OUT PATIENT

Medically necessary consultations, including pre and post natal

consultations during regular clinic hours, except prescribed
medicines.
Eye, ear, nose and throat (EENT) treatment prescribed by an
Accredited Physician/Specialist
Pre and Post Natal consultations covered up to 14 sessions per
member per year
Treatment for minor injuries such as lacerations, mild burns,
sprains and the like.
X-Ray, laboratory examinations, routine, diagnostic and
therapeutic procedures prescribed by an accredited
physician/specialist
Minor surgery not requiring confinement prescribed by an
Accredited Physician / Specialist.
Eye laser therapy for retinal hole, retinal detachment and
glaucoma, excluding eye correction such as Lasik, PRK and the like,
prescribed by an Accredited Physician/Specialist up to Php 10,000
per eye per member per year.
Physical therapy / Occupational therapy excluding subspecialties
such as cardiac rehabilitation, pulmonary rehabilitation and the
like. Shared limit of up to twelve (12) sessions per member per
year subject to MBL.
Cauterization of warts, except genital warts and condyloma
acuminata, prescribed by an Accredited Physician/Specialist up to
Php 1,000 per member per year.
Allergy testing / allergy screening and other related examinations
prescribed by an Accredited Physician up to Php 2,500 per
member per year.
Tuberculin test prescribed by an Accredited Physician up to
Php 600/member/year
Speech therapy (for stroke patients only) shall be covered as
charged up to 12 sessions/member/year(reimbursement basis)
Sclerotherapy for varicose veins (except medicines and for
cosmetic purposes) as prescribed by an Accredited Physician to be
availed through accredited Vascular Surgeons up to Php 30,000
/member/year

*Note: All room upgrading on an elective/ non-emergency case will not

be covered.
========================================================================================

AVAILMENT PROCEDURE (Non-Emergency Cases)

1. Secure Admitting Order from a Maxicare Accredited Specialist.
2. Call Maxicare at least 24 hours prior to admission for assistance in securing
the entitled room assignment and other verifications regarding the
coverage.
3. Member goes to the Admitting Section in the hospital and presents his
Maxicare swipe card/any valid ID and admitting order from the Maxicare
Coordinator/ Specialist to the admitting staff.
4. Hospital staff swipes the card on the POS terminal to verify members
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 hospitals
advice on the members confinement.
7. File PhilHealth on or before discharge.
8. All non-coverable and excess charges must be settled by the member
upon discharge.(extra food, extra pillow/blanket, etc.)

ANNUAL CHECK-UP

================================================================================

1.

2.
3.

4.
5.
6.
7.
8.
9.

AVAILMENT PROCEDURE
To avail of consultations or treatment, go to any Maxicare accredited
Clinics/Hospitals or Maxicare Primary Care Centers (PCC) and help desks
and secure the Letter of Approval (LOA). You may also secure LOA thru
the website by registering/visiting the Maxicare member gateway
(www.maxicare.com.ph). Present the Maxicare ID card, company ID and
any valid ID.
Member goes to the POS terminal in the hospital/clinic or at the PCC.
Hospital staff swipes the members magnetized 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.
Member proceeds to the Medical Coordinators clinic and presents his LOE
and Maxicare card for consultation.
If referred to an accredited Specialist, secure LOE and Referral Slip* from
the Medical Coordinator/ PCC.
Present Maxicare ID Card, LOE and Referral Slip to accredited Specialist to
avail of consultation.
If member is requested to take a laboratory test, secure the Laboratory
Slip* from the Medical Coordinator/ PCC.
Proceed to the laboratory and present the laboratory slip with the LOE and
avail of the test.
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 are necessary in order for the doctor to know that
Maxicare is to be billed for the procedure and is valid for three (3) days
upon issuance.
IN PATIENT

Room and Board accommodation subject to the members room

and board limit
Use of Operating and Recovery Rooms
Use of Intensive Care Unit (ICU) or isolation room
Dressings, conventional casts (plaster of Paris) and sutures.
Professional Fees of attending accredited doctor(s)
Drugs and medicines for use in the hospital
Anaesthesia, oxygen, and its administration
Standard nursing services
Standard admission kit
X-ray, laboratory examinations, routine, diagnostic and
therapeutic procedures incidental to confinement
Other supplies directly related to the medical management of
the patient

