing the doctor
associates 4. Member goes to the Admitting Section in the
· Legal referral/bail bond assistance hospital and presents his/her Maxicare swipe card
· Emergency flight, hotel or car rental re-booking and admitting order from the Maxicare Coordinator/
· Rental Vehicle Return Specialist to the admitting staff.
· Up to the minute travel delay reports
· Up to the minute information on local medicaladvisories,
5. Once the LOE is generated by the hospital staff, the 2. Initial submission of Medical Requirements is
member will be asked to sign on it. This will be applicable to enrollees who are 50 years old and
attached to the other admitting documents.
above, whether Principal or Dependent. The date of
6. Proceed to the reserved room entitled or operating
room (for operation) the conduction of these Medical Requirements should
7. Maxicare will issue the Letter of Authority (LOA) upon not exceed 6 months before the date of submission.
receiving hospital’s advice on the member’s
confinement. Medical Requirements for 49 years and 6 months old
8. Member must file Philhealth on or before discharge.  12 - lead ECG (Electrocardiogram) tracings w/ results
9. All uncoverable and excess charges must be settled
 Chest X-ray
by the member upon discharge.
 FBS (Fasting Blood Sugar)
Note: For queries and assistance, call Maxicare Hotline:  Creatinine
582-1900  SGPT
 Total Cholesterol
 Emergency Care  HDL-C (High Density Lipoprotein)
A life threatening or accidental injury or a sudden and  LDL-C (Low Density Lipoprotein)
Note: test results should not be more than 6 months from
unexpected onset of a condition which at the time of the
the date it was taken
occurrence reasonably appears to have the potential of
causing immediate disability or death, or which requires
3. Dependent’s plan must be the same plan as the
the immediate alleviation of pain or discomfort.
Principal or one plan lower.
4. Forward the accomplished application form and
The Member must notify MAXICARE HEAD OFFICE,
medical requirements (if applicable) to the Account
thru the Customer Care Department, WITHIN 24 HOURS
Officer for processing.
so that proper assistance is promptly rendered.
5. Once the application has been approved, the
Statement of Account shall be sent to your billing address
o Accredited Hospital
for settlement. Payments (cash or check) may be made
1. Go to the Emergency Room of nearest accredited
at the Maxicare Head Office or at any Banco de Oro
hospital.
branches via bills payments.
2. Avail of treatment at Emergency Room.
6. Member will receive Maxicare ID card as proof of
3. Present Maxicare ID Card to ER Staff. ER
membership.
Personnel will facilitate swiping for the LOE.
4. File Philhealth before discharge.
Who may be enrolled into the Maxicare Program and
what are the requirements?
Note: Settle charges not covered by Maxicare at the
Billing Section once the Discharge Order is
• The age eligibility for principal and dependents is from
issued by the attending doctor.
15 days old to 60 years and 5 months of age.
• Eligible dependents are as follows (in order):
o Non-Accredited Hospital
* For single enrollees: Mother, Father, then Siblings 21
1. Member may proceed to the Emergency Room of
years and 5 months old and below, according to age.
nearest hospital.
* For married enrollees: Spouse, then Children 21
2. Avail treatment at the Emergency Room.
years and 5 months old and below, according to age.
3. Call Maxicare within 24 hours to arrange transfer
• Individual Membership Requirements:
to an accredited hospital.
1. Application form
4. Settle all ER fees and secure Medical Certificate,
2. Medical requirements for 49 years and 6 months
Official Receipts, etc.
old
5. Forward all original documents to Maxicare for
3. Photocopy of ACR (Alien Certificate of Residency)
reimbursement within 30 days upon discharge.
if nationality is foreign
• Family Membership Requirements
XI. ENROLLMENT PROCESS AND GUIDELINES
Couples only:
1. Application form
1. Fill up the IFG application form completely. Indicate
2. Copy of marriage certificate
your Tax Identification Number (TIN) on the front page
3. Medical requirements if already 49 years and 6
if applicable.
months old (principal and dependent)
 4. Photocopy of ACR (Alien Certificate of Residency) Subsequent years of membership:
if nationality is foreign  Dreaded conditions not considered acquired are
5. With child dependent covered subject to below limits:
Plan Type Per illness per
1. Application form member per year
2. Copy of birth certificate (each child) Platinum Plus Php 20,000
3. Medical requirements if already 49 years and 6
Platinum 15,000
