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The Leader in Healthcare Services
MAXICARE HEALTHCARE
CORPORATION
Premium quality healthcare is deserved by
every individual.
MAXICARE, an industry leader with 29 years of solid
healthcare expertise, has been a trusted name among top corporations and
individuals.
I. IN-PATIENT BENEFITS
Room and Board Accommodation
• Use
of Operating Room, Intensive Care Unit (ICU), Isolation Room (if prescribed by
an attending accredited physician) and Recovery Rooms
• Professional
Fees of Attending Physicians, Surgeons, Anesthesiologist and Cardio-pulmonary
clearance before surgery and cardiac monitoring during surgery
• Standard
nursing services
• Medicines
for in-patient use
• Blood
product transfusions and intravenous fluids, including blood screening and
cross matching
• X-ray,
laboratory examinations, diagnostic tests and therapeutic procedures incidental
to confinement
• Dressings,
conventional casts (plaster of Paris) and sutures
• Anesthesia
and its administration
• Oxygen
and its administration
• Standard
admission kit
• All
other items directly related in the medical management of the patient, as
deemed medically
necessary by the attending
accredited physician
NOTE: Required to file Philhealth.
Non-Philhealth member will pay for the Philhealth portion.
II. OUT-PATIENT BENEFITS
The following services shall be
provided when medically necessary:
• Consultations
during regular clinic hours, except for medicines prescribed
• Eye,
ear, nose and throat (EENT) treatment prescribed by an accredited
physician/specialist
• Treatment
for minor injuries such as lacerations, mild burns, sprains and the like
• Dressing,
conventional casts (plaster of Paris) and sutures
• X-ray,
laboratory examinations, routine, diagnostic and therapeutic procedures
prescribed by an accredited physician/specialist, provided however that the
cost of diagnostic and therapeutic procedures covered shall be limited to the
amount set forth under pertinent sections below.
o Routine procedures to be covered at 100% of actual
cost and to be charged against
MBL:
1. Blood
Chemistries
2. Chest
X-Ray
3. Complete
Blood Count
4. Fecalysis
5. Urinalysis
o
Diagnostic procedures to be covered at 100% of
actual cost and to be charged against MBL: 1. 24-Hour
Electro Encephalogram Monitoring
2. Adrenocortical
Function
3. Anti-Nuclear
Antibody, C-Reactive Protein, Lupus Cell Exam
4. Arterial
Blood Gas
5. Arthroscopic
Procedures, Orthopedic
Arthroscopy
6. Audiograms
and Tympanograms
7. Bone
Densitometry Scan (Dexascan)
8. Bone
Mineral Density Studies
9. Cardiac
Ambulatory Monitoring
10. Cardiac
Stress Tests (Thallium and Dipyridamole Stress Tests)
11. Computed
Tomography (CT) Scans
12. Diagnostic
Angiogram: Cerebral, Coronary,
Mesentric, Flourescein Angiography
13. Diagnostic
Radiographs or X-rays
i.