This must be scheduled and coordinated with Maxicare by the Companys

HR

PREVENTIVE CARE

Periodic monitoring of health problems

Health education and counselling on diet and exercise
Family planning counselling
Wellness programs
EMERGENCY CARE

A. ACCREDITED HOSPITAL
Doctors 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
Active and Passive Vaccines for treatment of tetanus and animal
bites covered up to Php 18,000/member/year
Ambulance service up to MBL (Accredited Hospital/Clinic to
Accredited Hospital/Clinic) / Ambulance service Reimbursable up to
Php 2,500 per conduction (Non-Accredited Hospital/Clinic to
Accredited Hospital/Clinic).
Note: If there is no available room based on the members room and
board entitlement, Maxicare shall allow the member to upgrade to the
next room category without any additional cost for the 1st 24 hours
only.

PLAN TYPE
Platnum1

ROOM & BOARD

Open Private

MBL
200,000

Platnum2

Open Private

150,000

Platnum3

Open Private

130,000

B. NON-ACCREDITED HOSPITAL
Maxicare shall reimburse 80% of the total hospital bills and of
professional fees based on Maxicare rates up to Php 30,000
(reimbursement basis)

Note: It is very important that you call the Maxicare Hotline within 24
hours in order for the Customer Care to arrange the transfer from the
Non-Accredited Hospital to an Accredited Hospital.
C. OUTSIDE THE PHILIPPINES
Coverage for Outside the country availment is Up to MBL

D. AREAS WITHOUT ACCREDITED HOSPITALS (within the Philippines)

Maxicare shall reimburse 100% of the total hospital bills and of

professional fees based on maxicare rate up to MBL.

=====================================================

AVAILMENT PROCEDURE
(Emergency Cases)
A. ACCREDITED HOSPITAL
1. Go to Emergency Room (ER) of nearest Accredited Hospital.
2. Present Maxicare ID Card/Valid ID to ER Staff
3. If the Maxicare card is not on hand, kindly declare to the ER staff that
member is under Maxicare
4. Avail of treatment at Emergency Room.
5. ER personnel will facilitate swiping for the LOE.
6. Proceed to ER for further treatment.
7. File PhilHealth before discharge.
B. NON-ACCREDITED HOSPITAL
1. Go to Emergency Room of nearest hospital.
2. Avail of treatment at the Emergency Room.
3. If confinement is necessary, call Maxicare within 24 hours for assistance to
arrange the transfer to an accredited hospital.
4. Settle all ER fees and secure all original pertinent documents related to the
availment (i.e, Medical Certificate, Official Receipts, etc)
5. Forward all original documents and the Claim for Reimbursement Form to
Maxicare within 30 calendar days upon discharge.

DENTAL BENEFIT
STANDARD PACKAGE

Annual Dental examination and Consultations

Emergency out-patient dental treatment to be availed at
accredited dental clinics only.
Oral Prophylaxis
Simple tooth extractions
Restorative and Prosthodontic treatment Planning
Temporary Fillings unlimited
Desensitization of Hypersensitive up to 2 teeth
Simple adjustment of dentures
Recementation of loose crowns
Dental Nutrition and Dietary
Dental Health Education

Kindly schedule an appointment with the preferred Dentists prior to

availment. For inquiries, please call the contact details indicated below.
Maxicare Health Partners
(02)711-0025 to 28 / 0917-5385111
SPECIAL PROCEDURES

Therapeutic Procedures such as Dialysis,

Intravenous
Chemotherapy and Radiotherapy (cobalt, iodine, radioactive
cesium, linear accelerator therapy, brachytherapy) up to MBL
Speech therapy (for stroke patients only) shall be covered as
charged but on reimbursement basis up to 12
sessions/member/year
LIFE INSURANCE

Group Life

Php 10,000

REIMBURSEMENT GUIDELINES
1. Reimbursements must be filed within 30 calendar days from date of
availment or date of discharge. Otherwise, the reimbursement will
be forfeited.
2. Not all procedures may be reimbursed (i.e. consultations are not
reimbursable).

