Académique Documents
Professionnel Documents
Culture Documents
Plan
Maximum
Room & Board
Benefit Limit
Accommodation
(MBL)
Membership Fees
ACU Type
Annual
Semi-annual
Quarterly
Monthly***
PRINCIPALS
PLATINUM
PLATINUM
PLATINUM
PLATINUM
GOLD
GOLD
GOLD
SILVER
SILVER
BRONZE
Small Suite
Open Pvt
Open Pvt
Lrg Pvt
Reg Pvt
Reg Pvt
Reg Pvt
Semi-Pvt
Semi-Pvt
Ward
200,000
200,000
150,000
150,000
150,000
100,000
75,000
75,000
60,000
50,000
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
10,099
8,818
8,569
8,296
7,503
7,253
6,988
5,699
5,539
4,582
5,453
4,762
4,627
4,480
4,052
3,917
3,774
3,077
2,991
2,474
2,828
2,469
2,399
2,323
2,101
2,031
1,957
1,596
1,551
1,283
959
838
814
788
713
689
664
541
526
435
Small Suite
Open Pvt
Open Pvt
Lrg Pvt
Reg Pvt
Reg Pvt
Reg Pvt
Semi-Pvt
Semi-Pvt
Ward
200,000
200,000
150,000
150,000
150,000
100,000
75,000
75,000
60,000
50,000
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
14,048
11,990
11,740
11,403
10,274
10,024
9,759
7,749
7,590
6,226
7,586
6,475
6,340
6,158
5,548
5,413
5,270
4,184
4,099
3,362
3,933
3,357
3,287
3,193
2,877
2,807
2,733
2,170
2,125
1,743
1,335
1,139
1,115
1,083
976
952
927
736
721
591
DEPENDENTS
PLATINUM
PLATINUM
PLATINUM
PLATINUM
GOLD
GOLD
GOLD
SILVER
SILVER
BRONZE
*** Monthly Mode of payment is applicable only for Small accounts with First Aggregate Modal fee of at least Php 20,000.
SEPARATE FEE (Optional per account):
Standard Dental Package:
Basic Dental Package:
Life with AD&D (Php25,000):
Annual
292
172
72
Semi- Annual
158
93
39
Quarterly
Annual
1,066
Semi- Annual
576
Quarterly
82
48
20
Monthly***
28
16
7
298
Monthly***
101
A.
HEALTHCARE BENEFITS
OUT-PATIENT CARE
1
Subject to MBL
Subject to MBL
3
4
5
6
7
8
10
11
12
MAXICARE
Tuberculin test
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
IN-PATIENT CARE
1
2
3
Subject to MBL
Subject to MBL
a. Attending Physicians
b. Surgeons
c. Anesthesiologists
d. Cardio-pulmonary clearance before surgery and cardiac
monitoring during surgery.
4
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
10
Subject to MBL
11
Subject to MBL
6
7
12
C.
Subject to MBL
Subject to MBL
Subject to MBL
Blood Chemistries
Chest X-Ray
D.
Fecalysis
Urinalysis
DIAGNOSTIC PROCEDURES
1
Adrenocortical Function
10
11
12
13
Diagnostic Radiographs:
14
Diagnostic Ultrasounds:
a. 2D-Echo with Doppler
b. Abdomen
c. Duplex Scan
15
16
17
Endoscopic Procedures
18
Fluorescein Angiography
19
Impedance Plethysmography
20
21
22
23
Myelogram
24
25
Pap's Smear
26
Perfusion Scan
27
28
29
30
b. Gastrointestinal
c. Liver
e. Renal
f. Thyroid Scans
31
Radionuclide Ventriculography
32
E.
33
Thallium Scintigraphy
34
THERAPEUTIC PROCEDURES
1
Arthrocentesis
2
Dialysis
Intravenous Chemotherapy
4
Phlebotomy
5
Physical therapy / Occupational therapy excluding subspecialties
such as cardiac rehabilitation, pulmonary rehabilitation and the like.
6
Thoracentesis
7
Therapeutic Radiology:
a. Brachytherapy
Up to MBL
b. Cobalt
Up to MBL
Up to MBL
d. Radioactive Cesium
Up to MBL
Up to MBL
e. Radioactive Iodine
F.
Oral Chemotherapy
ANNUAL CHECK-UP
1
Separate Fee
ECG and Pap's Smear shall be for members 35 years old & above.
This shall be conducted at a designated Maxicare Accredited Clinic once a year.
*
F.
G.
ECU can be availed at TMC and MMC only if account chooses separate fee arrangement.
PREVENTIVE CARE
1
Covered
Covered
Wellness programs
Covered
Separate Fee
ADDITIONAL PROCEDURES AND MODALITIES (shared limit for OP and IP; Professional Fees, Hospital Bills and other incidental
expenses relative to the procedure shall form part of the limit)
1
100% of Actual Cost subject to MBL
Angiography (gastrointestinal, brain, retinal and peripheral vascular)
2
Coronary Angiogram and/or Angioplasty/Coronary Artery Bypass
100% of Actual Cost subject to MBL
Graft
3
100% of Actual Cost subject to MBL
Cryosurgery
4
100% of Actual Cost subject to MBL
Gamma Knife Surgery
5
Hysteroscopically-guided D&C
Laparoscopy
Lithotripsy
10
11
Conventional Hemorrhoidectomy
12
Scalpel Hemorrhoidectomy
13
Stapled Hemorrhoidectomy
14
Mammotome
15
16
Esophageal Manometry
17
18
19
20
CT Pulmonary Angiography
21
Photodynamic Therapy
Other medically necessary modalities not mentioned above and
those for which there are no comparable, conventional or traditional
counterparts
22
23
H.
In Accredited Hospitals
a. Doctors services
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
In Non-Accredited Hospitals
3
Outside the Philippines
4
5
6
J.
Subject to MBL
up to 24 hours
Reimbursable up to 80% of hospital bills & professional
fees based on Maxicare rates incurred during the first
24 hrs. of treatment up to Php 30,000 /availment
/member /year
Reimbursable up to 100% of actual cost up to Php30,
000 /availment /member /year
100% based on Maxicare rates up to MBL
Up to MBL
Reimbusable up to Php 2,500 per conduction
Note: The ambulance service provided herein shall be available regardless of the location within the Philippines
Covered for the first 24 hrs. from the time of bite
subject to MBL
Initial Treatment of Animal Bites
PRE-EXISTING CONDITIONS
1
Dreaded Conditions
Covered
Non-Dreaded Conditions
Covered
K.
EMERGENCY CARE
1
I.
Covered
Oral prophylaxis
Temporary Fillings
Covered
Covered
10
Covered
11
12
13
Covered
14
Covered
15
Covered
Covered
Covered - Once a year
Covered
Covered
Unlimited, As needed
Up to 2 teeth
Covered
2 Teeth per year
GROUP LIFE INSURANCE WITH ACCIDENTAL DEATH AND DISABLEMENT (AD&D) BENEFITS (Optional - Separate Fee)
1
Insurance Provider
Eligible Members
18 to 65 years of age (who are all regular, full time and
actively at work)
legal spouse whose insurance age is 18 to 65 years old
Dependents of Married employees
children whose insurance age is 15 days but not over
21 years old, unemployed and fully dependent on the
principal
parents
whose
insurance
age is 18 to 65 years old
Dependents of Single Employees
siblings who are 15 days but not more than 21 years
old, unemployed and fully dependent on the principal
children who are 15 days but not more than 21 years
old, or parents whose insurance age is 18 to 65 years
old
Dependents of Single Parent Employees
siblings who are 15 days but not more than 21 years
old. (Children and siblings must be unemployed and
fully dependent on the principal)
Payment of any insurance benefit shall not be made for any loss resulting from or caused directly or indirectly, wholly or
partially by:
a. bodily or mental infirmity or disease of any kind, or infection other than infection occuring simultaneously with and in
consequence of an accidental cut or wound; or
Employees
2
3
Chronic Dermatoses
Scabies
Exclusion #25
Hepatitis B
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 teeth for purposes of beautification. Dental examinations, extractions, fillings, other dental
treatment and their complications except 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.
10 Maternity care and all other conditions (except pre and post natal consultations) related to and/or resulting from pregnancy and/or
delivery which affect the conditions of the Member and the unborn child.
11 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 and their complications.
12 Experimental medical procedures and its complications.
13 Acupuncture, chirotherapy and other forms of therapies and its complications.
14 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.
15 Routine physical examinations required for obtaining or continuing employment, requirement in school, insurance/travel or government
licensing, health permit and other similar purposes.
16 Purchase or lease of durable medical equipment, oxygen dispensing equipment, and oxygen except during covered in-patient care.
17 Corrective appliances, prosthetics and orthotics such as but not limited to eye glasses and contact lenses, hearing aids, pacemaker,
artificial limbs, valves, knee-tibial insert for total knee arthroplasty, vascular grafts, titanium thread, myringotomy tube, intravascular
catheters, vascular stents, bone screws/plates, pins, wires, balloons, orthopedic internal fixator/fixation systems, orthopedic external
fixator/fixation systems, intraocular lens, braces, crutches.
18 Take-home medicine and out-patient medicine except:
a. chemotherapy medicine
b. medicine administered during an emergency treatment
19 Congenital, genetic and hereditary diseases and their complications (except for hernias) affecting functions of individuals.
20 All physical deformities prior to enrollment.
21 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 company-sponsored sports activities.
22 Injuries resulting from direct participation in riots, strikes, and other civil disturbances.
23 Treatment of injuries or illnesses resulting from war or any combat-related activities while in military service.
24 Sexually transmitted diseases, genital warts, AIDS and AIDS related diseases.
25 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 pre-existing).
26 Treatment for chronic dermatoses.
27 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.
28 Pre-existing Hepatitis B and screening and vaccines for all types of Hepatitis.
29 Animal bite/scratch/lick or snake bite including its complications.
30 Benefits covered by Philhealth and all other government funded healthcare entitlements as provided for by law.
31 Laser procedures/treatments.
32 Speech therapy for developmental and congenital diseases.
33 Weight reduction programs, surgical operation or procedure for treatment of obesity, including gastric stapling or balloon procedures
and liposuction.
34 Routine, diagnostic, therapeutic and other procedures of the same or similar nature not otherwise specified in this Agreement.
35 Cost of vaccines for immunization including its administration.
36 Cost of medico-legal cases.
37 All screening tests.
38 Treatment of work-related injuries of high-risk occupations such as but not limited to construction workers, miners, loggers and drillers.
39 Cost of the medical services and professional fees in excess of the MBL/ABL.