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Published by acidburntower, 2019-09-09 11:08:22

MYMAXICARE REVISED BROCHURE 2019

MYMAXICARE REVISED BROCHURE 2019

The Leader in Healthcare Services

MAXICARE HEALTHCARE CORPORATION

Premium quality healthcare is deserved by every individual.
MAXICARE, an industry leader with 30 years of solid healthcare expertise,

has been a trusted name among top corporations and individuals.

I. IN-PATIENT BENEFITS 5. X-ray, laboratory examinations, routine,
diagnostic and therapeutic procedures prescribed
1. Room and Board Accommodation by an accredited physician/specialist, provided
2. Use of Operating Room, Intensive Care Unit however that the cost of diagnostic and
therapeutic procedures covered shall be limited
(ICU), Isolation Room (if prescribed by an to the amount set forth under pertinent sections
attending accredited physician) and Recovery below.
Rooms
3. Professional Fees of Attending Physicians,  Routine procedures to be covered at
Surgeons, Anesthesiologist and Cardio- 100% of actual cost and to be charged
pulmonary clearance before surgery and cardiac against MBL:
monitoring during surgery 1. Blood Chemistries
4. Standard nursing services 2. Chest X-Ray
5. Medicines for in-patient use 3. Complete Blood Count
6. Blood product transfusions and intravenous 4. Fecalysis
fluids, including blood screening and cross 5. Urinalysis
matching
7. X-ray, laboratory examinations, diagnostic tests  Diagnostic procedures to be covered at
and therapeutic procedures incidental to 100% of actual cost and to be charged
confinement against MBL:
8. Dressings, conventional casts (plaster of Paris) 1. 24-Hour Electro
and sutures Encephalogram Monitoring
9. Anesthesia and its administration 2. Adrenocortical Function
10. Oxygen and its administration 3. Anti-Nuclear Antibody, C-
11. Standard admission kit Reactive Protein, Lupus Cell
12. All other items directly related in the medical Exam
management of the patient, as deemed medically 4. Arterial Blood Gas
necessary by the attending accredited physician 5. Arthroscopic Procedures,
Orthopedic Arthroscopy
NOTE: Required to file Philhealth. Non-Philhealth 6. Audiograms and
member will pay for the Philhealth portion. Tympanograms
7. Bone Densitometry Scan
SALIENT FEATURES (Dexascan)
8. Bone Mineral Density Studies
PLAN TYPE R & B MBL 9. Cardiac Ambulatory Monitoring
10. Cardiac Stress Tests (Thallium
Platinum Plus Large Private Php 200,000 and Dipyridamole Stress Tests)
Platinum Regular Private 150,000 11. Computed Tomography (CT)
Gold Regular Private 100,000 Scans
Silver Semi-Private 60,000 12. Diagnostic Angiogram:
Cerebral, Coronary, Mesentric,
R&B – Room and Board Accommodation (room category) Flourescein Angiography
MBL – Maximum Benefit Limit (limit per illness per year) 13. Diagnostic Radiographs or X-
rays
II. OUT-PATIENT BENEFITS i. Biliary Tract:
Cholecystogram and
The following services shall be provided when Cholangiogram
medically necessary: ii. Chest, Ribs, Sternum and
1. Consultations during regular clinic hours, except Clavicle
iii. Digestive Tract: Plain film
for medicines prescribed of the abdomen, Barium
2. Eye, ear, nose and throat (EENT) treatment Enema, Upper Gastro
Intestinal (GI) Series,
prescribed by an accredited physician/specialist
3. Treatment for minor injuries such as lacerations,

mild burns, sprains and the like
4. Dressing, conventional casts (plaster of Paris)

and sutures

Small Bowel Series, Lower vii. Total Body Scans
Gastro Intestinal Series 33. Radionuclide Ventriculography
iv. Face (including sinuses), 34. Surface Electromyography
Head and Neck
v. Urinary Tract: Kidney (SEMG)
Ureter Bladder (KUB), 35. Thallium Scintigraphy
Pyelograms, Cystograms 36. Treadmill Stress Test (TMST)
vi. X-ray of the extremities
and pelvis  Therapeutic procedures shall be
vii. X-ray of the Spine covered at 100% of actual cost and to
(cervical, thoracic, lumbo- be charged against MBL up to twelve
sacral) (12) sessions per member per year
14. Diagnostic Ultrasounds: 1. Dialysis
i. 2D-Echo with Doppler 2. Intravenous Chemotherapy
ii. Abdomen 3. Therapeutic Radiology
iii. Duplex Scan i. Brachytherapy
iv. Digestive and Urinary ii. Cobalt
Systems iii. Linear Accelerator
v. Ultrasound of the Lungs Therapy
15. Electro Encephalogram (EEG) iv. Radioactive Cesium
16. Electromyography & nerve v. Radioactive Iodine
conduction velocity studies 4. Physical therapy /
17. Endoscopic Procedures Occupational therapy (shared
18. Flourescein Angiography limit) excluding subspecialties
19. Impedance Plethysmography such as cardiac rehabilitation,
20. Lead Electrocardiogram pulmonary rehabilitation and
21. Magnetic Resonance the like. (Therapy of one (1)
Angiography (MRA) body area shall be considered
22. Magnetic Resonance Imaging as one (1) session.)
(MRI) 5. Minor surgery not requiring
23. Mammogram and confinement prescribed by an
Sonomammogram accredited physician/specialist
24. Microscopic Examinations 6. Eye laser therapy for retinal
25. Myelogram tear, retinal hole, retinal
26. Nuclear Radioactive Isotope detachment & glaucoma
Scan prescribed by an accredited
27. Pap’s Smear physician/specialist up to
28. Perfusion Scan Php10,000 per eye per
29. Plasma Urinary Cortisol, member per year. Eye
Plasma Aldosterone correction such as Lasik, PRK
30. Polysomnograms (Sleep and the like are not covered.
Recording) 7. Electrocauterization of skin
31. Pulmonary Function tests lesions such as plantar warts,
32. Radioisotope Scans and flat warts, periungual warts,
Function Studies: filiform warts and molluscum
i. Cardiac contagiosum, in any part of the
ii. Gastrointestinal body, except genital warts and
iii. Liver condyloma acuminata,
iv. Parathyroid, Bone, prescribed by an Accredited
Pulmonary (Perfusion, Physician/Specialist shall be
Ventilation Lung Scans) covered up to Php1,000 per
v. Renal member per year.
vi. Thyroid Scans