3. Reimbursement are only allowed for emergency cases availed at

Non accredited hospitals.
4. Requirements for Reimbursements:
1. Filled out Claims Reimbursement Form with signature of the attending
Physician and diagnosis
2. Medical Certificate indicating the diagnosis & procedure done (if any)
3. Original BIR-registered Official Receipts (with TIN#)
4. Statement of Account (summary of HB charges)
5. Charge slips or detailed itemized breakdown of charges (charges per item
paid)
6. Police Report (for cases of assault & vehicular accidents
7. Operative report (for surgical cases)
8. Clinical Abstract/History
9. Certification of non-availability of medicines from hospital pharmacy &
Original prescriptions signed by attending physician (for IP meds. bought
outside the hospital)
5. Submit the complete reimbursement forms and documents to:
Mr. Erick Payumo, Sales Support Department (6th Floor, 203
Maxicare Tower, Salcedo Street Legaspi Village, Makati City)
For inquiries regarding reimbursements, please call Maxicare
Claims Department at (02) 908-6900 loc 1116.
Pre-Existing Conditions

Pre Existing Dreaded and Non-dreaded Conditions Coverage:

a.)
For Existing members and New Employees : 100%
covered up to MBL

ELIGIBLE ENROLLEES
Employees
18 up to 65 years old
Dependents:
Spouse up to 65 years old
Single and unemployed children 15 days up to 21years old
Parents for single employees
Overage aged parents 66 to 70 years old
New dependents should be enrolled within 30 days from:
Date of marriage for newly married employees
15 days after date of birth for new born dependents
Date of appointment for newly eligible employees
FREQUENTLY ASKED QUESTIONS
How do I know if a certain diagnostic procedure requested by your
accredited doctor is covered under my program?
For inquiries on your benefit coverage, you can call our Call Center
hotlines (02.582.1900 and 02.798-7777). Our Call Center Specialists will
ask for your medical details to assess coverage of your availment based
on your Maxicare program.
What do you mean by Confinement or Hospitalization?
A person is said to be confined or hospitalized if he admitted in a
hospital as a registered bed patient for at least twelve (12) hours.
What do you mean by latest Modality?
A medical procedures defined as:
1. Available only to one or two tertiary medical care facilities
2. Requires the specialized skills from specialized personnel and :
3. Is sanctioned and recognized as a significant medical update and part
of the standard clinical practice guidelines by the corresponding clinical
and academic society or association responsible for certifying practicing
specialist physicians
Is it true that EENT, Neurologists and Urologists issued a
memorandum to all HMOs stating that they will charge extra
professional fees?
Yes, and to avoid this, please coordinate with our Customer Care
Department before each availment in order for them to make
arrangements with a doctor who does not charge extra fees.
What do I do if lose my Maxicare ID card?
You have to fill up the Maxicare Statement of Lost ID card and sumbit it
to the Maxicare Head Office together with Php 100 as payment for the
lost ID card. Your new ID card will be issued within 7 working days from
e date the necessary document were forwarded to Maxicare Head
Office, provided that all requirements are complete. If you wish to avail

of Maxicares services while your card has not arrived, call the Customer
Care Hotline (02-582.1900 and 02-798-7777) first before seeking
consultation. In an emergency, instruct Companion to contact
Maxicare.
Are your hotlines available even at midnight?
Our Call Center operates 24/7 and is manned by our Call Center
Specialists who are highly trained to assist you in any of your medical
availments.
Are you open on weekends?
Our Primary Care Centers and Maxicare Coordinators clinics are open
from Monday to Saturday. Our coordinators contact details and clinic
schedules are listed in websites Accredited Providers page
(www.maxicare.com.ph).
EXCLUSION CONDITIONS
1.

2.

3.
4.
5.

6.

7.

8.

9.

10.

11.

12.
13.

14.

15.

16.
17.