months old (principal and dependent)
Gold 10,000
4. Photocopy of ACR (Alien Certificate of Residency)
Silver 5,000
if nationality is foreign
Note: Maxicare may request for additional requirements  Non-dreaded conditions shall be covered up to MBL
when deemed necessary  Acquired dreaded conditions shall be covered up to
MBL
• HIERARCHY OF ENROLLMENT:
 Unless there is a valid reason for the non- Such dreaded conditions are as follows, but not limited
to:
enrollment of certain dependents (i.e. currently
enrolled in another HMO, abroad, separated, a. All malignancies (including indicated
deceased, etc.), applicants should enroll their chemotheraphy or radiotheraphy)
dependents in the priority specified above. b. Arthritis
• Sufficient documentation shall be requested by c. Blood Dyscrasias such as but not limited to
Maxicare from the applicant to validate the non- Leukemia, Idiopathic Thrombocytopenic
Purpura
eligibility of the dependent (i.e. photocopy of HMO
d. Chronic Cardiovascular Diseases and its
card, certificate of employment from company abroad, complications such as but not limited to
death certificate, etc.) Uncontrolled Hypertension of whatever
etiology, Aortic Dissection, Abdominal Aortic
REQUIREMENTS FOR ALIEN RESIDENTS/ FOREIGN Aneurysm, Myocardial infarction, Cardiac
NATIONALS: Arrest, Congestive Heart Failure, Cardiac
Arrhythmia, Cardiac Tamponade, Coronary
1. Photocopy of ACR (Alien Certificate of Residency) ID
Artery Disease, Cardiomyopathies and
2. Medical Requirements for enrollees 49 years and 6 Valvular Heart Disease, Aortic Dissection,
months old (if applicable) Abdominal Aortic Aneurysm and Peripheral
3. Certificate of employment (if applicable) Vascular Disease and its complications such
as but not limited to Buerger’s Disease
XII. DREADED DISEASE / CONDITION e. Cataract and Glaucoma
f. Cerebrovascular Diseases such as but not
Any condition that is considered to be chronic,
limited to Stroke, Cerebral, Cerebellar,
progressive, life-threatening and which may entail lifelong Thrombosis, Embolism and Ruptured
therapy. This refers also to conditions where complete aneurysm and all Intracranial Hemorrhage and
cure cannot be ensured. related conditions
g. Cholecystolithiasis and Choledocholithiasis
COVERAGE FOR DREADED AND NON-DREADED h. Chronic Endocrine Disorders and its
CONDITONS complications such as but not limited to
Dyslipidemia, Obesity, Diabetes Mellitus,
1st year of membership: Hormonal Dysfunctions excluding surgical
 Dreaded and Non-dreaded covered subject to below treatment/procedures for obesity
limits: i. Chronic Gastrointestinal Diseases such as but
Plan Type Per illness per not limited to Irritable Bowel Syndrome,
member per year Crohn’s disease
Platinum Plus Php 20,000 j. Chronic Genito-urinary Disorders
k. Chronic Kidney Disease/Failure & its
Platinum 15,000 complications
Gold 10,000 l. Chronic Liver Parenchymal Diseases such as
Silver 5,000 but not limited to Liver Cirrhosis, Chronic
hepatitis, Non-alcoholic Fatty Liver
Disease/Steatohepatisis (NASH)
m. Chronic Pulmonary Diseases such as but not
limited to Bronchial Asthma, Chronic
Obstructive Pulmonary Disease (COPD),
emphysema, and other chronic lung disease
 n. Collagen Vascular/Connective XIII. EXCLUSIONS AND LIMITATIONS
Tissue/Immunologic Disorders such as but not
limited to Systemic Lupus Erythematosus and
Notwithstanding any provisions to the contrary, the
its complications
o. Complications of immuno-compromised clinical following shall not be covered except otherwise specified
conditions except HIV/AIDS in Agreement:
p. Extrapulmonary Tuberculosis including Pott’s
disease and Multi-Drug Resistance Case  Services obtained for non-emergency conditions from
(MDR) case Physicians and Hospitals in any of the following
q. Multiple Organ Failure
circumstances:
r. Muscular Dystrophies such as but not limited to
Duchenne, Becker, limb girdle, o non-accredited physicians in non-accredited
facioscapulohumeral, myotonic, hospitals or clinics;
oculopharyngeal, distal, and Emery-Dreifuss o non-accredited physicians in accredited hospitals or
s. Neuro-surgical interventions and/or major clinics;
neurological diseases such as but not limited to o accredited physicians in non-accredited hospitals or
Poliomyelitis/Meningitis/Encephalitides,
other non accredited healthcare facility.
Demyelinating Neurologic diseases and its
complications/sequelae and Peripheral  Additional hospital charges and physician’s
Nervous System Disorders/Diseases professional fees resulting from:
t. Thyroid Dysfunctions due to disease of thyroid o room-upgrading beyond member’s allowable time
such as but not limited to Hypothyroidism and during emergency care;