8. Sclerotherapy for varicose o Areas without accredited hospitals within the
veins (except medicines and Philippines
for cosmetic purposes) as Maxicare shall reimburse 100% of the total
prescribed by an accredited hospital bills and Professional fees based on
physician up to Php5,000 per Maxicare rates.
leg per member per year to be
availed through accredited o Outside the Philippines
vascular surgeons Maxicare shall reimburse 100% actual costs up
to Php30,000 per availment per member.
9. Allergy testing / allergy
screening and other related Ambulance Service
examinations prescribed by an Maxicare will cover road ambulance service for
accredited physician up to transfers from an accredited hospital to another
Php2,500 per member per year accredited hospital up to MBL and Php2,500 per
conduction if it is from a non-accredited Hospital to
10. Speech therapy (for stroke an accredited Hospital (on reimbursement basis).
patients only) shall be covered
as charged but on Note: it is very important that you call the Maxicare Hotline
reimbursement basis up to within 24 hours in order for Customer Care to arrange a
Php10,000 per member per transfer from the non-accredited hospital to the accredited
year. Consultations shall be hospital.
part of the limit and treated as
sessions for purposes of IV. PREVENTIVE CARE
determining coverage
1. Passive and active vaccines for treatment of
11. Tuberculin test up to Php600 tetanus and animal bites shall be covered up to
per member per year Php18,000 per member per year

III. EMERGENCY CARE 2. Periodic monitoring of health problems
3. Health education and counseling on diets and
Accredited Hospital
o Doctor’s services exercise
o Emergency Room fees 4. Health habits & family planning counseling
o Medicines used for immediate relief and during
V. ANNUAL CHECK-UP (ACU)
treatment
o Oxygen, intravenous fluids and blood products Basic 5 Routine; Clinic-based: (Applicable to Platinum
o Dressings, conventional casts (plaster of Paris) Plus, Platinum, Gold and Silver Plan Type)

and sutures  History and Physical Exam
o Initial treatment of animal bites shall be covered  CBC (Complete Blood Count)
 Routine Urinalysis
for the first twenty-four (24) hours from the time  Routine Fecalysis
of bite subject to MBL.  Chest X-ray (PA and Lateral)
o X-rays, laboratory, diagnostic examinations and
other medical services related to the emergency The ACU however, may only be availed within the contract
treatment of the patient period after (1) payment of at least six (6) month worth of
membership, and (2) must be a member of at least six (6)
Non-Accredited Hospitals months starting from the effectivity date. Member must
notify Maxicare’s Customer Care Department (CCD) at least
o Within the Philippines one (1) month prior to preferred schedule. Any request for
Maxicare shall reimburse up to 80% of the actual rescheduling or change of venue must be in writing and shall
hospital bills and 80% of the professional fees be allowed only once provided request was forwarded to
based on Maxicare rates incurred during the first CCD at least one (1) week prior to the original ACU
twenty-four (24) hours of treatment up to Php schedule. Otherwise, ACU entitlement shall be forfeited.
30,000 per availment per member.

VI. DENTAL CARE (OPTIONAL) Angiography, etc. shall also be covered up to
Php5,000 per procedure per member per year.
Exclusive for Dental Hub Provider Only Should you wish to have details or list of hospitals that
cater to these procedures, you may contact us for
1. Annual Oral/Dental Examinations & Consultation information/reference.
2. Emergency Dental Treatment
3. Annual Oral Prophylaxis  Transurethral Microwave Therapy of Prostate
4. Simple Tooth Extractions covered up to Php25,000 per member per year
5. Restorative and Prosthodontic Treatment
VIII. VALUE ADDED FEATURES
Planning
6. Permanent fillings up to 2 fillings per year MAXICARE’S INTERNATIONAL ASSISTANCE
7. Unlimited temporary fillings, as needed PROGRAM
8. Desensitization of hypersensitive teeth – 2 per
Maxicare has partnered with Insurance Company of
year North America (A Chubb Company) for frequent
9. Simple adjustment of dentures travelers throughout the year under One Policy.
10. Recementation of loose crowns, inlays or on-lays
11. Dental nutrition and dietary counseling Benefits:
12. Dental Health Education
1. Medical Necessary Expense
Note: Dental Benefit is optional for an additional fee of 2. Emergency Medical Evacuation
Annual fee: P387, Semi-annual: P209, Quarterly 3. Repatriation Expense
P108 4. Personal Accident

