I. IN PATIENT
• Room and Board Accommodation
• Use of Operating and Recovery Rooms
• Use of Intensive Care Unit (ICU)
• Professional Fees of attending doctor(s)
• Drugs and medicines for use in the hospital
• Whole blood and human blood products and IV fluids
• X-ray, laboratory examinations and diagnostic tests
• Dressings, casts and sutures
• Anesthesia and its administration
• Oxygen and its administration
• Laparoscopy and Lithotripsy covered up to Maximum Benefit Limit.
• Standard nursing/resident doctors’ services
• Admission kit including ice cap and wee bag
• Other supplies directly related to the medical management of the patient

II. OUT PATIENT
• Medically necessary consultations during regular clinic hours, except medicines
• Eye, ear, nose and throat (EENT) treatment
• Treatment of minor injuries, such as lacerations, mild burns, sprains and the like
• X-ray, laboratory examinations, routine, diagnostic and therapeutic procedures such as Chemotherapy, Dialysis, etc., prescribed by an affiliated doctor
• Minor surgery not requiring confinement
• Physical Therapy up to 6 sessions
• Laser Therapy for retinal detachment and glaucoma prescribed by an affiliated physician or specialist up to Php1,500/ eye /member/year.
• Cauterization of Warts up to P1,000/member/year

III. SALIENT FEATURES

R&B – Room and Board Accommodation (room category as charged)
MBL – Maximum Benefit Limit (benefit per illness per year)

IV. PREVENTIVE CARE
• Active and emergency care immunization for treatment of animal bites, snake bites and tetanus up to Php 18,000 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
A. AFFILIATED HOSPITAL
• Doctor’s services
• Emergency Room fees
• Medicines used for immediate relief and during treatment
• Oxygen, intravenous fluids, whole blood and human blood products
• Dressings, casts and sutures
• X-rays, laboratory and diagnostic examinations and other medical services related to the medical management of the patient


B. NON-AFFILIATEDHOSPITAL
• Maxicare shall reimburse 80% of the total hospital bills and 80% of the professional fees based on Maxicare’s rates up to Php 15,000 per case during the first 24 hours of treatment.

VI. ANNUAL CHECK-UP
Note: Inclusive tests are subject to change based on hospital’s/clinic‘s current ACU package.

Platinum Plus Plan: (Multi – Phasic B)
• CBC (Complete Blood Count)
• Blood Chemistry (Fasting Blood Sugar, Potassium, Total Cholesterol HDL, LDL, VLDL Cholesterol Triglycerides, Urea, Creatinine, SGOT, SGPT, Alkaline Phosphatase, Total Bilirubin, Total Protein, Albumin, Globulin, Calcium, Uric Acid
• Thyroid Function: TSH-IRMA
• Hepatitis Screening: HbsAg, Anti-HBs, Anti-HBc (choose 2)
• Routine Urinalysis
• Routine Fecalysis
• Cardiac Work-up (12- Lead ECG, Treadmill Stress Test)
• Chest X-ray
• Abdominal Work-up (Upper Gastrointestinal series or Barium Enema, Ultrasound of Liver, Gallbladder & Pancreas, Proctosigmoidoscopy)
▪ Prostate Ultrasound for male members regardless of age
▪ Consultations to a Gastroenterologist, Gynecologist/Urologist and Cardiologist

Platinum Plan: (Executive Check-up)
• Physical Examination
• Urinalysis
• Fecalysis
• Chest X-ray
• CBC (Complete Blood Count)
• Blood Chemistry (Fasting Blood Sugar, Potassium, Triglycerides, Creatinine, SGOT, SGPT, Alkaline, Phosphatase, Total Protein, Albumin, Calcium, Uric Acid, BUN, Total Bilirubin, HDL and Cholesterol)
• 12 – Lead ECG
• Ultrasound of the Gallbladder
• Treadmill Stress Test

Gold Plan:
• Physical Examination
• Urinalysis
• Fecalysis
• Chest X-ray
• CBC (Complete Blood Count)
• Blood Chemistry (FBS, SGPT, Cholesterol, Creatinine, Uric Acid)
• 12 – Lead ECG
• Papsmear

Silver Plan: (Routine)
• Physical Examination
• Urinalysis
• Fecalysis
• Chest X-ray
• CBC (Complete Blood Count)
• 12 – Lead ECG (exclusive for 40 years old & above as an optional package)
• Papsmear (exclusive for 40 years old & above as an optional package)
Note: Inclusive tests are subject to change based on hospital’s/clinic‘s current ACU package.