Hyperthyroidism o extension of hospital stay despite release of
u. Any illness other than above which would
discharge order from member’s attending physician;
require Critical Care/Intensive Care Unit (ICU)
Confinement o fees of the assistant surgeons/ resident doctors who
v. All complications resulting from above list of assisted the Attending Physician in the process of
conditions rendering the above mentioned services shall not be
chargeable to the Member and/or Maxicare except
Such non-dreaded conditions are as follows, but not for hospitals that do not have resident physicians to
limited to:
assist during surgeries subject to the prior approval
a. All benign tumors of Maxicare;
b. Anal Fistulae o use of extra bed, TV, electric fan, DVD/VCD, and
c. Cervical Polyps (if benign biopsy) other similar items unless such appliances and items
d. Conjunctivitis (except chemical, complicated) are necessarily and ordinarily included in the
e. Endometrioses/Controlled Dysfunctional Uterine Member’s Room & Board Accommodation;
Bleeding (except if caused by uterine malignancies) o extra food;
f. Hemorrhoids
g. Hepatitis A o toilet articles like face towel, soap, toothbrush and
h. Gastritis, Duodenitis or Uncomplicated Gastric / the like;
Duodenal Ulcer o difference in room and board, the incremental rate
i. Inactive Pulmonary Tuberculosis differences for professional fees, diagnostic and
j. Migraine laboratory examinations, and other ancilliary medical
k. Non-surgical Ear-Nose-Throat conditions such as but services brought about by obtaining a room
not limited to Sinusitis, Rhinitis, Tonsillopharyngitis,
Laryngitis, Parotitis, Otitis Media, Otitis Externa and accommodation higher than the Member’s Room
Surgical Ear-Nose-Throat conditions such as but not and Board Accommodation limit;
limited to Tonsillectomy, Nasal Polypectomy, o services of a private or a special nurse; and
Tympanoplasty, Sialolithotomy, Sialodochoplasty. o all other items not medically necessary in the
l. Non-Toxic Goiter (if uncomplicated) medical management of the patient
m. Ovarian cysts Uncomplicated Cholecystitis,  Custodial, domiciliary, convalescent and intermediate
Cholelithiasis
care.
n. Uncomplicated Hernias (Congenital Hernia will have
coverage as listed in the Congenital Clause)  Long-term rehabilitation and psychiatric care and/or
o. Uncomplicated Hypertension psychological illnesses and conditions including
p. Uncomplicated Urinary Tract Infection, Stones/Calculi neurotic and psychotic behavior disorders; anxiety
q. Urinary Incontinence disorders.
 Treatment for injury and its complications resulting
from self-inflicted injuries including infections as a
result of tattoos, piercing of the ear or in any body part,
 whether self-inflicted or done by a third party or  Purchase or lease of durable medical equipment,
attempted suicide or self-destruction, whether sane or oxygen dispensing equipment, and oxygen, except
insane. during in-patient care.
 Developmental disorders including functional disorders  Corrective appliances, prosthetics and orthotics such
of the mind, such as but not limited to Attention-Deficit as but not limited to artificial limbs, hearing aids,
Disorder (ADD)/Attention-Deficit Hyperactivity Disorder intraocular lens, eyeglasses, contact lenses, braces,
(ADHD), Autism Spectrum Disorders, Bipolar crutches, pacemaker, pins, screws, plates, wires,
Disorders, Central Auditory Processing Disorder balloons, valves, knee-tibial insert for total knee
(CAPD), Cerebral Palsy, Down Syndrome, Neural arthroplasty, orthopedic internal fixator/fixation
Tube Defects, and Mental Retardation. systems, orthopedic external fixator/fixation systems,
 Treatment of any injury received when there is bone screws and plates, vascular grafts/stents,
negligence, unauthorized use of prohibited or regulated intravascular catheters, myringotomy tube.
drugs, alcoholic liquor intake, direct or indirect  Take-home medicine and outpatient medicine except
participation in the commission of a crime whether o chemotherapy medicine
consummated or not, violation of a law or ordinance or o medicine administered during an emergency
unnecessary exposure to imminent danger, knowingly treatment
or unknowingly or hazard to health, by the member.  Congenital, genetic and heredity diseases and their
Maxicare may, in its discretion, rely on Police and complications (except for hernias) affecting functions of
Doctor’s report in evaluating such claim. individuals.
 Aesthetic, cosmetic and reconstructive surgery or any  All physical deformities prior to enrollment.
consultation or treatment for any beautification  Treatment of injuries/illnesses caused directly or