VII. ADDITIONAL BENEFITS 24-Hour Emergency Medical Accident Assistance
Services
 Life coverage with Accidental Death & · Telephone Medical Assistance
Dismemberment up to Php50,000 · Medical Service Provider Referral
· Arrangement of Appointments with Local Doctors
 Motor vehicular accidents shall be covered
up to MBL. for Treatment
· Arrangement of Hospital Admission
 Scoliosis including necessary procedures, · Guarantee of Medical Expenses Incurred during
except physical therapy sessions, shall be
covered up to Php20,000 per member per Hospitalization
year. Physical Therapy sessions shall form · Monitoring of Medical Condition During and After
part of the Physical therapy /Occupational
therapy limits. Hospitalization
· Arrangement of Emergency Medical Evacuation
 Congenital illness, except physical therapy · Arrangement of Emergency Medical Repatriation
sessions and developmental disorders, · Arrangement of Transportation of Mortal
shall be covered up to Php20,000 per
member per year. Physical Therapy Remains
sessions shall form part of the Physical · Arrangement of Compassionate Visit
therapy /Occupational therapy limits.
24-Hour Travel Assistance Services
 Congenital hernia shall be covered up to · Emergency Message Transmission Assistance
MBL. · Legal Referral
· Inoculation and Visa Requirement Information
 Consultations for Chronic Dermatoses · Interpreter Referral
shall be covered up to MBL. · Lost Luggage Assistance
· Lost Passport Assistance
 Medically necessary Modalities and · Embassy Referral
Procedures are covered up to Php5,000 · Weather and Foreign Exchange Information
whether done thru in-patient or out-patient
(shared limit). Complete list of modalities Services
will be available on the membership
agreement upon enrollment and activation. CHUBB 24-HOUR EMERGENCY HOTLINE:
(632) 328-2460
Please note that other medically necessary
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

IX. DREADED DISEASE / CONDITION f. Cerebrovascular Diseases such as but not
limited to Stroke, Cerebral, Cerebellar,
Any condition that is considered to be chronic, Thrombosis, Embolism and Ruptured
progressive, life-threatening and which may entail life- aneurysm and all Intracranial Hemorrhage
long therapy wherein complete cure cannot be and related conditions
ensured
g. Cholecystolithiasis and Choledocholithiasis
COVERAGE FOR DREADED AND NON-DREADED h. Chronic Endocrine Disorders and its
CONDITONS
complications such as but not limited to
1st year of membership: Dyslipidemia, Obesity, Diabetes Mellitus,
Hormonal Dysfunctions excluding surgical
 Dreaded and Non-dreaded covered subject to treatment/procedures for obesity
i. Chronic Gastrointestinal Diseases such as
below limits: but not limited to Irritable Bowel Syndrome,
Crohn’s disease
Plan Type Per illness per j. Chronic Genito-urinary Disorders
k. Chronic Kidney Disease/Failure & its
member per year complications
l. Chronic Liver Parenchymal Diseases such
Platinum Plus Php 20,000 as but not limited to Liver Cirrhosis, Chronic
hepatitis, Non-alcoholic Fatty Liver
Platinum 15,000 Disease/Steatohepatisis (NASH)
m. Chronic Pulmonary Diseases such as but
Gold 10,000 not limited to Bronchial Asthma, Chronic
Silver 5,000 Obstructive Pulmonary Disease (COPD),
emphysema, and other chronic lung
Subsequent years of membership: disease
n. Collagen Vascular/Connective
 Dreaded conditions not considered acquired are Tissue/Immunologic Disorders such as but
not limited to Systemic Lupus
covered subject to below limits: Erythematosus and its complications
o. Complications of immuno-compromised
Plan Type Per illness per clinical conditions except HIV/AIDS
p. Extrapulmonary Tuberculosis including
member per year Pott’s disease and Multi-Drug Resistance
Case (MDR) case
Platinum Plus Php 20,000 q. Multiple Organ Failure
r. Muscular Dystrophies such as but not
Platinum 15,000 limited to Duchenne, Becker, limb girdle,
facioscapulohumeral, myotonic,
Gold 10,000 oculopharyngeal, distal, and Emery-
Silver 5,000 Dreifuss
s. Neuro-surgical interventions and/or major
 Non-dreaded conditions shall be covered up to neurological diseases such as but not
MBL limited to
Poliomyelitis/Meningitis/Encephalitides,
 Acquired dreaded conditions shall be covered up Demyelinating Neurologic diseases and its
to MBL complications/sequelae and Peripheral
Nervous Ssystem Disorders/disease
Such dreaded conditions are as follows, but not t. Thyroid Dysfunctions due to disease of
limited to: thyroid such as but not limited to
Hypothyroidism and Hyperthyroidism
a. All malignancies (including indicated u. Any illness other than above which would
chemotherapy or radiotherapy) require Critical Care/Intensive Care Unit
(ICU) Confinement
b. Arthritis v. All complications resulting from above list of
c. Blood Dyscrasias such as but not limited to conditions