Services obtained for non-emergency conditions from Physicians and Hospitals in

any of the following circumstances: 1)Non-Accredited Physicians and NonAccredited Hospitals, 2) Non-Accredited Physicians and Accredited Hospitals, 3)
Accredited Physicians and non-Accredited Hospitals or other non accredited
healthcare facility.
Additional hospital charges resulting from: room upgrading beyond members
allowable time during emergency care, extension of hospital stay despite release
of discharge order from members attending physician, 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 sugject to the prior approval of Maxicare, extensin of hospital
stay despite release of discharge order from Members attending physician,
additional personal confort tems such as additional telephone and TV, etc. not
ordinarily included in the Members Room and Board Accomodation, use of extra
bed , TV, electric fan, DVD / VCD and other similar tems unless such appliances
and tems are necessarily and ordinarily included in the Members Room and
Board Accomodation, extra food, toilets article like face towel, soap, toothbrush
and the like; difference in room and board, the incremental rate differences for
the profesional fees, diagnostic and laboratory examinations, and other ancillary
medical services brought about by obtaining a room accomodation higher than
the Members Room and Board Accomodation limit, services of a prvate or a
special nurse and all other tems not medically necessary in the medical
management of the patient.
Custodial, domiciliary, convalescent and intermediate care.
Long-term rehabilitation and Psychiatric care.
Treatment resulting from self-inflicted injuries (including infections or
complications 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 selfdestruction, 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 which is proved to be attributable to the
Members own misconduct such as gross negligence, alcohol intoxication,
intemperate use of drugs or alcoholic liquor including alcoholism and drug
addiction or substance, direct or direct participation in the commission of a crime
whether consummated or not, violation of a law or ordinance, and unnecessary
exposure to imminent danger or hazard to health.
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.
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.
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.
Experimental medical procedures and its complications.
Acupuncture, chirotherapy and other forms of rehabilitation therapies and its
complications.

All expenses incurred in the process of organ donation and transplantation

if the Member is the donor of suh donation or transplantation, its
complications.
Routine physical examinations required for obtaining or continuing
employment, requirement in school, insurance or government licensing,
health permit and other similar purposes.
Purchase or lease of durable medical equipment, oxygen dispensing
equipment, and oxygen except during covered Inpatient Care.
Corrective appliances, artificial aids, prosthetic appliances such as but not
limited to artificial limbs, hearing aids, intraocular lens, eyeglasses, contact
lenses, braces, crutches, pace maker, pins, screws, plates, wires, balloons,
valves, knee-tibial insert for total knee arthoplasty, orthopedic internal
fixator/fixation systems, orthopedic external fixator/ fixation systems,

18.

19.
20.
21.

22.
23.
24.
25.

26.
27.

28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.

bone screws and plates, vascular grafts/stents, intravascular catheters,

myringotomy tube.
Take-home medicine and outpatient medicine except 1)intravenous
medicine 2)oral chemotherapy medicine, and 3)medicine administered
during an emergency treatment.
Congenital diseases, abnormalities and their complications (except
hernias) affecting functions of individuals.
All physical deformities prior to enrollment.
Treatment of injuries/illnesses caused directly or indirectly by engaging in
any hazardous sport or activity such as but not limited to scuba diving,
surfing, water skiing, mountain climbing, rock climbing, mountaineering,
parachuting, airsoft, drag racing, painballing, wakeboarding and bungee
jumping, except for activities under company-sponsored sports activities.
Injuries resulting from direct participation in riots, strikes and other civil
disturbances.
Treatment of injuries or illnesses resulting from war, or any combat
related activities while in military Service.
Sexually transmitted diseases, AIDS and AIDS related diseases.
Valvular heart disease (congenital and/or acquired) including
Cardiomyopathies, Chronic Glomerulonephritis, previous craniotomy
sequelae/hearing impairement/Neurologic disease and Spinal Stenosis (if
pre-existing)/Poliomyelitis /Slipped disc(if pre-existing) and Gullain-Barre
Syndome, 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 of Chronic Dermatoses.
Infectious diseases (according to the local epidemiologic patterns) that
may arise in times of an epidemic or pandemic (i.e. Avian Flu,
Meningococcemia, etc.) as declared by Department of Health, World
Health Organization or any recognized health organization.
Pre-existing 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 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 for immunization including its administration.
Cost of medico-legal cases.
All screening test.
Treatment of work related injuries of high-risk occupations such as but not
limited to construction workers, miners, loggers and drillers.
Cost of medical services and professional fees in excess of the MBL.
Intravenous Immunoglobulin
IMPORTANT: This is merely a summary of your healthcare Benefits. All
provisions in the contract shall prevail during actual availment.