Biliary Tract:
Cholecystogram and
Cholangiogram
ii. Chest, Ribs, Sternum and Clavicle iii. Digestive Tract: Plain film of the
abdomen, Barium Enema, Upper Gastro Intestinal (GI) Series, Small Bowel Series,
Lower Gastro
Intestinal Series iv. Face
(including sinuses), Head and Neck
v. Urinary Tract: Kidney
Ureter Bladder (KUB),
Pyelograms,
Cystograms vi. X-ray of the extremities and pelvis vii. X-ray of the Spine
(cervical, thoracic, lumbosacral)
14. Diagnostic
Ultrasounds:
i. 2D-Echo
with Doppler ii. Abdomen iii. Duplex
Scan iv. Digestive and Urinary Systems v. Ultrasound
of the Lungs
15. Electro
Encephalogram (EEG)
16. Electromyography
& nerve conduction velocity studies
17. Endoscopic
Procedures
18. Flourescein
Angiography
19. Impedance
Plethysmography
20. Lead
Electrocardiogram
21. Magnetic
Resonance Angiography (MRA)
22. Magnetic
Resonance Imaging (MRI)
23. Mammogram
and Sonomammogram
24. Microscopic
Examinations
25. Myelogram
26. Nuclear
Radioactive Isotope Scan
27. Pap’s
Smear
28. Perfusion
Scan
29. Plasma
Urinary Cortisol, Plasma Aldosterone
30. Polysomnograms
(Sleep Recording)
31. Pulmonary
Function tests
32. Radioisotope
Scans and Function Studies:
i. Cardiac ii. Gastrointestinal
iii. Liver
iv. Parathyroid,
Bone, Pulmonary (Perfusion,
Ventilation Lung Scans)
v. Renal
vi. Thyroid Scans vii. Total Body Scans
33. Radionuclide
Ventriculography
34. Surface
Electromyography (SEMG)
35. Thallium
Scintigraphy
36. Treadmill
Stress Test (TMST)
Therapeutic procedures shall
be covered at 100% of actual cost and to be charged against MBL up to twelve
(12) sessions per member per year o
Dialysis o
Intravenous Chemotherapy o Therapeutic Radiology
1. Brachytherapy
2. Cobalt
3. Linear
Accelerator Therapy
4. Radioactive
Cesium
5. Radioactive
Iodine o
Physical therapy / Occupational therapy (shared limit) excluding subspecialties
such as cardiac rehabilitation, pulmonary rehabilitation and the like. (Therapy
of one (1) body area shall be considered as
one (1) session.)
• Minor
surgery not requiring confinement prescribed by an accredited
physician/specialist
• Eye
laser therapy for retinal tear, retinal hole, retinal detachment & glaucoma
prescribed by an accredited physician/specialist up to Php10,000 per eye per
member per year. Eye correction such as Lasik, PRK and the like are not
covered.
• Electrocauterization
of skin lesions such as plantar warts, flat warts, periungual warts, filiform
warts and molluscum contagiosum, in any part of the body, except genital warts
and condyloma acuminata, prescribed by an Accredited Physician/Specialist shall
be covered up to Php1,000 per member per year.
• Sclerotherapy
for varicose veins (except medicines and for cosmetic purposes) as prescribed by an accredited physician
up to Php5,000 per leg per member per year
to be availed through accredited
vascular surgeons
• Allergy
testing / allergy screening and other related examinations prescribed by an
accredited physician up to Php2,500 per member per year
• Speech
therapy (for stroke patients only) shall be covered as charged but on
reimbursement basis up to Php10,000 per member per year. Consultations shall be
part of the limit and treated as sessions for purposes of
determining coverage
• Tuberculin
test up to Php600 per member per year
III. SALIENT
FEATURES
|
PLAN
TYPE
|
R
& B
|
MBL
|
|
Platinum Plus
|
Large Private
|
Php 200,000
|
|
Platinum
|
Regular Private
|
150,000
|
|
Gold
|
Regular Private
|
100,000
|
|
Silver
|
Semi-Private
|
60,000
|
R&B – Room and Board Accommodation (room category)
MBL – Maximum
Benefit Limit (limit per illness per year)
IV. PREVENTIVE
CARE
• Passive
and active vaccines for treatment of tetanus and animal bites shall be covered
up to Php18,000 per member per year
• Periodic
monitoring of health problems
• Health
education and counseling on diets and exercise
• Health
habits & family planning counseling
V.
EMERGENCY
CARE
Accredited Hospital o Doctor’s services o Emergency Room fees
o
Medicines used for immediate relief and during
treatment
o Oxygen,
intravenous fluids and blood products o Dressings, conventional casts
(plaster of Paris) and sutures
o X-rays,
laboratory, diagnostic examinations and other medical services related to the
emergency treatment
of the patient
Non-Accredited Hospitals o
Within the Philippines
Maxicare shall reimburse up to
80% of the actual hospital bills and 80% of the professional fees based on
Maxicare rates incurred during the first twenty-four (24) hours of treatment up
to Php 30,000 per availment per member.
o Areas without accredited hospitals within the Philippines
Maxicare shall reimburse 100% of the total
hospital bills and Professional fees based on Maxicare rates. o
Outside the Philippines
Maxicare shall reimburse 100%
actual costs up to Php30,000 per availment per member.
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
• Life
coverage with Accidental Death & Dismemberment up to Php25,000
• Motor
vehicular accidents shall be covered up to MBL.