VII. DENTAL CARE (OPTIONAL)
• Annual Oral/Dental Examination & Consultation
• Emergency Dental Treatment
• Annual Oral Prophylaxis
• Simple tooth extractions
• Restorative and Prosthodontic Treatment Planning
• Permanent fillings up to 2 fillings/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 & dietary counseling -2006
• Dental Health Education
Note: Dental Benefit is optional for an additional fee of Annual fee: P650, Semi-annual: P351, Quarterly: P182

VIII. VALUE ADDED FEATURES MAXICARE’S INTERNATIONAL EMERGENCY ASSIST PROGRAM

Maxicare has partnered with International SOS, the world’s largest medical and emergency assistance company, to give you Maxicare International Assist Program. It gives you worldwide access to 24-hour expert advice and assistance - - whether it’s help you need to prepare you for your travels or emergency advice and medical care while abroad.

Medical Assistance
• 24-Hour Telephone Medical Advice
• Emergency Medical Evacuation
• Emergency Medical Repatriation
• Repatriation of Mortal Remains
• Hospital Referral, arrangement of admission and Guarantee of Medical Expenses
• Monitoring of Medical Condition
• Delivery of Essential Medicine
• Discounted Hospitalization Expenses in the United States

The limit of indemnity for a member per event, per illness or condition per year is US$1,000,000. International SOS retains the absolute right to decide whether the member’s medical condition is sufficiently serious to warrant Emergency Medical Evacuation or Repatriation. If and when member’s condition does not merit an evacuation, repatriation afs per International SOS assessment and the member requests for such evacuation / repatriation, International SOS shall carry out the request, however, expenses shall be the member’s responsibility. All pre-existing conditions are waived under this coverage.

Travel Assistance
• Pre-trip Information Services
• Embassy / Legal / Interpreter Referrals
• Lost luggage and Passport Assistance
• Emergency Message Transmission or Document Delivery Assistance

*Any advice through the hotline is free. All third
party costs shall be member’s responsibility.

24 hour Alarm Center: (+632) 687-8522

IX. AVAILMENT PROCEDURES

A. 1. OUTPATIENT
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 889-9000.

B. INPATIENT
1. Secure an Admitting Order from a Maxicare Accredited Specialist.
2. If possible, call Maxicare at least 24 hours prior to admission for assistance in securing the doctor and entitled room assignment.
3. 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.
4. Hospital staff swipes the card on the POS terminal to generate the LOE which will verify the member’s eligibility and room designation.
5. Once the LOE is printed out the member will be asked to sign on it. This will be attached to the other admitting documents.
6. Maxicare will issue the Letter of Authority (LOA) upon receiving hospital’s advice on the member’s confinement.
7. Member must file Philhealth on or before discharge.
8. All uncoverable and excess charges must be settled by the member upon discharge.
Note: For queries and assistance, call Maxicare Hotline: 889-9000

C. EMERGENCY CASE
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.

    I. AFFILIATED HOSPITAL
    1. Go to the Emergency Room of nearest Affiliated 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.

    II. NON-AFFILIATED 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 affiliated 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.

X. ENROLLMENT PROCESS & 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 40 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.
3. Dependent’s plan must be the same plan as the Principal or one plan lower.