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

Such non-dreaded conditions are as follows, but not g) If member is requested to take a laboratory test,
limited to: secure the Laboratory Slip* from the Medical
Coordinator/ PCC.
a) All benign tumors
b) Anal Fistulae h) Proceed to the laboratory and present the
c) Cervical Polyps (if benign biopsy) laboratory slip with the LOE and avail of the test.
d) Conjunctivitis (except chemical, complicated)
e) Endometrioses/Controlled Dysfunctional i) For follow-up consultations, follow steps 1-5 to
secure LOE and referral slip/ laboratory slip from
Uterine Bleeding (except if caused by uterine Maxicare Centers and/or Coordinator.
malignancies)
f) Hemorrhoids Note: Referral Slips and Laboratory Slips* are
g) Hepatitis A necessary in order for the doctor to know that
h) Gastritis, Duodenitis or Uncomplicated Maxicare is to be billed for the procedure. For queries
Gastric / Duodenal Ulcer and assistance, please call Maxicare Hotline at
i) Inactive Pulmonary Tuberculosis 582-1900.
j) Migraine
k) Non-surgical Ear-Nose-Throat conditions 2. In-patient
such as but not limited to Sinusitis, Rhinitis,
Tonsillopharyngitis, Laryngitis, Parotitis, a) Secure an Admitting Order from a Maxicare
Otitis Media, Otitis Externa and Surgical Ear- Accredited Specialist.
Nose-Throat conditions such as but not
limited to Tonsillectomy, Nasal Polypectomy, b) Coordinate with the admitting section and
Tympanoplasty, Sialolithotomy, coordinator in the hospital for room reservation
Sialodochoplasty.
l) Non-Toxic Goiter (if uncomplicated) c) If possible, call Maxicare at least 24 hours prior to
m) Ovarian cysts Uncomplicated Cholecystitis, admission for assistance in securing the doctor
Cholelithiasis
n) Uncomplicated Hernias (Congenital Hernia d) Member goes to the Admitting Section in the
will have coverage as listed in the Congenital hospital and presents his/her Maxicare swipe
Clause) card and admitting order from the Maxicare
o) Uncomplicated Hypertension Coordinator/ Specialist to the admitting staff.
p) Uncomplicated Urinary Tract Infection,
Stones/Calculi e) Once the LOE is generated by the hospital staff,
q) Urinary Incontinence the member will be asked to sign on it. This will
be attached to the other admitting documents.
X. AVAILMENT PROCEDURES
f) Proceed to the reserved room entitled or
1. Out-patient operating room (for operation)

a) To avail of consultations or treatment, go to any g) Maxicare will issue the Letter of Authority (LOA)
Maxicare Accredited Clinics/Hospitals or upon receiving hospital’s advice on the member’s
Maxicare Primary Care Centers (PCC). confinement.

b) Member goes to the POS terminal in the h) Member must file Philhealth on or before
hospital/clinic (Billing/ER/Admitting section) or at discharge.
the PCC.
i) All uncoverable and excess charges must be
c) Hospital staff swipes the member’s swipe card. settled by the member upon discharge.
The Letter of Eligibility (LOE) will be given to the
member with his Maxicare card. Note: For queries and assistance, call Maxicare
Hotline: 582-1900
Please note that the LOE is valid only on the
same date that it was swiped. Availment/s made 3. Emergency Care
on different dates will need an LOE per date. A life threatening or accidental injury or a sudden and
unexpected onset of a condition which at the time of
d) Member proceeds to the Medical Coordinator’s the occurrence reasonably appears to have the
clinic and presents his LOE and Maxicare card potential of causing immediate disability or death, or
for consultation. which requires the immediate alleviation of pain or
discomfort.
e) If referred to an accredited specialist, secure LOE
and Referral Slip* from the Medical Coordinator/ The Member must notify MAXICARE HEAD OFFICE,
PCC. thru the Customer Care Department, WITHIN 24
HOURS so that proper assistance is promptly
f) Present Maxicare ID Card, LOE and Referral Slip rendered.
to accredited specialist to avail of consultation.
o Accredited Hospital
1. Go to the Emergency Room of nearest
accredited hospital.

2. Avail of treatment at Emergency Room. address for settlement. Payments (cash or
3. Present Maxicare ID Card to ER Staff. ER check) may be made at the Maxicare Head Office
or at any Banco de Oro branches via bills
Personnel will facilitate swiping for the LOE. payments.
4. File Philhealth before discharge. 4. Member will receive Maxicare ID card as proof of
membership.
Note: Settle charges not covered by Maxicare at
the Billing Section once the Discharge Order is Who may be enrolled into the Maxicare Program
issued by the attending doctor and what are the requirements?

o Non-Accredited Hospital • The age eligibility for principal and dependents is
1. Member may proceed to the Emergency Room from 15 days old to 60 years and 5 months of age.
of nearest hospital. • Eligible dependents are as follows (in order):
2. Avail treatment at the Emergency Room.
3. Call Maxicare within 24 hours to arrange * For single enrollees: Mother, Father, then Siblings
transfer to an accredited hospital. 21 years and 5 months old and below, according
4. Settle all ER fees and secure Medical to age.
Certificate, Official Receipts, etc.
5. Forward all original documents to Maxicare for * For married enrollees: Spouse, then Children 21
reimbursement within 30 days upon discharge. years and 5 months old and below, according to
age.
XI. ENROLLMENT PROCESS AND GUIDELINES
• Individual Membership Requirements:
1. Fill out the IFG application form completely. 1. Application form
Indicate your Tax Identification Number (TIN) on 2. Medical requirements for 49 years and 6
the front page if applicable. months old
3. Photocopy of ACR (Alien Certificate of
2. Initial submission of Medical Requirements is Residency) if nationality is foreign
applicable to enrollees who are 50 years old and
above, whether Principal or Dependent. The date of • Family Membership Requirements
the conduction of these Medical Requirements Couples only:
should not exceed 6 months before the date of 1. Application form
submission. 2. Copy of marriage certificate
3. Medical requirements if already 49 years and 6
Medical Requirements for 49 years and 6 months months old (principal and dependent)
old (optional) 4. Photocopy of ACR (Alien Certificate of
 12 - lead ECG (Electrocardiogram) tracings w/ Residency) if nationality is foreign
5. With child dependent
results 1. Application form
 Chest X-ray 2. Copy of birth certificate (each child)
 FBS (Fasting Blood Sugar) 3. Medical requirements if already 49 years and 6
 Creatinine months old (principal and dependent)
 SGPT 4. Photocopy of ACR (Alien Certificate of
 Total Cholesterol Residency) if nationality is foreign
 Triglycerides
 HDL-C (High Density Lipoprotein) Note: Maxicare may request for additional
 LDL-C (Low Density Lipoprotein) requirements when deemed necessary
Note: test results should not be more than 6 months
from the date it was taken • HIERARCHY OF ENROLLMENT:
1. Dependent’s plan must be the same plan as the  Unless there is a valid reason for the non-
enrollment of certain dependents (i.e.
Principal or one plan lower. currently enrolled in another HMO, abroad,
2. Forward the accomplished application form and separated, deceased, etc.), applicants
should enroll their dependents in the priority
medical requirements (if applicable) to the specified above.
Account Officer for processing.
3. Once the application has been approved, the • Sufficient documentation shall be requested by
Statement of Account shall be sent to your billing Maxicare from the applicant to validate the non-
eligibility of the dependent (i.e. photocopy of HMO

card, certificate of employment from company g. difference in room and board, the
abroad, death certificate, etc.) incremental rate differences for
professional fees, diagnostic and
REQUIREMENTS FOR ALIEN RESIDENTS/ laboratory examinations, and other
FOREIGN NATIONALS: ancilliary medical services brought
1. Photocopy of ACR (Alien Certificate of Residency) about by obtaining a room
ID accommodation higher than the
2. Medical Requirements for enrollees 49 years and 6 Member’s Room and Board
months old (if applicable) Accommodation limit;
3. Certificate of employment (if applicable)
h. services of a private or a special
XIII. EXCLUSIONS AND LIMITATIONS nurse; and

Notwithstanding any provisions to the contrary, the i. all other items not medically
following shall not be covered except otherwise necessary in the medical
specified in Agreement: management of the patient

1. Services obtained for non-emergency 3. Custodial, domiciliary, convalescent and
conditions from Physicians and Hospitals in intermediate care.
any of the following circumstances:
a. non-accredited physicians in non- 4. Long-term rehabilitation and psychiatric care
accredited hospitals or clinics; and/or psychological illnesses and conditions
b. non-accredited physicians in including neurotic and psychotic behavior
accredited hospitals or clinics; disorders; anxiety disorders.
c. accredited physicians in non-
accredited hospitals or other non- 5. Treatment for injury and its complications
accredited healthcare facility. resulting from self-inflicted injuries including
infections as a result of tattoos, piercing of
2. Additional hospital charges and physician’s the ear or in any body part, whether self-
professional fees resulting from: inflicted or done by a third party or attempted
a. room-upgrading beyond member’s suicide or self-destruction, whether sane or
allowable time during emergency insane.
care;
b. extension of hospital stay despite 6. Developmental disorders including functional
release of discharge order from disorders of the mind, such as but not limited
member’s attending physician; to Attention-Deficit Disorder (ADD)/Attention-
c. fees of the assistant surgeons/ Deficit Hyperactivity Disorder (ADHD),
resident doctors who assisted the Autism Spectrum Disorders, Bipolar
Attending Physician in the process Disorders, Central Auditory Processing
of rendering the above mentioned Disorder (CAPD), Cerebral Palsy, Down
services shall not be chargeable to Syndrome, Neural Tube Defects, and Mental
the Member and/or Maxicare Retardation.
except for hospitals that do not
have resident physicians to assist 7. Treatment of any injury received when there
during surgeries subject to the prior is negligence, unauthorized use of prohibited
approval of Maxicare; or regulated drugs, alcoholic liquor intake,
d. use of extra bed, TV, electric fan, direct or indirect participation in the
DVD/VCD, and other similar items commission of a crime whether
unless such appliances and items consummated or not, violation of a law or
are necessarily and ordinarily ordinance or unnecessary exposure to
included in the Member’s Room & imminent danger, knowingly or unknowingly
Board Accommodation; or hazard to health, by the member.
e. extra food; Maxicare may, in its discretion, rely on Police
f. toilet articles like face towel, soap, and Doctor’s report in evaluating such claim.
toothbrush and the like;
8. 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.

9. Oral surgery following accidental injury to 19. Congenital, genetic and heredity disease
teeth for purposes of beautification. Dental and their complications (except for hernias)
examinations, extractions, fillings, other affecting functions of individuals.
dental treatment and their complications to
the extent that are medically necessary for 20. All physical deformities prior to enrollment.
repair or alleviation of damage to the 21. Treatment of injuries/illnesses caused
member caused solely by an accident.
Medical care resulting from any dental directly or indirectly by engaging in any
related conditions. professional sport or hazardous activity such
as but not limited to scuba diving, surfing,
10. Maternity care and all other conditions, water skiing, mountain climbing, rock
including pre and post-natal consultations, climbing, mountaineering, parachuting,
related to and/or resulting from pregnancy airsoft, drag racing, paintballing,
and/or delivery which affect the conditions of wakeboarding and bungee jumping, except
the principal member and the unborn child. for activities under company-sponsored
sports activities.
11. Circumcision (except for treatment of 22. Injuries resulting from direct participation in
urological conditions), sex transformation, riots, strikes, and other civil disturbances.
diagnosis, treatment and procedures related 23. Treatment of injuries or illnesses resulting
to fertility or infertility, artificial insemination, from war and any combat-related activities
sterilization or reversal of such procedures while in military service.
and their complications. 24. Sexually transmitted diseases, genital warts,
AIDS and AIDS related diseases.
12. Experimental medical procedures and its 25. Valvular heart disease (congenital and/or
complications. acquired) including Cardiomyopathies,
Chronic Glomerulonephritis, previous
13. Acupuncture and chirotheraphy and other craniotomy sequelae/hearing impairment/
forms of therapies, and its complications. Neurologic disease and Spinal Stenosis (if
pre-existing)/Poliomyelitis/Slipped disc (if
14. All expenses incurred in the process of pre-existing) and Guillain-Barre Syndrome,
organ donation and transplantation if the Diabetes and its complications (if pre-
member is the donor of such donation or existing), Complicated Hypertension (e.g.
transplantation, and its complications. those with history of stroke, myocardial
ischemia or infarction and poor kidney
15. Routine physical examinations required for function), and all malignant tumors (if pre-
obtaining or continuing employment, existing).
requirement in school, insurance, 26. Treatment for Chronic Dermatoses, except
government licensing, health permit and Scabies.
other similar purposes. 27. Infectious diseases (i.e. Avian Flu,
Meningococcemia, etc.) that are declared
16. Purchase or lease of durable medical epidemic or pandemic by the Department of
equipment, oxygen dispensing equipment, Health, World Health Organization or any
and oxygen, except during in-patient care. recognized health authority.
28. Hepatitis B and screening and vaccines for
17. Corrective appliances, prosthetics and all types of Hepatitis.
orthotics such as but not limited to artificial 29. Animal bite/scratch/lick or snake bite
limbs, hearing aids, intraocular lens, including its complications.
eyeglasses, contact lenses, braces, 30. Benefits covered by Philhealth, and all other
crutches, pacemaker, pins, screws, plates, government funded healthcare entitlements
wires, balloons, valves, knee-tibial insert for as provided for by law.
total knee arthroplasty, orthopedic internal 31. Laser procedures/treatments.
fixator/fixation systems, orthopedic external 32. Speech therapy for developmental and
fixator/fixation systems, bone screws and congenital diseases.
plates, vascular grafts/stents, intravascular 33. Weight reduction programs, surgical
catheters, myringotomy tube. operation or procedure for treatment of