================================================================

CUSTOMER CARE HOTLINES

(02) 582-1900
(02) 798-7777
24/7 MOBILE NUMBER
(0918) 907-2652
TOLL FREE NUMBER (for Provincial Inquiries)
1-800-10-582- 1900 (PLDT)
1-800-8-582-1900 (GLOBE)
================================================================

CALAMBA MEDICAL CENTER

Ground Floor, Central Registration
Crossing, Calamba City
(02) 584-4109 local1207
CAPITOL MEDICAL CENTER
Quezon Avenue corner
Scout Magnabua
Quezon City
(02) 3723825 loc 5101
(02) 5069942

ACCOUNT MANAGEMENT TEAM:

Prislette Rosero - Account Management Officer
Email: prislette.rosero@maxicare.com.ph
Tel. #: 908-6900 loc.1116
Arlenne V. Custodio- Account Management Manager
Email: arlenne.custodio@maxicare.com.ph
Tel. #: 908-6900 loc.1107

MANILA DOCTORS HOSPITAL

Room 220, Manila Doctors
Hospital
(02) 542-3011 loc 4510
UNIVERSITY OF STO. TOMAS
Espana Boulevard, Manila
(02) 731 3001 loc 2508
(02) 383 4032

HEALTHCARE PROGRAM

CARDINAL SANTOS MEDICAL CENTER

Ground Floor, Main Hospital Building, Cardinal
Santos Medical Center Wilson St., Greenhills West
San Juan City
(02) 506-9948

FOR

================================================================
MAXICARE PRIMARY CARE CENTERS

============================================================

SALES AND ACCOUNT MANAGEMENT TEAM

HEALTHCARE PROGRAM

MAXICARE HELPDESK
Following helpdesks are authorized to issue Letter of Authorization (LOA)

MAKATI MEDICAL CENTER (In-Patient)

1st Floor Tower One Makati Medical Center, Amorsolo Street,
Makati City
Tel. Nos: (02) 893-6064/ 893-9820/ (02) 888-8999 loc 2109 & 2110
FILOMENA BUILDING (Out Patient)
Filomena Bldg, Amorsolo St. Legaspi Village, Makati City
Tel Nos: (02) 893-3898 / (02) 893-4858
THE NEW MEDICAL CITY
MGR04, Ground Floor, Medical Arts Tower I (MATI), Ortigas Avenue, Pasig
Tel Nos: (02) 635-6789 loc 5073/ (02) 706-1526/(02) 706-5080
ST. LUKES MEDICAL CENTER
Room 1501, North Tower, Cathedral Heights,
Quezon City
Tel. Nos: (02) 723-5329/ (02) 723-0101 loc 5151
CHINESE GENERAL HOSPITAL
10th Floor Medical Arts and Parking Building,
Chinese General Hospital, Sta. Cruz, Manila
Tel. Nos: (02) 567-6286 to 87
ASIAN HOSPITAL & MEDICAL CENTER
Lower Ground Floor, Asian Hospital & Medical Center
2205 Civic Drive, FCC Alabang, Muntinlupa
Tel. Nos.: (02) 836-7493
MY HEALTH CLINIC SHANGRILA
Unit 146, Shangri-La Plaza Mall, Shaw corner Edsa Boulevard, Mandaluyong
City
Tel. Nos: (02) 570-4325/710-9137
MY HEALTH CLINIC FESTIVAL MALL
A-3 Level 2 Style Boulevard, Festival Supermall, Filinvest Corporate City,
Alabang, Muntinlupa City
Tel. Nos.: (02) 850-4855
MY HEALTH CLINIC- NORTH EDSA
2nd Floor, North Link Building F, SM City
North Edsa, North Avenue, Quezon City
Tel. Nos.: (02) 441-4106
MY HEALTH CLINIC- ROBINSONS CYBERGATE
3rd Floor Robinsons Cybergate Mall, fuente Osmena St.,Cebu City
Tel. Nos.: (032) 268-8502 to 03

REED ELSEVIER SHARED SERVICES

PHILS INC.
December 1, 2014 November 30, 2015

MAXICARE HEALTHCARE CORPORATION

Maxicare Tower
203 Salcedo Street,
Legaspi Village, Makati City
(02) 582-1900/ (02) 798-7777

SALES:
Angelica Cruz -Accounts Officer
Email: angelica.cruz@maxicare.com.ph
Tel. #:908-6900 loc. 1106
Paul Bryan Lorenzo -Sales Manager
Email: bryan.lorenzo@maxicare.com.ph
Tel. #:908-6900 loc. 1163
Mobile Number: 0917-5873958

Arranged by: