16 June 2018

MR/MS. NAME
Position
COMPANY
Address

Thru: Agent name / Broker Name,

Accredited Independent Agent / Health Benefit Agent / Accredited Broker

Dear Mr/Ms. Surname:

We trust this finds you in good health.

For the past twenty-eight (28) years now, Maxicare has continued its legacy of
providing the most comprehensive healthcare benefits, through our
Medical Providers nationwide, composed of 16,714 Affiliated Specialists, Fellows and
Diplomates and more than 759 hospitals and clinics nationwide, and excellent delivery
system through superior Customer Service, highlighted by a 24 hour, seven days a week
call center. It is the primary concern and objective of Maxicare to attend to our
members’ healthcare needs through our brand of premium quality care.

With stability and service excellence combined – the distinguished medical consultants
in the Philippines’ medical field and esteemed businessmen in different industries as
our major shareholders, and the country’s prestigious medical institutions as the
foundation of our service delivery – Maxicare remains to be the healthcare company of
choice of the Best Employers in Asia and the Philippines and the country’s Top 2,000
companies.

You will find the details of the program for reference. We are looking forward for a
presentation with your good office to discuss the pertinent details of the program, and
how we may link up for an efficient and cost-effective administration of your employee
healthcare requirements.

Thank you and looking forward to seeing you soon.

389994186.xls 06/16/2018 02:55:43

Maxicare Healthcare Corporation
 MAXICARE STARTER PLAN (5-9)
SALIENT FEATURES & MEMBERSHIP FEES

OPTION 1

Nationwide access to all accredited hospitals/clinics including 9 major hospitals (Asian Hospital & Medical Center, The
Medical City, St. Luke's Medical Center - Quezon City, St. Luke's Medical Center - Global City, Makati Medical Center,
Cardinal Santos Medical Center, Cebu Doctors Hospital, Chong Hua Hospital & Davao Doctors Hospital) Without access to
Healthway clinics

RATES FOR EMPLOYEES PER HEAD

Maximum
Plan Type Room and Board Annual Check-up Annual Semi-Annual
Benefit Limit
Platinum Small Suite Routine (Clinic) 230,000 22,605 12,207
Platinum Large Private Routine (Clinic) 185,000 18,783 10,143
Gold Regular Private Routine (Clinic) 160,000 16,954 9,156
Gold Regular Private Routine (Clinic) 110,000 16,008 8,645
Silver Semi-Private Routine (Clinic) 90,000 13,277 7,170
Silver Semi-Private Routine (Clinic) 70,000 12,892 6,962
Bronze Ward Routine (Clinic) 60,000 10,888 5,880
RATES FOR DEPENDENTS PER HEAD
Maximum
Plan Type Room and Board Annual Check-up Annual Semi-Annual
Benefit Limit
Platinum Small Suite Routine (Clinic) 230,000 30,971 16,725
Platinum Large Private Routine (Clinic) 185,000 25,367 13,699
Gold Regular Private Routine (Clinic) 160,000 22,829 12,328
Gold Regular Private Routine (Clinic) 110,000 21,883 11,817
Silver Semi-Private Routine (Clinic) 90,000 17,623 9,517
Silver Semi-Private Routine (Clinic) 70,000 17,237 9,309
Bronze Ward Routine (Clinic) 60,000 14,375 7,763

OPTION 2

Nationwide access to all accredited hospitals/clinics excluding 9 major hospitals (Asian Hospital & Medical Center, The
Medical City, St. Luke's Medical Center - Quezon City, St. Luke's Medical Center - Global City, Makati Medical Center,
Cardinal Santos Medical Center, Cebu Doctors Hospital, Chong Hua Hospital & Davao Doctors Hospital). Without access to
Healthway clinics