18. Take-home medicine and outpatient
medicine except
a. chemotherapy medicine
b. medicine administered during an
emergency treatment

obesity, including gastric stapling or balloon OTHER PROVISIONS:
procedures and liposuction.
34. Routine, diagnostic, therapeutic and other CUT OFF DATES
procedures of the same or similar nature not
otherwise specified in this Agreement For Individual and Family
35. Cost of vaccines and immunization including
its administration. PAYMENT RECEIVED or EFFECTIVE DATE
36. Cost of medico-legal cases. Official Receipt dates 1st of the following
37. All screening tests if patient is 1st to the 15th of the
month
a. asymptomatic, no clinical signs and month 16th of the following
symptoms; 16th to 30th/ 31st of the
month
b. no previous history of the disease month
for which the test is requested for;
and LAPSATION

c. personal request of the member If a member fails to pay a membership fee on its due
which may fall under the above date, his or her membership shall be considered
reasons. lapsed effective the day after the due date. A
member whose membership has lapsed will not be
38. Treatment of work-related injuries of high- entitled to any Benefit during the period that his
risk occupations such as but not limited to membership is on a lapsed status, except in
construction workers, miners, loggers and connection with illness or injury that supervened prior
drillers. to such lapsation and for which the member had at
that time made the necessary claim for the benefits
39. Cost of the medical services and under this Agreement.
professional fees in excess of the MBL.
REINSTATEMENT
40. All cases of assault whether provoked or
unprovoked, whether initiated by the A member whose coverage has lapsed for failure to
member or by a known or unknown third pay the membership fee on the due date may apply to
party. reinstate his or her coverage within forty-five (45)
calendar days from the date it is considered lapsed by
41. Open heart surgeries, angioplasties, (a) submitting a written request for reinstatement; (b)
valvuloplasties, permanent pacemaker, paying the membership fee due with arrears,
balloon valvuloplasties, percutaneous intra- including five hundred pesos (Php500) per member;
aortic balloon counter pulsation and balloon (c) for modes of payment other than annual, paying in
atrial septostomy. advance the membership fee due for the next period,
provided however that there shall be no coverage of
42. Home service. any benefit to the reinstated member within 30
43. Additional modalities and procedures not calendar days from the effective date of
reinstatement.
specified in this Agreement, in excess of Php
5,000. If the membership fees due including five hundred
44. Multiple sclerosis, epilepsy and seizures. pesos (Php500) remain unpaid within forty-five (45)
45. Neurologic degenerative diseases such as days from the date it is considered lapsed, Maxicare
but not limited to Alzheimer’s disease, reserves the right to suspend all services under this
Parkinson’s disease, Amyotrophic lateral Agreement until full payment of all fees have been
sclerosis and others Intravenous paid and settled.
Immunoglobulin (IVIG)
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**

2019 INDIVIDUAL MEMBERSHIP FEES PLATINUM
PLATINUM PLUS Php 150,000
Regular Private
AGE BRACKET Annual Php 200,000 Quarterly Annual Semi-Annual Quarterly
55,795 Large Private 32,708 9,158
15 days old -5 45,684 26,202 17,662 7,337
6-10 37,647 Semi-Annual 21,089 14,149 5,905
11-15 36,469 19,475 11,388 5,453
16-20 36,262 30,129 15,623 20,317 10,517 5,689
21-25 37,647 24,669 12,792 22,466 10,971 6,290
26-30 45,114 20,329 10,541 26,628 12,132 7,456
31-35 56,720 19,693 10,211 35,081 14,379 9,823
36-40 72,045 19,581 10,153 47,696 18,944 13,355
41-45 85,818 20,329 10,541 64,367 25,756 18,023
46-50 96,827 24,362 12,632 78,447 34,758 21,965
51-55 106,919 30,629 15,882 88,834 42,361 24,874
56-60 38,904 20,173 47,970
Annual 46,342 24,029 Annual Quarterly
AGE BRACKET 28,955 52,287 27,112 21,456 SILVER 6,008
22,668 57,736 29,937 17,877 Php 60,000 5,006
15 days old -5 18,650 GOLD 15,129 Semi Private 4,236
6-10 17,847 Php 100,000 Quarterly 14,390 Semi-Annual 4,029
11-15 17,434 Regular Private 14,390 4,029
16-20 20,454 Semi-Annual 16,372 11,586 4,584
21-25 24,668 17,635 9,654 4,938
26-30 32,376 15,636 8,107 21,474 8,170 6,013
31-35 41,460 12,241 6,347 32,192 7,771 9,014
36-40 49,701 10,071 5,222 38,536 7,771 10,790
41-45 51,988 9,637 4,997 38,547 8,841 10,793
46-50 60,618 9,414 4,882 42,825 9,523 11,991
51-55 11,045 5,727 11,596
56-60 13,321 6,907 17,384
17,483 9,065 20,809
22,388 11,609 20,815
26,839 13,916 23,126
28,074 14,557
32,734 16,973