        Medical Requirements for 40 years old and above
        • 12 - lead ECG (Electrocardiogram)
        • Chest X-ray
        • FBS (Fasting Blood Sugar)
        • Total Cholesterol
        • HDL-C (High Density Lipoprotein)
        • LDL-C (Low Density Lipoprotein)

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?
• The age eligibility for principal and dependents is from 2 to 60 years of age.
• Eligible dependents are as follows (in order):
    * For single enrollees: Mother, Father, then Siblings 21 years old and below, according to age.
    * For married enrollees: Spouse, then Children 21 years old and below, according to age.

HIERARCHY OF ENROLLMENT:
• 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 non-eligibility 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. Completely filled-out IFG Application Form
2. Photocopy of ACR (Alien Certificate of Residency)
3. ID cards / Retirement ID
4. Photocopy of passport
5. Medical Requirements for enrollees 40 years old and above (if applicable)
6. Certificate of employment (if applicable)

PRE – EXISTING CONDITIONS:
An illness or injury shall be considered preexisting if it has been present prior to effective date of the member’s coverage:
1. any professional advice or treatment has been obtained for such illness or injury.
2. such illness or injury was evident upon medical examination in connection with the Member’s application; or
3. the natural history of such illness or injury can be clinically determined to have started prior to the effective date of coverage whether or not the Member is aware of such illness or injury.

The following illnesses/conditions and their complications, among others shall be considered as pre-existing when occurring during the first year of coverage:
• Hernias
• Tumors/Neoplasms
• Hemorrhoids
• Ear-Nose Throat conditions requiring surgery
• Hypothyroidism / Goiter / Hyperthyroidism
• Cataracts and Glaucoma
• Asthma
• Cirrhosis of the liver
• Tuberculosis
• Anal fistulae
• Cholecystitis / Cholelithiasis
• Calculi of the urinary system
• Gastric or duodenal ulcer
• Hallux valgus
• Collagen conditions

PRE - EXISTING CONDITION - waiting period
Contestability Period
1st year: No coverage
2nd year: 100% covered

OTHER CONDITIONS:
The following pre-existing disorders /diseases are permanently excluded from coverage including its related conditions but not limited to: (a) cerebrovascular accident (stroke) (b) central nervous system lesions (poliomyelitis / meningitis/encephalitis/neurosurgical conditions); (c) cardiovascular diseases; (d) chronic pulmonary diseases; (e) liver parenchymal disease (f) chronic-genito urinary tract disorders; (g) chronic gastro-intestinal tract diseases (h) connective tissue disorders / immunologic disorders (i) chronic endocrine disorders and their complications (j) malignancies and blood dyscrasias (cancer, leukemia, idiopathic thrombocytopenic purpura); (k) injuries and subsequent complications from accidents, assaults, frustrated homicide or frustrated murder (l) complications of apparent immunocompromise status; and (m) any illness other than the above which would require Intensive Care Unit confinements.