• Scoliosis
including necessary procedures, except physical therapy sessions, shall be
covered up to Php20,000 per member per year. Physical Therapy sessions shall
form part of the Physical therapy /Occupational therapy limits.
• Congenital
illness, except physical therapy sessions and developmental disorders, shall be
covered up to Php20,000 per member per year. Physical Therapy sessions shall
form part of the Physical therapy /Occupational therapy limits.
• Congenital
hernia shall be covered up to MBL.
• Consultations
for Chronic Dermatoses shall be covered up to MBL.
• Additional
Modalities and Procedures covered at 100% of their actual cost up to MBL
whether done in inpatient or out-patient:
1. Angiography
(gastrointestinal, brain, retinal and peripheral vascular)
2. Coronary
Angiogram
3. Cryosurgery
4. Gamma
Knife Surgery
5. Hysterescopic
Myoma Resection
6. Hysterescopically-guided
Dilation & Curettage
7. Laparoscopy
8. Lithotripsy
9. Percutaneous
Ultrasonic Nephrolithomy
10. Conventional
Hemmorhoidectomy
11. Scalpel
Hemmorhoidectomy
• The
following procedures shall be covered up to Php5,000 per procedure per Member
per year:
-
Stapled Hemorrhoidectomy
-
Mammotome
-
4D Ultrasound except for maternity-related cases
-
Stapled Hemorrhoidectomy
-
Mammotome
-
4D Ultrasound except for maternity-related cases
-
Esophageal Manometry
-
Intensified Modulated Radiotheraphy
-
Botox which is not cosmetic in nature nor for
beautification purpose
-
Photodynamic Therapy
• Other
medically necessary modalities are procedures/modalities that are not readily
available in the major tertiary hospitals, costly relative to more conventional
procedures and relatively new or recently introduced in the Philippines, such
as but not limited to Capsule Endoscopy, CT Pulmonary Angiography, Positron
Emission Tomography, etc. shall be covered up to Php 5,000 per procedure per
member per year.
• Transurethral
Microwave Therapy of Prostate covered up to Php25,000 per member per year
VII. ANNUAL CHECK-UP
(ACU)
Basic 5 Routine; Clinic-based:
(Applicable to Platinum
Plus, Platinum, Gold and Silver
Plan Type)
• History and Physical Exam
• CBC (Complete Blood Count)
• Routine Urinalysis
• Routine Fecalysis
• Chest X-ray (PA and Lateral)
The ACU however, may
only be availed within the contract period after (1) payment of at least six
(6) months worth of membership, and (2) must be a member of at least six (6)
months starting from the effectivity date.
Member must notify Maxicare’s
Customer Care Department (CCD) at least one (1) month prior to preferred
schedule. Any request for rescheduling or change of venue must be in writing
and shall be allowed only once provided request was forwarded to CCD at least
one (1) week prior to the original ACU schedule.
Otherwise, ACU entitlement shall
be forfeited
VIII. DENTAL CARE (OPTIONAL)
• Annual
Oral/Dental Examinations & Consultation
• Emergency
Dental Treatment
• Annual
Oral Prophylaxis
• Simple
Tooth Extractions
• Restorative
and Prosthodontic Treatment Planning
• Permanent
fillings up to 2 fillings per year
• Unlimited
temporary fillings,as needed
• Desensitization
of hypersensitive teeth – 2 per year
• Simple
adjustment of dentures
• Recementation
of loose crowns, inlays or onlays
• Dental
nutrition and dietary counseling
• Dental
Health Education
Note: Dental Benefit is
optional for an additional fee of Annual fee: P387, Semi-annual: P209,
Quarterly P108 IX. VALUE ADDED FEATURES
MAXICARE’S
INTERNATIONAL EMERGENCY ASSIST PROGRAM
Maxicare has partnered with
Insurance Company of North America (A Chubb Company) for frequent travelers
throughout the year under One Policy.