NOTES:

1) Above rates are inclusive of 12% VAT

2) With access to all affiliated hospitals and clinics EXCEPT Healthway Clinics

3) Status quo benefits and arrangements including the following:

a. ACU/ECU type: ACU Basic 5 only (applicable to ALL plan types)

b. Philhealth provision: Required to file Philhealth. Non-Philhealth member will pay for the Philhealth portion.

c. Riders: Built-in on Rates

i. International Assistance Program

ii. Group Life with Accidental Death, Dismemberment & Disablement (ADD&D) up to Php 50,000

Separate Fee

Rider 2018 Rates

Annual Semi-Annual Quarterly

Standard Dental Benefit 387 209 108

d. Submission of Medical Requirements with option to remove the submission of medical requirements upon
enrollment of enrollees ages 49 years old and 6 months and above with corresponding additional fee of 2,500

per member per year.

2019 FAMILY MEMBERSHIP FEES

PLATINUM PLUS PLATINUM

AGE BRACKET Annual Php 200,000 Quarterly Annual Php 150,000 Quarterly
45,626 Large Private Regular Private 8,321
15 days old -5 37,336 Semi-Annual Semi-Annual 6,685
6-10 32,525 5,422
11-15 29,673 24,638 12,775 29,718 16,048 4,961
16-20 29,966 20,161 10,454 23,874 12,892 5,302
21-25 31,382 17,564 9,107 19,363 10,456 5,842
26-30 35,492 16,023 8,308 17,718 9,568 7,030
31-35 40,508 16,182 8,390 18,937 10,226 8,887
36-40 52,442 16,946 8,787 20,864 11,267 11,548
41-45 70,360 19,166 9,938 25,107 13,558 15,440
46-50 82,710 21,874 11,342 31,741 17,140 18,836
51-55 95,025 28,319 14,684 41,244 22,272 22,165
56-60 37,994 19,701 55,143 29,777
Annual 44,663 23,159 67,272 36,327 Quarterly
AGE BRACKET 23,904 51,314 26,607 79,162 42,747 5,266
19,266 SILVER 4,290
15 days old -5 15,887 GOLD Quarterly Annual Php 60,000 3,683
6-10 14,192 Php 100,000 6,693 18,808 Semi Private 3,499
11-15 13,992 Regular Private 5,394 15,322 Semi-Annual 3,487
16-20 16,470 Semi-Annual 4,448 13,152 10,156 3,869
21-25 19,230 12,908 3,974 12,497 8,274 4,191
26-30 24,371 10,404 3,918 12,455 7,102 4,991
31-35 30,369 4,612 13,817 6,748 7,189
36-40 38,681 8,579 5,384 14,967 6,726 8,957
41-45 40,621 7,664 6,824 17,824 7,461 8,997
46-50 47,023 7,556 8,503 25,674 8,082 9,991
51-55 8,894 10,831 31,990 9,625
56-60 10,384 11,374 32,132 13,864
13,160 13,166 35,682 17,275
16,399 17,351
20,888 19,268
21,935
25,392

NOTES:

1) Above rates are inclusive of 12% VAT

2) With access to all affiliated hospitals and clinics EXCEPT Healthway Clinics

3) Status quo benefits and arrangements including the following:
a. ACU/ECU type: ACU Basic 5 only (applicable to ALL plan types)

b. Philhealth provision: Required to file Philhealth. Non-Philhealth member will pay for the Philhealth portion.
c. Riders: Built-in on Rates

i. International Assistance Program
ii. Group Life with Accidental Death, Dismemberment & Disablement (ADD&D) up to Php 50,000

Separate Fee

Rider 2018 Rates

Annual Semi-Annual Quarterly

Standard Dental Benefit 387 209 108

d. Submission of Medical Requirements with option to remove the submission of medical requirements upon

enrollment of enrollees ages 49 years old and 6 months and above with corresponding additional fee of 2,500

per member per year.