purposes except if necessary to treat a functional indirectly by engaging in any professional sport or
defect due to accidental injury within the initial hazardous activity such as but not limited to scuba
confinement. diving, surfing, water skiing, mountain climbing, rock
 Oral surgery following accidental injury to teeth for climbing, mountaineering, parachuting, airsoft, drag
purposes of beautification. Dental examinations, racing, paintballing, wakeboarding and bungee
extractions, fillings, other dental treatment and their jumping, except for activities under company-
complications to the extent that are medically sponsored sports activities.
necessary for repair or alleviation of damage to the  Injuries resulting from direct participation in riots,
member caused solely by an accident. Medical care strikes, and other civil disturbances.
resulting from any dental related conditions.  Treatment of injuries or illnesses resulting from war
 Maternity care and all other conditions, including pre and any combat-related activities while in military
and post natal consultations, related to and/or resulting service.
from pregnancy and/or delivery which affect the  Sexually transmitted diseases, genital warts, AIDS and
conditions of the principal member and the unborn AIDS related diseases.
child.  Valvular heart disease (congenital and/or acquired)
 Circumcision (except for treatment of urological including Cardiomyopathies, Chronic
conditions), sex transformation, diagnosis, treatment Glomerulonephritis, previous craniotomy
and procedures related to fertility or infertility, artificial sequelae/hearing impairment/ Neurologic disease and
insemination, sterilization or reversal of such Spinal Stenosis (if pre-existing)/Poliomyelitis/Slipped
procedures and their complications. disc (if pre-existing) and Guillain-Barre Syndrome,
 Experimental medical procedures and its Diabetes and its complications (if pre-existing),
complications. Complicated Hypertension (e.g. those with history of
 Acupuncture and chirotheraphy and other forms of stroke, myocardial ischemia or infarction and poor
therapies, and its complications. kidney function), and all malignant tumors (if pre-
 All expenses incurred in the process of organ donation existing).
and transplantation if the member is the donor of such  Treatment for Chronic Dermatoses, except Scabies.
donation or transplantation, and its complications.  Infectious diseases (i.e. Avian Flu, Meningococcemia,
 Routine physical examinations required for obtaining or etc.) that are declared epidemic or pandemic by the
continuing employment, requirement in school, Department of Health, World Health Organization or
insurance, government licensing, health permit and any recognized health authority.
other similar purposes.  Hepatitis B and screening and vaccines for all types of
Hepatitis.
 Animal bite/scratch/lick or snake bite including its
complications.
 Benefits covered by Philhealth, and all other
government funded healthcare entitlements as
provided for by law.
 Laser procedures/treatments.
 Speech therapy for developmental and congenital
diseases.
 Weight reduction programs, surgical operation or
procedure for treatment of obesity, including gastric
stapling or balloon procedures and liposuction.
 Routine, diagnostic, therapeutic and other procedures
of the same or similar nature not otherwise specified in
this Agreement
 Cost of vaccines and immunization including its
administration.
 Cost of medico-legal cases.
 All screening tests if patient is
o asymptomatic, no clinical signs and symptoms;
o no previous history of the disease for which the test
is requested for; and
o personal request of the member which may fall
under the above reasons.
 Treatment of work-related injuries of high-risk
occupations such as but not limited to construction
workers, miners, loggers and drillers.
 Cost of the medical services and professional fees in
excess of the MBL.
 All cases of assault whether provoked or unprovoked,
whether initiated by the member or by a known or
unknown third party.
 Open heart surgeries, angioplasties, valvuloplasties,
permanent pacemaker, balloon valvuloplasties,
percutaneous intra-aortic balloon counter pulsation and
balloon atrial septostomy.
 Home service.
 Additional modalities and procedures not specified in
this Agreement, in excess of Php 5,000.
 Multiple sclerosis, epilepsy and seizures.
 Neurologic degenerative diseases such as but not
limited to Alzheimer’s disease, Parkinson’s disease,
Amyotrophic lateral sclerosis and others
 Intravenous Immunoglobulin (IVIG)
OTHER PROVISIONS:

CUT OFF DATES

For Individual and Family

PAYMENT RECEIVED or
Official Receipt dates EFFECTIVE DATE
st th st
1 to the 15 of the month 1 of the following month
th th st th
16 to 30 / 31 of the month 16 of the following month

LAPSATION

If a member fails to pay a membership fee on its due date, his or her membership shall be considered lapsed
effective the day after the due date. A member whose membership has lapsed will not be entitled to any Benefit
during the period that his membership is on a lapsed status, except in connection with illness or injury that
supervened prior to such lapsation and for which the member had at that time made the necessary claim for the
benefits under this Agreement.

REINSTATEMENT

A member whose coverage has lapsed for failure to pay the membership fee on the due date may apply to reinstate
his or her coverage within forty-five (45) calendar days from the date it is considered lapsed by (a) submitting a
written request for reinstatement; (b) paying the membership fee due with arrears, including five hundred pesos
(Php500) per member; (c) for modes of payment other than annual, paying in advance the membership fee due for
the next period, provided however that there shall be no coverage of any benefit to the reinstated member within 30
calendar days from the effective date of reinstatement.

If the membership fees due including five hundred pesos (Php500) remain unpaid within forty-five (45) days from the
date it is considered lapsed, Maxicare reserves the right to suspend all services under this Agreement until full
payment of all fees have been paid and settled.

After the forty-five (45) days of non-payment of membership fees, Maxicare reserves the right to disapprove
reinstatement and will require the member to re-apply.

***May change without prior notice**

 2016 INDIVIDUAL MEMBERSHIP FEES

PLATINUM PLUS PLATINUM

Php 200,000 Php 150,000

AGE BRACKET Large Private Regular Private

Annual Semi-Annual Quarterly Annual Semi-Annual Quarterly

15 days old -5 55,795 30,129 15,623 32,708 17,662 9,158
6-10 45,684 24,669 12,792 26,202 14,149 7,337
11-15 37,647 20,329 10,541 21,089 11,388 5,905
16-20 36,469 19,693 10,211 19,475 10,517 5,453
21-25 36,262 19,581 10,153 20,317 10,971 5,689
26-30 37,647 20,329 10,541 22,466 12,132 6,290
31-35 45,114 24,362 12,632 26,628 14,379 7,456
36-40 56,720 30,629 15,882 35,081 18,944 9,823
41-45 72,045 38,904 20,173 47,696 25,756 13,355
46-50 85,818 46,342 24,029 64,367 34,758 18,023
51-55 96,827 52,287 27,112 78,447 42,361 21,965
56-60 106,919 57,736 29,937 88,834 47,970 24,874

GOLD SILVER

Php 100,000 Php 60,000

AGE BRACKET Regular Private Semi Private

Annual Semi-Annual Quarterly Annual Semi-Annual Quarterly

15 days old -5 28,955 15,636 8,107 21,456 11,586 6,008
6-10 22,668 12,241 6,347 17,877 9,654 5,006
11-15 18,650 10,071 5,222 15,129 8,170 4,236
16-20 17,847 9,637 4,997 14,390 7,771 4,029
21-25 17,434 9,414 4,882 14,390 7,771 4,029
26-30 20,454 11,045 5,727 16,372 8,841 4,584
31-35 24,668 13,321 6,907 17,635 9,523 4,938
36-40 32,376 17,483 9,065 21,474 11,596 6,013
41-45 41,460 22,388 11,609 32,192 17,384 9,014
46-50 49,701 26,839 13,916 38,536 20,809 10,790
51-55 57,764 31,193 16,174 42,830 23,128 11,992
56-60 67,353 36,371 18,859 47,583 25,695 13,323

Note:

1) Exclusive of Dental Benefit

2) Rates are inclusive of 12% VAT. Additional VAT that may be imposed at the time of transaction is to be shouldered by the member
3) Rates are valid to members which effective date falls from July 1, 2016 to December 31, 2016.
 2016 FAMILY MEMBERSHIP FEES

PLATINUM PLUS PLATINUM

Php 200,000 Php 150,000

AGE BRACKET Large Private Regular Private

Annual Semi-Annual Quarterly Annual Semi-Annual Quarterly

15 days old -5 45,626 24,638 12,775 29,718 16,048 8,321
6-10 37,336 20,161 10,454 23,874 12,892 6,685
11-15 32,525 17,564 9,107 19,363 10,456 5,422
16-20 29,673 16,023 8,308 17,718 9,568 4,961
21-25 29,966 16,182 8,390 18,937 10,226 5,302
26-30 31,382 16,946 8,787 20,864 11,267 5,842
31-35 35,492 19,166 9,938 25,107 13,558 7,030
36-40 40,508 21,874 11,342 31,741 17,140 8,887
41-45 52,442 28,319 14,684 41,244 22,272 11,548
46-50 70,360 37,994 19,701 55,143 29,777 15,440
51-55 82,710 44,663 23,159 67,272 36,327 18,836
56-60 95,025 51,314 26,607 79,162 42,747 22,165

GOLD SILVER

Php 100,000 Php 60,000

AGE
BRACKET Regular Private Semi Private

Annual Semi-Annual Quarterly Annual Semi-Annual Quarterly

15 days old -5 23,904 12,908 6,693 18,808 10,156 5,266
6-10 19,266 10,404 5,394 15,322 8,274 4,290
11-15 15,887 8,579 4,448 13,152 7,102 3,683
16-20 14,192 7,664 3,974 12,497 6,748 3,499
21-25 13,992 7,556 3,918 12,455 6,726 3,487
26-30 16,470 8,894 4,612 13,817 7,461 3,869
31-35 19,230 10,384 5,384 14,967 8,082 4,191
36-40 24,371 13,160 6,824 17,824 9,625 4,991
41-45 30,369 16,399 8,503 25,674 13,864 7,189
46-50 38,681 20,888 10,831 31,990 17,275 8,957
51-55 45,134 24,372 12,638 35,702 19,279 9,997
56-60 52,248 28,214 14,629 39,647 21,409 11,101

Note:

1) Exclusive of Dental Benefit

2) Above membership fees are inclusive of 12% VAT. Additional VAT that may be imposed at the time of transaction is to be shouldered by the
member
3) Rates are valid to members which effective date falls from July 1, 2016 to December 31, 2016.
4) Family membership consists of 2 or more individual enrollees: 1 Principal member and legal spouse and / or children. Hierarchy rule applies.
MAXICARE PRIMARY CARE CENTERS were put together with your convenience in mind. These are well-
appointed to give the cardholders access to quality health care close enough to where they work or live. Each center
has its staff of Customer Service Assistants, Primary Care Physicians (specialists in some centers on certain days)
and additional services like urinalysis and CBC. Because our centers are located close to major hospitals, our
Customer Service Assistants are able to facilitate easy access to quality diagnostics, specialist consultation and
hospitalization when you need it.

MAXICARE PRIMARY CARE CENTERS AND MYHEALTH CLINICS

MAKATI MEDICAL CENTER (Out-Patient)

3rd Floor Tower One, Makati Medical Center, Amorsolo St., Makati City
Clinic Hours: Monday – Friday, 7AM-7PM;
Saturday, 7 AM—7 PM
Contact Nos.: (02) 888-8999 loc. 7330;
(02) 908 6900 loc. 1375

MAKATI MEDICAL CENTER (In-Patient)

8th floor Maxicare Wing, Tower 1 Makati Medical Center
Amorsolo St., Makati City
Contact Nos.: Tel. no. : 8888-999 local 7331

THE MEDICAL CITY

MGR04, Ground Floor, Medical Arts Tower 1 , Ortigas Avenue, Pasig City
Contact Numbers: (02) 706-5080/ 706-5081/
635-6789 loc. 5073/3006
Clinic Hours: 7AM –6PM Monday—Friday;
Saturday, 7AM– 4PM

ST. LUKE’S MEDICAL CENTER—GLOBAL CITY

Rm. 325 Medical Arts Building, 32nd Street, Corner 5th Avenue Bonifacio Global City, Taguig
Contact Numbers: (02) 789-7700 loc. 7325
Clinic Hours: 8AM– 5PM Monday—Friday;
Saturday 8AM—4PM

ST. LUKE’S MEDICAL CENTER – QUEZON CITY

Unit 1501, North Tower, Cathedral Heights,
St. Lukes Compound E. Rodriguez Quezon City
Tel. Nos: (02)723-5329/ (02)723-0101 loc 5150 or 5151
Clinic Hours: Monday- Friday 7am-6pm
Saturday 7am-4pm

CHINESE GENERAL HOSPITAL

th
10 floor, Medical Arts and Parking Building,
Blumentritt St.Sta. Cruz, Manila
Tel. Nos: (02)567-6286 to 87
Clinic Hours: 8am-5pm Monday- Friday;
8am-4pm Saturday

ASIAN HOSPITAL AND MEDICAL CENTER

Lower Ground Floor, Asian Hospital and Medical Center
2205 Civic Drive, FCC Alabang, Muntinlupa City
Tel. Nos.: (02) 836-7493/ 771-9000 loc. 8004
Clinic Hours: Monday– Saturday 7AM—5PM
MY HEALTH CLINIC- SHANGRILA
Unit 146, Level 1 Shangri La Plaza Mall, Mandaluyong City
Tel. Nos.: (02) 570-4325 loc. 206
Clinic Hours: 7am- 8pm Monday- Sunday

MY HEALTH CLINIC- NORTH EDSA

nd
2 Floor, North Link Bldg., F, SM City North Edsa
North Avenue, Quezon City
Tel. Nos.: (02) 441-4106 loc. 206
Clinic Hours: 7am-9pm, Monday-Sunday

CUSTOMER CARE CENTERS

BACOLOD
Rm. 215 North Point Building
B.S. Aquino Drive, Bacolod City
Tel. Nos: (034) 433-3044 | (034) 434-9230

CAGAYAN DE ORO
2/F Unit 215, De Leon Bldg.
Yacapin St. Cor Velez St., Cagayan De Oro
(08822) 71-47-25 | 71-47-26

DAVAO
2nd Floor Room 17 Jocar Complex
C. de Guzman Street, Davao City
(082) 227-2941 | 300-5553

GENERAL SANTOS
General Santos Doctors’ Hospital
Engineering Office
Ground Floor near 1B Station
National Highway, General Santos City
Tel. Nos: (083) 553-3963

ILOILO
2nd Floor, M22 AJL Annex Bldg.
cor. Ibarra & General Luna Sts.,
Iloilo City
Tel. No: (033) 337-1051

*For Providers’ Directory, please refer to List of Accredited Hospitals & Clinics at www.maxicare.com.ph
Your Easy Guide to Maxicare’s SMS Inquiry Service (0918-889-MAXI)

1) To request list of accredited providers per area

a) Hospital
Key in: prov <space> hos <space> location
Examples: prov hos makati
prov hos bacolod

b) Clinic
Key in: prov <space> clinic <space> location
Examples: prov clinic makati
prov clinic ortigas

2) To request list of accredited doctors per specialization per hospital

Key in: doc <space> hospital name <slash> specialization
Examples: doc makati med/gastro
doc riverside/cardio

3) To request doctor’s schedule and contact number per hospital

Key in: sked<day> <space> hospital name <slash> doctor’s surname
Key words for each day: mon, tue, wed, thu, fri, sat, sun
Examples: skedmon medical city/flandes
skedsat makati med/genuino

Domestic: 908-6900
International Assist Hotline: (02) 687-8522
Customer Care Center: 582-1900
Toll Free No. for Provincial Inquiries (PLDT Line): 1-800-10-582-1900
SMS Inquiry: 0918-889-MAXI
www.maxicare.com.ph