XI. EXCLUSION CONDITIONS
a) Services obtained from Physicians and Hospitals in any of the following circumstances:
    • Non – affiliated Physicians and non – affiliated hospitals,
    • Non – affiliated Physicians and affiliated hospitals,
    • Affiliated physicians and non – affiliated hospitals,
    • Physicians affiliated in other hospitals or clinics but not affiliated in the hospital or clinic where the    Member is seeking medical attention.
    Except as provided under emergency care at non – affiliated hospitals, including adverse medical conditions arising from treatment by non – affiliated physicians.
b) Cost of non-medically necessary hospitalizations, medical services, medicine and other expenses incurred as a result of patient’s sole decision to avail of such hospitalization, medical services treatment or procedures, not prescribed or contrary to what has been prescribed by the affiliated physician.
c) Costs of hospitalizations, medical services, medicine and other expenses that exceed the Maximum Benefit Limit, Room and Board limit and other internal limits.
d) Except as otherwise provided under Emergency Care provisions, additional hospital charges resulting from obtaining or occupying a room accommodation different from the Member’s room and board accommodation or additional personal comfort items such as additional telephones and television sets, etc., not ordinarily included in the Member’s room and board accommodation.
e) Purchase or lease of durable medical equipment, oxygen dispensing equipment, and oxygen, except during in-patient care.
f) Artificial aids and or devices.
g) Open heart surgeries, angioplasties, valvuloplasties, permanent pacemaker, balloon valvuloplasties, percutaneous intraaortic balloon counter pulsation and balloon atrial setpostomy.
h) Diagnostic services for hypersensitivity and desensitization treatment.
i) Vaccination, except as stated.
j) Routine, diagnostic, therapeutic and other procedures of the same or similar nature not otherwise specified under the provision for Out – Patient Care.
k) Confinements for purely diagnostic purposes, rest cures, custodial, domiciliary, convalescent and intermediate care.
l) Home service
m) Routine physical examinations required for obtaining or continuing employment, requirement in school, insurance or government licensing.
n) Medico legal fees
o) Long-term rehabilitation and Psychiatric care.
p) Treatment for functional disorders of the mind, psychiatric disorders, alcoholism and drug addiction or abuse.
q) Treatment resulting from voluntary or selfinflicted injuries or attempted suicide or selfdestruction, whether sane or insane. This includes infections or complications as a result of tattoos, piercing of the ear or any body part, whether self-inflicted or done by a third party.
r) Acupuncture, speech therapy and chirotheraphy
s) Cosmetic or reconstructive surgery to improve, alter or enhance appearance except to treat a functional defect due to accidental injury within the initial confinement.
t) Surgical operation or procedure for treatment of obesity including gastric stapling or balloon procedures and liposuction.
u) Dental examinations, extractions, fillings and other dental treatment except if medically necessary for repair or alleviation of damage caused solely by an accident.
v) Maternity care and all pregnancy related conditions including pre and post natal consultations.
w) Circumcision, sex transformation, diagnosis and treatment of fertility or infertility, artificial insemination, sterilization or reversal of such procedures.
x) Newer modalities including other procedures not specified in benefit package in excess of Php 5,000.
y) Experimental medical procedures
z) Alternative medicines and or procedures.
    aa) All expenses incurred in the process of organ donation and transplantation, unless the Member is the recipient of such donation or transplantation
    bb) Take-home medicine; Out-patient medicine except intravenous chemotherapy medicine and medicines administered during an emergency treatment.
    cc) Congenital deformities and abnormalities affecting functions of individuals, except for hernias, developmental disorders and hearing impairment.
    dd) All physical deformities including, but not limited to, scoliosis and kyphosis.
    ee) Guillain Barre syndrome, multiple sclerosis and epilepsy.
    ff) Psoriasis, Vitiligo and all other chronic dermatoses.
    gg) Degenerative diseases such as Alzheimer’s and Parkinson’s diseases, Amyotrophic laberal sclerosis and others.
    hh) Sexually transmitted diseases (e.g. herpes, gonorrhea, syphilis) and conditions such as vulvar warts.
    ii) Hepatitis B, AIDS and AIDS-related diseases.
    jj) Valvular heart disease (congenital and/or acquired) including Mitral Valve Prolapse and Cardiomyopathies.
    kk) Treatment of all injuries caused directly or indirectly by engaging in any hazardous sport or activity (i.e. scuba diving, mountain climbing, parachuting, etc.).
    ll) All injuries sustained as a result of an assault by a third party, provoked directly or indirectly by the Member. mm)Treatment of injuries or illnesses resulting from war or any combat-related activities while in military service.
    nn) Treatment of injuries resulting from directly or indirectly participating in strikes, riots and other civil disturbances.
    oo) Financial responsibility for medical care covered by Medicare and Employee’s Compensation Act Benefits already enjoyed by the Member by reason of compulsory coverage therein.
    pp) All government-funded healthcare
entitlements as provided by law.

OTHER PROVISIONS:
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 membership has lapsed for failure to pay a Membership fee on a due date may apply to reinstate his or her membership within forty-five (45) days from the date his membership is considered lapsed by (a) submitting a written request for reinstatement; (b) paying the membership fee due with arrears; (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 days from the effective date of reinstatement.