MAXICARE PRIMARY CARE CENTERS were put ST. LUKE’S MEDICAL CENTER – QUEZON CITY
together with your convenience in mind. These are Unit 1501, North Tower, Cathedral Heights,
well- appointed to give the cardholders access to St. Lukes Compound E. Rodriguez Quezon City
quality health care close enough to where they work Tel. Nos: (02)723-5329/ (02)723-0101 loc 5150 or
or live. Each center has its staff of Customer Service 5151
Assistants, Primary Care Physicians (specialists in Clinic Hours: Monday- Friday 7am-6pm
some centers on certain days) and additional services Saturday 7am-4pm
like urinalysis and CBC. Because our centers are
located close to major hospitals, our Customer CHINESE GENERAL HOSPITAL
Service Assistants are able to facilitate easy access 10th floor, Medical Arts and Parking Building,
to quality diagnostics, specialist consultation and Blumentritt St.Sta. Cruz, Manila
hospitalization when you need it. Tel. Nos: (02)567-6286 to 87
Clinic Hours: 8am-5pm Monday- Friday;
MAXICARE PRIMARY CARE CENTERS AND 8am-4pm Saturday
MYHEALTH CLINICS
CARDINAL SANTOS MEDICAL CENTER
MAKATI MEDICAL CENTER (Out-Patient) Room 160, Ground Floor of Medical Arts Building
3rd Floor Tower One, Makati Medical Center, 10 Wilson Street, Greenhills West, San Juan City
Amorsolo St., Makati City Tel. Nos.: 0917 8172941
Clinic Hours: Monday – Friday, 7AM-7PM; Clinic Hours: 8am-5pm Monday to Saturday
Saturday, 7 AM—7 PM
Contact Nos.: (02) 888-8999 loc. 7330; CENTURIA
(02) 908 6900 loc. 1375 Unit 933, Centuria Medical Makati, Century City,
Kalayaan Ave. cor. Salamanca St. Brgy. Poblacion,
MAKATI MEDICAL CENTER (In-Patient) Makati City
8th floor Maxicare Wing, Tower 1 Makati Medical Contact Nos: 793-8652 / 863-0618
Center Clinic Hours: Monday – Friday 8am-5pm
Amorsolo St., Makati City (Closed during Saturdays and Holidays)
Contact Nos.: Tel. no. : 8888-999 local 7331
W CITY CENTER
THE MEDICAL CITY Ground Floor, W City Center , 7th Avenue cor. 30th St.,
MGR04, Ground Floor, Medical Arts Tower 1 , Ortigas Bonifacio Global City, Taguig
Avenue, Pasig City Contact Nos: 908-6957
Contact Numbers: (02) 706-5080/ 706-5081/ Clinic Hours: Open 24 hours daily
635-6789 loc. 5073/3006
Clinic Hours: 7AM –6PM Monday—Friday; MY HEALTH CLINIC – TAGUIG CITY
Saturday, 7AM– 4PM 2nd Floor, Venice Grand Canal Mall, McKinley Hills,
Taguig City
ST. LUKE’S MEDICAL CENTER—GLOBAL CITY Tel Nos: (+632) 784-6930
Rm. 325 Medical Arts Building, 32nd Street, Corner Clinic Hours: Open 24 hours daily
5th Avenue Bonifacio Global City, Taguig
Contact Numbers: (02) 789-7700 loc. 7325 MY HEALTH CLINIC- FILOMENA MAKATI
Clinic Hours: 8AM– 5PM Monday—Friday; Ground Floor, Filomena Bldg., Amorsolo Street,
Saturday 8AM—4PM Makati City
Tel Nos.: (02) 893-4858/ (02) 812-3726
Clinic Hours: 7am-9pm Monday-Saturday

MY HEALTH CLINIC- SHANGRILA *For Providers’ Directory, please refer to List of
Unit 146, Level 1 Shangri La Plaza Mall, Accredited Hospitals & Clinics at www.maxicare.com.ph
Mandaluyong City
Tel. Nos.: (02) 570-4325 loc. 206 Your Easy Guide to Maxicare’s SMS Inquiry Service
Clinic Hours: 7am- 8pm Monday- Sunday (0918-889-MAXI)

MY HEALTH CLINIC- NORTH EDSA 1) To request list of accredited providers per
2nd Floor, North Link Bldg., F, SM City North Edsa area
North Avenue, Quezon City
Tel. Nos.: (02) 441-4106 loc. 206 a) Hospital
Clinic Hours: 7am-9pm, Monday-Sunday Key in: prov <space> hos <space>
location
MY HEALTH CLINIC- FESTIVAL MALL Examples: prov hos makati
21 Style Blvd, Festival Mall, Alabang, Muntinlupa City prov hos bacolod
Tel. Nos.: (02) 850-4855 loc.102; Telefax (02) 809-
4388 b) Clinic
Clinic Hours: 7am-8pm Monday to Saturday Key in: prov <space> clinic <space>
location
MY HEALTH CLINIC- ROBINSON’S CYBERGATE Examples: prov clinic makati
3rd Floor, Room 305-306, Robinson’s Cybergate Mall, prov clinic ortigas
Fuente Osmeña Street, Cebu City
Tel. Nos.: (032) 268-8502 loc. 204 or 205 2) To request list of accredited doctors per
Clinic Hours: 7am-7pm Monday to Saturday specialization per hospital
REGIONAL CUSTOMER CARE CENTERS Key in: doc <space> hospital name
<slash> specialization
BACOLOD Examples: doc makati med/gastro
Rm. 215 North Point Building doc riverside/cardio
B.S. Aquino Drive, Bacolod City
Tel. Nos: (034) 433-3044 | (034) 434-9230 3) To request doctor’s schedule and contact
number per hospital
CAGAYAN DE ORO Key in: sked<day> <space> hospital
2/F Unit 215, De Leon Bldg. name <slash> doctor’s surname
Yacapin St. Cor Velez St., Cagayan De Oro Key words for each day: mon, tue, wed,
(08822) 71-47-25 | 71-47-26 thu, fri, sat, sun
Examples: skedmon medical city/flandes
DAVAO skedsat makati med/genuino
2nd Floor Room 17 Jocar Complex
C. de Guzman Street, Davao City Sales Dept: 908 6900 local 1155 /1141/1267
(082) 227-2941 | 300-5553 Maxicare Hotline: 908-6900
International Assist Hotline: (02) 328 2460
GENERAL SANTOS Customer Care Department: 582-1900
General Santos Doctors’ Hospital Toll Free No. for Provincial Inquiries (PLDT
Engineering Office Line): 1-800-10-582-1900
Ground Floor near 1B Station SMS Inquiry: 0918-889-MAXI
National Highway, General Santos City www.maxicare.com.ph
Tel. Nos: (083) 553-3963

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


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