RATES FOR EMPLOYEES PER HEAD

Maximum
Plan Type Room and Board Annual Check-up Annual Semi-Annual
Benefit Limit
Platinum Small Suite Routine (Clinic) 230,000 17,421 9,408
Platinum Large Private Routine (Clinic) 185,000 14,595 7,882
Gold Regular Private Routine (Clinic) 160,000 13,203 7,130
Gold Regular Private Routine (Clinic) 110,000 12,542 6,773
Silver Semi-Private Routine (Clinic) 90,000 10,520 5,681
Silver Semi-Private Routine (Clinic) 70,000 10,224 5,522
Bronze Ward Routine (Clinic) 60,000 8,748 4,724
RATES FOR DEPENDENTS PER HEAD
Maximum
Plan Type Room and Board Annual Check-up Annual Semi-Annual
Benefit Limit
Platinum Small Suite Routine (Clinic) 230,000 23,615 12,753
Platinum Large Private Routine (Clinic) 185,000 19,466 10,512
Gold Regular Private Routine (Clinic) 160,000 17,550 9,477
Gold Regular Private Routine (Clinic) 110,000 16,887 9,119
Silver Semi-Private Routine (Clinic) 90,000 13,736 7,418
Silver Semi-Private Routine (Clinic) 70,000 13,438 7,257
Bronze Ward Routine (Clinic) 60,000 11,326 6,116
Notes:
• Rates and benefits are valid up to SEPTEMBER 30, 2017 and based on a 12-month coverage only.

• Above rates are applicable for accounts beginning 5 to 9 employees only even if the combined total enrollees for both
Principals and Dependents would be greater than 99 during inception period.
• Rates presented above are inclusive of 12% VAT
• No access to Healthway Clinics
• In case an extraordinary inflation or deflation of the Philippine Peso should supervene during the term of this agreement,
Maxicare shall be authorized to adjust the Membership fees accordingly or shall be released in whole or in part, from
performance of its obligation, when such has become so difficult on its part as to be manifestly beyond that contemplated in
this Agreement. Extraordinary inflation or deflation shall be conclusively presumed to have supervened if the exchange rate
of the Philippine Peso to the U.S. Dollar should change by more than twenty-five percent (25%) during any twelve (12)
month period.

• In case accredited hospitals increase their rates by more than thirty percent (30%), Maxicare shall be authorized to adjust
the membership fees accordingly or exclude such accredited hospital where a Member can seek medical services from,
accroding to the option chosen by the Client. In this circumstance, Maxicare shall notify the Client in writing at least fifteen
(15) days from effectivity of membership fee adjustment or exclusion of such accredited hospital.

• Benefit program should be in uniform basis or superior accordingly to their rank classification.
• Enrollment of Dependents must follow hierarchy
• Special Provision for the enrollment of additional dependents: There will be a 30 days grace period to enroll their eligible
dependents. Otherwise, only newly wed, newly born, and dependents of newly regularized employees shall be considered
for enrollment after 30 days grace period.

• Dependents' benefits should be on a uniform basis or superior accordingly to their rank classification.
• Escalation Clause: Should there be a significant decrease in the number of enrollees per membership type and/ or did not
meet the existing participation requirement in enrolling of eligible dependents, the following adjustment clause shall apply:

The dependent fees presented above will be applicable if 75% participation requirement is met. Otherwise, the below
provision shall apply:
at least 75% standard rates
60% - 74.9% + 10% to standard rates
40% - 59.9% + 20% to standard rates
Below 40% + 35% to standard rates

Riders:
Benefit (inclusive in rates)
Annual Check up (Routine Clinic)
Standard Dental
Life with AD&D - Php 25,000
 MAXICARE STARTER PLAN
SUMMARY OF BENEFITS

HEALTHCARE BENEFITS MAXICARE'S COVERAGE

A. OUT-PATIENT CARE
1 Consultations during regular clinic hours, except prescribed medicines Subject to MBL
2 Pre and Post Natal consultations Subject to MBL
Eye, ear, nose and throat (EENT) treatment prescribed by an Accredited
3 Subject to MBL
Physician/Specialist
Treatment for minor injuries such as lacerations, mild burns, sprains and
4 Subject to MBL
the like
5 Dressings, conventional casts (plaster of Paris) and sutures. Subject to MBL
X-Ray, laboratory examinations, routine, diagnostic and therapeutic
procedures prescribed by an Accredited Physician/Specialist, provided
6 Subject to MBL
however that the cost of diagnostic and therapeutic procedures covered
shall be limited to a specific amount.
Minor surgery not requiring confinement prescribed by an Accredited
7 Subject to MBL
Physician / Specialist
Eye laser therapy only for retinal tear, retinal hole, retinal detachment
8 and glaucoma prescribed by an Accredited Physician/Specialist. Eye Up to Php 10,000 /eye /member /year
correction such as Lasik, PRK and the like are not covered.
Electrocauterization of skin lesions such as plantar warts, flat warts,
periungual warts, filiform warts and molluscum contagiosum, in any part
9 Up to Php 1,000 /member /year
of the body, except genital warts and condyloma acuminata, prescribed
by an Accredited Physician/Specialist.
Sclerotherapy for varicose veins (except medicines and for cosmetic
10 purposes) as prescribed by an Accredited Physician, to be availed Up to Php 5,000 / leg / member / year
through accredited vascular surgeons.
Allergy Testing/ allergy screening and other related examinations
11 Up to Php 2,500 / member / year
prescribed by an Accredited Physician
Covered as charged up to Php 10,000 / member / year (reimbursement basis)
12 Speech therapy (for stroke patients only)
Note: Consultations shall be part of the limit and treated as sessions
13 Tuberculin test Up to Php 600 / member / year

B. IN-PATIENT CARE
1 Room and Board Accommodation Subject to the Member's Room and Board limit
Use of operating room, Intensive Care Unit (ICU), isolation room (if
2 Subject to MBL
prescribed by attending Accredited Physician) and recovery room.
3 Professional fees in accordance with Maxicare Schedule of Rates.
a. Attending Physicians Subject to MBL
b. Surgeons Subject to MBL
c. Anesthesiologists Subject to MBL
d. Cardio-pulmonary clearance before surgery and cardiac monitoring
Subject to MBL
during surgery.
4 Standard Nursing Services Subject to MBL
5 Medicines for in-patient use Subject to MBL
Blood products transfusions and intravenous fluids, including blood
6 Subject to MBL
screening and cross matching.
X-Ray, laboratory examinations, routine, diagnostic tests and therapeutic
7 Subject to MBL
procedures incidental to confinement
8 Dressings, conventional casts (plaster of Paris) and sutures Subject to MBL
9 Anesthesia and its administration Subject to MBL
10 Oxygen and its administration Subject to MBL
11 Standard Admission kit Subject to MBL

All other items directly related in the medical management of the patient,
12 Subject to MBL
as deemed medically necessary by the attending Accredited Physician

C. ROUTINE PROCEDURES (whether IP or OP)

1 Blood Chemistries 100% of Actual Cost subject to MBL
2 Chest X-Ray 100% of Actual Cost subject to MBL
3 Complete Blood Count (CBC) 100% of Actual Cost subject to MBL
4 Fecalysis 100% of Actual Cost subject to MBL
5 Urinalysis 100% of Actual Cost subject to MBL

D. DIAGNOSTIC PROCEDURES
 1 12-Lead Electrocardiogram (ECG) 100% of Actual Cost subject to MBL
2 24-Hour Electroencephalogram (EEG) Monitoring 100% of Actual Cost subject to MBL
3 24-hour Holter Monitoring 100% of Actual Cost subject to MBL
4 Adrenocortical Function 100% of Actual Cost subject to MBL
5 Anti-Nuclear Antibody, C-Reactive Protein, Lupus Cell Exam 100% of Actual Cost subject to MBL
6 Arterial Blood Gas 100% of Actual Cost subject to MBL
7 Arthroscospic Procedures, Orthopedic Arthroscopy 100% of Actual Cost subject to MBL
8 Audiograms and Tympanograms 100% of Actual Cost subject to MBL
9 Bone Densitometry Scan (Dexascan) 100% of Actual Cost subject to MBL
10 Bone Mineral Density Studies 100% of Actual Cost subject to MBL
11 Cardiac Stress Tests (Thalium and Dipyridamole Stress Tests) 100% of Actual Cost subject to MBL
12 Computed Tomography Scans 100% of Actual Cost subject to MBL
13 Diagnostic Radiographs:
a. Biliary tract: Cholecystogram and Cholangiogram 100% of Actual Cost subject to MBL
b. Chest, ribs, sternum and clavicle 100% of Actual Cost subject to MBL
c. Digestive: Plain film of the abdomen, Barium Enema, Upper GI Series,
100% of Actual Cost subject to MBL
Lower GI Series, Small Bowel series
d. Face (including sinuses), Head and Neck 100% of Actual Cost subject to MBL

e. Urinary: Kidney, Ureter, Bladder (KUB), Pyelograms and Cystograms 100% of Actual Cost subject to MBL

f. X-ray of the extremities and pelvis 100% of Actual Cost subject to MBL
g. X-ray of the spine (cervical, thoracic, lumbo-sacral) 100% of Actual Cost subject to MBL
14 Diagnostic Ultrasounds:
a. 2D-Echo with Doppler 100% of Actual Cost subject to MBL
b. Abdomen 100% of Actual Cost subject to MBL
c. Duplex Scan 100% of Actual Cost subject to MBL
d. Digestive and Urinary Systems 100% of Actual Cost subject to MBL
e. Ultrasound of the Lungs 100% of Actual Cost subject to MBL
15 Electroencephalogram (EEG) Monitoring 100% of Actual Cost subject to MBL
16 Electromyelography and Nerve Conduction Studies 100% of Actual Cost subject to MBL
17 Endoscopic Procedures 100% of Actual Cost subject to MBL
18 Fluorescein Angiography 100% of Actual Cost subject to MBL
19 Impedance Plethysmography 100% of Actual Cost subject to MBL
20 Magnetic Resonance Angiography (MRA) 100% of Actual Cost subject to MBL
21 Magnetic Resonance Imaging (MRI) 100% of Actual Cost subject to MBL
22 Mammography and Sonomammogram 100% of Actual Cost subject to MBL
23 Myelogram 100% of Actual Cost subject to MBL
24 Nuclear Radioactive Isotope Scan 100% of Actual Cost subject to MBL
25 Pap's Smear 100% of Actual Cost subject to MBL
26 Perfusion Scan 100% of Actual Cost subject to MBL
27 Plasma Urinary Cortisol, Plasma Aldosterone 100% of Actual Cost subject to MBL
28 Polysomnograms (Sleep Recording) 100% of Actual Cost subject to MBL
29 Pulmonary Function Tests 100% of Actual Cost subject to MBL
30 Radioisotope Scans and Function Studies:
a. Cardiac 100% of Actual Cost subject to MBL
b. Gastrointestinal 100% of Actual Cost subject to MBL
c. Liver 100% of Actual Cost subject to MBL

d. Parathyroid Bone, Pulmonary (Perfusion/ Ventilation Lung Scans) 100% of Actual Cost subject to MBL

e. Renal 100% of Actual Cost subject to MBL

f. Thyroid Scans 100% of Actual Cost subject to MBL
g. Total Body Scans 100% of Actual Cost subject to MBL
31 Radionuclide Ventriculography 100% of Actual Cost subject to MBL
32 Surface Electromyography (SEMG) 100% of Actual Cost subject to MBL
33 Thallium Scintigraphy 100% of Actual Cost subject to MBL
34 Treadmill Stress Test (TMST) 100% of Actual Cost subject to MBL

E. THERAPEUTIC PROCEDURES
1 Arthrocentesis Up to six (6) sessions subject to MBL for OP; Up to MBL for IP
2 Dialysis Up to MBL shared limit for OP and IP
3 Intravenous Chemotherapy Up to MBL shared limit for OP and IP
4 Phlebotomy Up to six (6) sessions subject to MBL for OP; Up to MBL for IP
Shared limit of up to twelve (12) sessions/member/year subject to MBL for OP;
Physical therapy / Occupational therapy excluding subspecialties such as
5 Up to MBL for IP.
cardiac rehabilitation, pulmonary rehabilitation and the like.
Note: Therapy of one (1) body area shall be considered as one (1) session.
6 Thoracentesis Up to six (6) sessions subject to MBL for OP; Up to MBL for IP
7 Therapeutic Radiology:
 a. Brachytherapy Up to MBL shared limit for OP and IP
b. Cobalt Up to MBL shared limit for OP and IP
c. Linear Accelerator Therapy Up to MBL shared limit for OP and IP
d. Radioactive Cesium Up to MBL shared limit for OP and IP
e. Radioactive Iodine Up to MBL shared limit for OP and IP
8 Continuous Positive Airway Pressure (CPAP) Up to Php 60,000 shared limit for OP and IP
9 Oral Chemotherapy Up to Php 60,000 shared limit for OP and IP

F. ANNUAL CHECK-UP (OPTIONAL, SEPARATE FEE)

* The following Routine ACU program shall be conducted at a designated Maxicare Accredited Clinic once a year:
1 Routine (clinic) which includes:
Physical Examination √
Complete Blood Count √
Urinalysis √
Fecalysis √
Chest X-ray √
ECG Applicable for members 35 years old and above
Pap Smear Applicable for members (women) 35 years old and above
Can be availed under Fee for Service. Billing shall be based on actual cost plus
2 Pre-employment in lieu of ACU
13.5% Claims Handling Fee

G. PREVENTIVE CARE
1 Passive and active vaccines for treatment of tetanus and animal bites Covered up to Php 20,000 / member / year
2 Periodic monitoring of health problems Covered
3 Health-education and counselling on diets or exercise Covered
4 Health habits and Family Planning counseling Covered

ADDITIONAL PROCEDURES AND MODALITIES (shared limit for OP and IP; Professional Fees, Hospital Bills and other incidental expenses relative to the
H.
procedure shall form part of the limit)

1 Angiography (gastrointestinal, brain, retinal and peripheral vascular) 100% of Actual Cost subject to MBL

Coronary Angiogram and/or Angioplasty/Coronary Artery Bypass

2 100% of Actual Cost subject to MBL
Graft
3 Cryosurgery 100% of Actual Cost subject to MBL
4 Gamma Knife Surgery 100% of Actual Cost subject to MBL
5 Hysterescopic Myoma Resection 100% of Actual Cost subject to MBL
6 Hysteroscopically-guided D&C 100% of Actual Cost subject to MBL
7 Laparoscopy 100% of Actual Cost subject to MBL
8 Lithotripsy 100% of Actual Cost subject to MBL
9 Percutaneous Ultrasonic Nephrolithotomy 100% of Actual Cost subject to MBL
10 Stereotactic Brain Biopsy 100% of Actual Cost subject to MBL
11 Conventional Hemorrhoidectomy 100% of Actual Cost subject to MBL
12 Scalpel Hemorrhoidectomy 100% of Actual Cost subject to MBL
13 Stapled Hemorrhoidectomy Covered up to Php 5,000 /member /year
14 Mammotome Covered up to Php 5,000 /member /year
15 4D Ultrasound except for maternity-related cases Covered up to Php 5,000 /member /year
16 Esophageal Manometry Covered up to Php 5,000 /member /year
17 Intensified Modulated Radiotheraphy Covered up to Php 5,000 /member /year
18 Botox which is not cosmetic in nature nor for beautification purpose Covered up to Php 5,000 /member /year
19 Positron Emission Tomography Covered up to Php 5,000 /member /year
20 CT Pulmonary Angiography Covered up to Php 5,000 /member /year
21 Photodynamic Therapy Covered up to Php 5,000 /member /year

Other medically necessary modalities not mentioned above and those for
22 Covered up to Php 5,000/ procedure /member /year
which there are no comparable, conventional or traditional counterparts

23 Transurethral Microwave Therapy of Prostate Covered up to Php 25,000 /member /year

I. EMERGENCY CARE
1 In Accredited Hospitals
a. Doctor’s services Subject to MBL
b. Emergency Room Fees Subject to MBL
c. Medicines used for immediate relief during treatment Subject to MBL
d. Oxygen, Intravenous fluids and blood products. Subject to MBL
e. Dressings, conventional casts (plaster of Paris) and sutures. Subject to MBL
f. X-Rays, laboratory and diagnostic examinations, and other medical
Subject to MBL
services related to the emergency treatment of the patient.
 g. Room Upgrade in case of room unavailability up to 24 hours

Reimbursable up to 80% of hospital bills & professional fees based on

2 In Non-Accredited Hospitals 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 /
3 Outside the Philippines
year
4 Areas without Accredited Hospital 100% based on Maxicare rates up to MBL
Ambulance Service (Accredited Hospital/Clinic to Accredited
5 Up to MBL
Hospital/Clinic)
Ambulance Service (Non-accredited Hospital/Clinic to Accredited
6 Reimbusable up to Php 2,500 per conduction
Hospital/Clinic)
Note: The ambulance service provided herein shall be available regardless of the location within the Philippines
7 Initial Treatment of Animal Bites Covered for the first 24 hrs. from the time of bite subject to MBL

J. PRE-EXISTING CONDITIONS

1 Dreaded Conditions Up to Php 5,000 / member / illness / year

Covered up to: 1st Year Up to Php 5,000 / member / illness ;

2 Non-Dreaded Conditions 2nd Year covered Up to MBL
Note: Application of PEC Coverage will be based on member's effective date

K. DENTAL CARE (OPTIONAL, SEPARATE FEE)

1 Dental examination/consultation only Covered
2 Oral prophylaxis Covered - Once a year
3 Uncomplicated tooth extraction (anterior tooth, posterior tooth, ) Covered
4 Temporary Fillings Covered, as advised by Dentist
Desensitization of hypersensitive teeth (limited to the application of
5 Up to 2 teeth
necessary medicament to the affected teeth)
6 Simple denture adjustment and repair Covered
7 Recementation of loose jacket crowns, bridges, inlays and onlays Covered
8 Palliative treatment for simple mouth sores and blisters Covered
9 Open incision and drainage (intraoral) Covered
10 Dental Nutrition and Dietary Counseling Covered
11 Dental Health Education Covered
12 Pre-natal consultation on teeth and gums Covered
13 Temporo Mandibular Joint Consultation Initial Consultation -Covered
14 Permanent Fillings 2 teeth per year

L. GROUP LIFE INSURANCE WITH ACCIDENTAL DEATH AND DISABLEMENT (AD&D) BENEFITS (OPTIONAL, SEPARATE FEE)
1 Insurance Provider The Philippine American Life & General Insurance Company
2 Death (amount of insurance) up to Php 25,000 /member
3 Corporate Personal Accidental Death & Dismemberment (AD&D)
A. Schedule of Losses for AD&D Coverage
i.) Loss of Life 100% of amount of insurance

ii.) Accidental Death, Dismemberment & Disablement or Loss of Use of Limbs

Both Hands 100% of amount of insurance

Both Feet 100% of amount of insurance
One hand and One foot 100% of amount of insurance
One hand 50% of amount of insurance
Arm between elbow and wrist 60% of amount of insurance
Arm at or above elbow 70% of amount of insurance
Leg below knee 60% of amount of insurance
Leg at or above knee 70% of amount of insurance
iii.) Loss of sight
Both eyes 100% of amount of insurance
One eye 50% of amount of insurance
iv.) Loss of speech 100% of amount of insurance
v.) Loss of hearing
Both ears 100% of amount of insurance
One ear 50% of amount of insurance
vi.) Accidental Dismemberment or Loss of Use of Fingers
All of one hand 50% of amount of insurance
vii.) Accident Permanent Total Disability Benefit
 3% of the amount of insurance (less any amount paid or payable) starting on
Monthly cash benefit to an Insured member who has been totally
the 7th month up to 32 months, and 4% of the amount of insurance on the 33rd
and permanently disabled for 6 months due to accidental causes.
month.
viii.) Murder and Homicide
Injury due to murder or any attempt thereof 100% of amount of insurance (but not exceeding 250,000)
Injury due to homicide or any attempt thereof not occasioned by
100% of amount of insurance
provocation of Insured member
ix.) Flying Coverage

Pays a benefit if the Insured member suffers an injury while a passenger boarding or alighting from a certified passenger aircraft provided by a commercial
airline on any regular, scheduled or non-scheduled, special or chartered flight and operated by a properly certified pilot flying between duly established and
maintained airports over an established passenger route.