Benefits:
1. Medical Necessary Expense
2. Emergency Medical Evacuation
3. Repatriation Expense
4. Personal Accident
24-Hour Emergency
Medical Accident Assistance
Services
·
Telephone Medical Assistance
·
Medical Service Provider
Referral
· Arrangement
of Appointments with Local Doctors for Treatment
·
Arrangement of Hospital
Admission
· Guarantee
of Medical Expenses Incurred during Hospitalization
· Monitoring
of Medical Condition During and After Hospitalization
·
Arrangement of Emergency
Medical Evacuation
· Arrangement
of Emergency Medical Repatriation
·
Arrangement of Transportation
of Mortal Remains
·
Arrangement of Compassionate
Visit
24-Hour Travel
Assistance Services
·
Emergency Message Transmission
Assistance
·
Legal Referral
·
Inoculation and Visa
Requirement Information
·
Interpreter Referral
· Lost
Luggage Assistance · Lost Passport Assistance
· Embassy Referral
· Weather and Foreign Exchange Information
Services
CHUBB 24-HOUR EMERGENCY HOTLINE CHUBB Assistance Number is (632) 864-0865
X. AVAILMENT
PROCEDURES
Out-patient
1. To
avail of consultations or treatment, go to any
Maxicare Accredited
Clinics/Hospitals or Maxicare Primary Care Centers (PCC).
2. Member
goes to the POS terminal in the hospital/clinic (Billing/ER/Admitting section)
or at the PCC.
3. Hospital
staff swipes the member’s swipe card.
The Letter of Eligibility (LOE) will be given to the member with his
Maxicare card.
Please note that the LOE is valid only on the same date that it was swiped.
Availments made on different dates will need an LOE per date.
4. Member
proceeds to the Medical Coordinator’s clinic and presents his LOE and Maxicare
card for consultation.
5. If
referred to an accredited specialist, secure LOE and Referral Slip* from the Medical Coordinator/ PCC.
6. Present
Maxicare ID Card, LOE and Referral Slip to accredited specialist to avail of
consultation.
7. If
member is requested to take a laboratory test, secure the Laboratory Slip* from the Medical Coordinator/ PCC.
8. Proceed
to the laboratory and present the laboratory slip with the LOE and avail of the
test.
9. For
follow-up consultations, follow steps 1-5 to secure LOE and referral slip/
laboratory slip from Maxicare Centers and/or Coordinator.
Note: Referral Slips and Laboratory Slips* are necessary in order
for the doctor to know that Maxicare is to be billed for the procedure. For queries and assistance, please call
Maxicare Hotline at 582-1900.
In-patient
1.
Secure an Admitting
Order from a Maxicare
Accredited Specialist.
2.
Coordinate with the admitting section and
coordinator in the hospital for room
reservation
3.
If possible, call Maxicare at least 24 hours
prior to admission for assistance in securing the doctor
4.
Member goes to the Admitting Section in the hospital and presents his/her Maxicare swipe card and admitting order from the Maxicare Coordinator/ Specialist to the
admitting staff.
5.
Once the LOE is generated by the hospital staff,
the member will be asked to sign on it.
This will be attached to the other admitting documents.
6.
Proceed to the reserved room entitled or
operating room (for operation)
7.
Maxicare will issue the Letter of Authority
(LOA) upon receiving hospital’s advice on the member’s confinement.
8.
Member must file Philhealth on or before
discharge.
9.
All uncoverable and excess charges must be
settled by the member upon discharge.
Note: For queries and
assistance, call Maxicare Hotline:
582-1900
Emergency Care
A life threatening or accidental
injury or a sudden and unexpected onset of a condition which at the time of the
occurrence reasonably appears to have the potential of causing immediate
disability or death, or which requires the immediate alleviation of pain or discomfort.
The Member must notify MAXICARE
HEAD OFFICE, thru the Customer Care Department, WITHIN 24 HOURS so that proper
assistance is promptly rendered.
o
Accredited Hospital
1. Go to the
Emergency Room of nearest accredited hospital.
2. Avail of
treatment at Emergency Room.
3. Present
Maxicare ID Card to ER Staff. ER
Personnel
will facilitate swiping for the LOE.
4. File
Philhealth before discharge.
Note: Settle
charges not covered by Maxicare at the Billing Section once the Discharge Order
is issued by the attending doctor.
o
Non-Accredited Hospital
1. Member may
proceed to the Emergency Room of nearest hospital.
2. Avail
treatment at the Emergency Room.
3. Call
Maxicare within 24 hours to arrange transfer to an accredited hospital.
4. Settle all
ER fees and secure Medical Certificate, Official Receipts, etc.
5. Forward
all original documents to Maxicare for reimbursement within 30 days upon
discharge.
XI. ENROLLMENT PROCESS
AND GUIDELINES
1. Fill up
the IFG application form completely.
Indicate your Tax Identification Number (TIN) on the front page if
applicable.
2. Initial
submission of Medical Requirements is applicable to enrollees who are 50 years
old and above, whether Principal or Dependent. The date of the conduction of
these Medical Requirements should not exceed 6 months before the date of
submission.
Medical Requirements
for 49 years and 6 months old
• 12
- lead ECG (Electrocardiogram) tracings w/ results
• Chest
X-ray
• FBS
(Fasting Blood Sugar)
• Creatinine
• SGPT
• Total
Cholesterol
• Triglycerides
• HDL-C
(High Density Lipoprotein)
• LDL-C
(Low Density Lipoprotein)
Note: test results should not be more than 6
months from the date it was taken
3.
Dependent’s plan must be the same plan as the
Principal or one plan lower.
4.
Forward the accomplished application form and
medical requirements (if applicable) to the Account Officer for processing.
5.
Once the application has been approved, the
Statement of Account shall be
sent to your billing address for settlement.
Payments (cash or check) may be made at the Maxicare Head Office or at
any Banco de Oro branches via bills payments.
6.
Member will receive Maxicare ID card as proof of
membership.
Who may be enrolled
into the Maxicare Program and what are the requirements?
• The
age eligibility for principal and dependents is from 15 days old to 60 years and 5 months of
age.
• Eligible
dependents are as follows (in order):
* For
single enrollees: Mother, Father, then Siblings 21 years and 5 months old and
below, according to age.
* For
married enrollees: Spouse, then Children 21 years and 5 months old and below,
according to age.
• Individual Membership
Requirements:
1. Application
form
2. Medical
requirements for 49 years and 6 months old
3. Photocopy
of ACR (Alien Certificate of Residency) if nationality is foreign
• Family Membership
Requirements Couples only:
1. Application
form
2. Copy
of marriage certificate
3. Medical
requirements if already 49 years and 6 months old (principal and dependent)
4. Photocopy
of ACR (Alien Certificate of Residency) if nationality is foreign
5. With child dependent
1. Application
form
2. Copy
of birth certificate (each child)
3. Medical
requirements if already 49 years and 6 months old (principal and dependent)
4. Photocopy
of ACR (Alien Certificate of Residency) if nationality is foreign
Note: Maxicare may request for additional
requirements
when deemed necessary
• HIERARCHY OF ENROLLMENT:
Ø Unless there is a valid reason for the nonenrollment of
certain dependents (i.e. currently enrolled in another HMO, abroad, separated,
deceased, etc.), applicants should enroll their dependents in the priority
specified above. • Sufficient documentation shall be requested by Maxicare from
the applicant to validate the noneligibility of the dependent (i.e. photocopy
of HMO card, certificate of employment from company abroad,
death certificate, etc.)
REQUIREMENTS FOR ALIEN
RESIDENTS/ FOREIGN NATIONALS:
1.
Photocopy of ACR (Alien Certificate of Residency) ID 2. Medical Requirements
for enrollees 49 years and 6 months old
(if applicable) 3. Certificate of
employment (if applicable)
XII. DREADED
DISEASE / CONDITION
Any condition that is considered
to be chronic, progressive, life-threatening and which may entail lifelong
therapy. This refers also to conditions where complete cure cannot be ensured.
COVERAGE FOR DREADED
AND NON-DREADED CONDITONS
1st year of membership:
•
Dreaded and Non-dreaded covered subject to below
limits:
|
Plan
Type
|
Per illness per member per year
|
|
Platinum Plus
|
Php 20,000
|
|
Platinum
|
15,000
|
|
Gold
|
10,000
|
|
Silver
|
5,000
|
Subsequent years of membership:
•
Dreaded conditions not considered acquired are
covered subject to below limits:
|
Plan
Type
|
Per illness per member per year
|
|
Platinum Plus
|
Php 20,000
|
|
Platinum
|
15,000
|
|
Gold
|
10,000
|
|
Silver
|
5,000
|
•
Non-dreaded conditions shall be covered up to
MBL
•
Acquired dreaded conditions shall be covered up
to MBL
Such dreaded conditions are as follows, but not limited to:
a. All
malignancies (including indicated chemotheraphy or radiotheraphy)
b. Arthritis
c. Blood
Dyscrasias such as but not limited to Leukemia, Idiopathic Thrombocytopenic
Purpura
d. Chronic
Cardiovascular Diseases and its complications such as but not limited to
Uncontrolled Hypertension of whatever etiology, Aortic Dissection, Abdominal
Aortic Aneurysm, Myocardial infarction,
Cardiac Arrest, Congestive Heart Failure, Cardiac Arrhythmia, Cardiac
Tamponade, Coronary Artery Disease, Cardiomyopathies and
Valvular Heart Disease, Aortic
Dissection,
Abdominal Aortic Aneurysm and
Peripheral Vascular Disease and its complications such
as but not limited to Buerger’s
Disease
e. Cataract
and Glaucoma
f. Cerebrovascular
Diseases such as but not limited to Stroke, Cerebral, Cerebellar, Thrombosis, Embolism and Ruptured
aneurysm and all Intracranial Hemorrhage
and related conditions
g. Cholecystolithiasis
and Choledocholithiasis
h. Chronic
Endocrine Disorders and its
complications such as but not limited to Dyslipidemia, Obesity, Diabetes
Mellitus, Hormonal Dysfunctions excluding surgical treatment/procedures for
obesity
i. Chronic
Gastrointestinal Diseases such as but not limited to Irritable Bowel Syndrome,
Crohn’s disease
j. Chronic
Genito-urinary Disorders
k. Chronic
Kidney Disease/Failure & its complications
l. Chronic
Liver Parenchymal Diseases such as 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
Tissue/Immunologic Disorders
such as but not limited to Systemic Lupus Erythematosus and its
complications
o. Complications
of immuno-compromised clinical conditions except HIV/AIDS
p. Extrapulmonary Tuberculosis including Pott’s disease and
Multi-Drug Resistance Case
(MDR) case
q. Multiple
Organ Failure
r. Muscular
Dystrophies such as but not limited to
Duchenne, Becker, limb girdle,
facioscapulohumeral, myotonic, oculopharyngeal, distal, and Emery-Dreifuss
s. Neuro-surgical
interventions and/or major neurological diseases such as but not limited to
Poliomyelitis/Meningitis/Encephalitides, Demyelinating Neurologic diseases and
its complications/sequelae and Peripheral
Nervous System
Disorders/Diseases
t. Thyroid
Dysfunctions due to disease of thyroid such as but not limited to
Hypothyroidism and
Hyperthyroidism
u. Any
illness other than above which would require Critical Care/Intensive Care Unit
(ICU)
Confinement
v. All
complications resulting from above list of conditions
Such non-dreaded conditions are as follows, but not limited to:
a. All
benign tumors
b. Anal
Fistulae
c. Cervical
Polyps (if benign biopsy)
d. Conjunctivitis
(except chemical, complicated)
e. Endometrioses/Controlled
Dysfunctional Uterine Bleeding (except if caused by
uterine malignancies)
f. Hemorrhoids
g. Hepatitis
A
h. Gastritis,
Duodenitis or Uncomplicated Gastric /
Duodenal Ulcer
i. Inactive
Pulmonary Tuberculosis
j. Migraine
k. Non-surgical
Ear-Nose-Throat conditions such as but not limited to Sinusitis, Rhinitis,
Tonsillopharyngitis, Laryngitis, Parotitis, Otitis Media, Otitis Externa and
Surgical Ear-Nose-Throat conditions such as but not limited to Tonsillectomy,
Nasal Polypectomy,
Tympanoplasty, Sialolithotomy, Sialodochoplasty.
l. Non-Toxic Goiter (if uncomplicated)
m. Ovarian
cysts Uncomplicated Cholecystitis,
Cholelithiasis
n. Uncomplicated
Hernias (Congenital Hernia will have coverage as listed in the Congenital
Clause) o. Uncomplicated Hypertension
p. Uncomplicated
Urinary Tract Infection, Stones/Calculi
q. Urinary
Incontinence
XIII. EXCLUSIONS
AND LIMITATIONS
Notwithstanding any provisions to
the contrary, the following shall not be covered except otherwise specified in
Agreement:
Services obtained for
non-emergency conditions from Physicians and Hospitals in any of the following
circumstances:
o non-accredited
physicians in non-accredited hospitals or clinics;
o non-accredited
physicians in accredited hospitals or clinics;
o accredited
physicians in non-accredited hospitals or other non accredited healthcare
facility.
Additional hospital charges and physician’s professional fees resulting from:
o room-upgrading
beyond member’s allowable time during emergency care;
o extension
of hospital stay despite release of discharge order from member’s attending
physician;
o fees of
the assistant surgeons/ resident doctors who assisted the Attending Physician
in the process of rendering the above mentioned services shall not be
chargeable to the Member and/or Maxicare except for hospitals that do not have
resident physicians to assist during surgeries subject to the prior approval of
Maxicare;
o use of
extra bed, TV, electric fan, DVD/VCD, and other similar items unless such
appliances and items are necessarily and ordinarily included in the
Member’s Room
& Board Accommodation; o extra food; o toilet articles like face
towel, soap, toothbrush and the like;
o difference
in room and board, the incremental rate differences for professional fees,
diagnostic and laboratory examinations, and other ancilliary medical services
brought about by obtaining a room accommodation higher than the Member’s Room
and Board Accommodation limit;
o services
of a private or a special nurse; and o all other items not medically
necessary in the medical management of the patient
• Custodial,
domiciliary, convalescent and intermediate care.
• Long-term
rehabilitation and psychiatric care and/or psychological illnesses and
conditions including neurotic and psychotic behavior disorders; anxiety
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 attempted suicide or self-destruction, whether sane or
insane.
• Developmental
disorders including functional disorders of the mind, such as but not limited
to Attention-Deficit Disorder (ADD)/Attention-Deficit Hyperactivity Disorder
(ADHD), Autism Spectrum Disorders, Bipolar Disorders, Central Auditory
Processing Disorder (CAPD), Cerebral Palsy, Down Syndrome, Neural Tube Defects,
and Mental Retardation.
• Treatment
of any injury received when there is negligence, unauthorized use of prohibited
or regulated drugs, alcoholic liquor intake, direct or indirect participation
in the commission of a crime whether consummated or not, violation of a law or
ordinance or unnecessary exposure to imminent danger, knowingly or unknowingly
or hazard to health, by the member. Maxicare may, in its discretion, rely on
Police and
Doctor’s report in evaluating such
claim.
• Aesthetic,
cosmetic and reconstructive surgery or any consultation or treatment for any
beautification purposes except if necessary to treat a functional defect due to
accidental injury within the initial confinement.
• Oral
surgery following accidental injury to teeth for purposes of beautification.
Dental examinations, extractions, fillings, other dental treatment and their
complications to the extent that are medically necessary for repair or
alleviation of damage to the member caused solely by an accident. Medical care
resulting from any dental related conditions.
• Maternity
care and all other conditions, including pre and post natal consultations,
related to and/or resulting from pregnancy and/or delivery which affect the
conditions of the principal member and the unborn child.
• Circumcision
(except for treatment of urological conditions), sex transformation, diagnosis,
treatment and procedures related to fertility or infertility, artificial
insemination, sterilization or reversal of such procedures and their
complications.
• Experimental
medical procedures and its complications.
• Acupuncture
and chirotheraphy and other forms of therapies, and its complications.
• All
expenses incurred in the process of organ donation and transplantation if the
member is the donor of such donation or transplantation, and its complications.
• Routine
physical examinations required for obtaining or continuing employment,
requirement in school, insurance, government licensing, health permit and other
similar purposes.
• Purchase
or lease of durable medical equipment, oxygen dispensing equipment, and oxygen,
except during in-patient care.
• Corrective
appliances, prosthetics and orthotics such as but not limited to artificial
limbs, hearing aids, intraocular lens, eyeglasses, contact lenses, braces,
crutches, pacemaker, pins, screws, plates, wires, balloons, valves, knee-tibial
insert for total knee arthroplasty, orthopedic internal fixator/fixation
systems, orthopedic external fixator/fixation systems, bone screws and plates,
vascular grafts/stents, intravascular catheters, myringotomy tube.
• Take-home
medicine and outpatient medicine except o chemotherapy medicine o
medicine administered during an emergency treatment
• Congenital,
genetic and heredity diseases and their
complications (except for hernias) affecting functions of individuals.
• All
physical deformities prior to enrollment.
• Treatment
of injuries/illnesses caused directly or indirectly by engaging in any
professional sport or hazardous activity such as but not limited to scuba
diving, surfing, water skiing, mountain climbing, rock climbing,
mountaineering, parachuting, airsoft, drag racing, paintballing, wakeboarding
and bungee jumping, except for activities under companysponsored sports
activities.
• Injuries
resulting from direct participation in riots, strikes, and other civil
disturbances.
• Treatment
of injuries or illnesses resulting from war and any combat-related activities
while in military service.
• Sexually
transmitted diseases, genital warts, AIDS and AIDS related diseases.
• Valvular
heart disease (congenital and/or acquired) including Cardiomyopathies, Chronic
Glomerulonephritis, previous craniotomy sequelae/hearing impairment/ Neurologic
disease and Spinal Stenosis (if pre-existing)/Poliomyelitis/Slipped disc (if
pre-existing) and Guillain-Barre Syndrome, Diabetes and its complications (if
pre-existing), Complicated Hypertension (e.g. those with history of stroke,
myocardial ischemia or infarction and poor kidney function), and all malignant
tumors (if preexisting).
• Treatment
for Chronic Dermatoses, except Scabies.
• Infectious
diseases (i.e. Avian Flu, Meningococcemia, etc.) that are declared epidemic or
pandemic by the Department of Health, World Health Organization or any
recognized health authority.
• 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
|
|
1st to the 15th of
the month
|
1st of the following month
|
|
16th to 30th/ 31st
of the month
|
16th 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**
2017 INDIVIDUAL MEMBERSHIP FEES
|
AGE
BRACKET
|
PLATINUM
PLUS
|
|
PLATINUM
|
|
||
|
Php
200,000
|
|
|
Php
150,000
|
|
||
|
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
|
|
AGE
BRACKET
|
GOLD
|
|
|
SILVER
|
|
|
|
Php
100,000
|
|
|
Php 60,000
|
|
||
|
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 January 1, 2017 to December 31, 2017.
2017 FAMILY MEMBERSHIP FEES
|
AGE
BRACKET
|
|
PLATINUM
PLUS
|
|
PLATINUM
|
|
|||
|
|
Php
200,000
|
|
|
Php
150,000
|
|
|||
|
|
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
|
||
|
AGE BRACKET
|
|
GOLD
|
|
|
SILVER
|
|
||
|
|
Php 100,000
|
|
|
Php 60,000
|
|
|||
|
|
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 January 1, 2017 to December
31, 2017.
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
10th 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
CARDINAL
SANTOS MEDICAL CENTER
Room 160, Ground Floor of Medical
Arts Building
10 Wilson Street, Greenhills
West, San Juan City
Tel. Nos.: 0917 8172941
Clinic Hours: 8am-5pm Monday to
Saturday
MY HEALTH CLINIC- FILOMENA MAKATI
Ground Floor, Filomena Bldg.,
Amorsolo Street, Makati City
Tel Nos.: (02) 893-4858/ (02)
812-3726
Clinic Hours: 7am-9pm
Monday-Saturday
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
2nd 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
MY HEALTH CLINIC- FESTIVAL MALL
21 Style Blvd, Festival Mall,
Alabang, Muntinlupa City
Tel. Nos.: (02) 850-4855 loc.102;
Telefax (02) 809-4388
Clinic Hours: 7am-8pm Monday to
Saturday
MY HEALTH CLINIC- ROBINSON’S CYBERGATE
3rd Floor, Room 305-306, Robinson’s Cybergate
Mall,
Fuente Osmeña Street, Cebu City
Tel. Nos.: (032) 268-8502 loc.
204 or 205
Clinic Hours: 7am-7pm Monday to Saturday
REGIONAL 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) 864-0865
Customer
Care Center: 582-1900
Toll
Free No. for Provincial Inquiries (PLDT Line): 1-800-10-582-1900
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