B. Renewal Bonus
Increases the original amount of insurance for Accident Insurance (up to the first P250,000) of the Insured by 5% each year for the first five (5) consecutive
years, starting on the second year.
4 Terminal Illness Benefit

A lump sum benefit of 50% of the applicable aamount of insurance in-force up to a maximum of P250,000 if the Insured member is medically diagnosed as
terminally ill with a life expectancy of twelve (12) months or less.

5 Exclusions
Any loss or expense caused by or resulting from the following will not be paid:
i.) Suicide during the first year
ii.) War, Invasion or Act of Foreign Enemy
iii.) Service in the Armed Forces of any country or international authority whether in peace or war.
6 General Guidelines
A. Eligibility Age
Benefits:
Principals, Spouse / Parent: 18 to 69 years old; Children / Sibling: 14 days to 26
Life
years old
Principals, Spouse / Parent: 18 to 65 years old; Children / Sibling: 14 days to 26
AD&D
years old
B. Eligible Dependents
Legal spouse who are actively performing the daily normal chores of life
i.) Dependents of Married employees Children who are single, unemployed and fully dependent on the principal for
support
Parents who are actively performing the daily normal chores of life
ii.) Dependents of Single Employees Siblings who are single, unemployed and fully dependent on the principal for
support
Parents who are actively performing the daily normal chores of life
iii.) Dependents of Single Parent Employees Children who are single, unemployed and fully dependent on the principal for
support
C. The No Evidence Limit (NEL) is Php250,000
For any amount of insurance in excess of NEL, proof of good health must be submitted (i.e. accomplished Health Statement, Medical exam).

M. CONDITIONS WITH SPECIFIC LIMITATIONS

1 Work Related Conditions based on conditions covered by ECC Up to MBL (Principals only)
2 Motor Vehicular Accidents Covered subject to MBL and Exclusions and Limitations Provisions

Provoked and Unprovoked Assault, including domestic violence,

3 Up to MBL
whether initiated by the Member or by a known or unknown third party

Up to Php 40,000 /member /year (shared limit for OP and IP)

Scoliosis, including necessary procedures, except physical therapy Note: Physical Therapy sessions shall form part of the Physical therapy
4
sessions, whether congenital, pre-existing, developmental or acquired /Occupational therapy limits.

up to Php 40,000 /member /year (shared limit for OP and IP)

Congenital Conditions except physical therapy sessions and
5 Note: Physical Therapy sessions shall form part of the Physical therapy
developmental disorders
/Occupational therapy limits.
Congenital Hernia Covered up to MBL
6 Chronic Dermatoses Consultations only
7 Scabies Consultations and treatments
8 Exclusion #25 Covered up to MBL
9 Hepatitis B Covered up to MBL (if acquired)

N. ADDED PROGRAM FEATURES

1 24-Hour/7 Days a Week Customer Care Hotline √
2 Roving Customer Care Representative √
3 Manner of Access:
 a. Hospitals
more than 1,000 Hospitals (65% are tertiary hospitals) and Clinics
b. Clinics
Maxicare Primary Care Centers at Makati Medical Center, Filomena Bldg., St.
Luke's Medical Center - Quezon City, The Medical City, Chinese General
c. Primary Care Centers
Hospital, Asian Hospital, My Health Clinic - Festival Mall, My Health Clinic -
EDSA Shangri-La Plaza
d. Maxicare Centers Cebu, Bacolod, Iloilo, General Santos & Davao
e. Accredited Doctors over 27,000 accredited doctors (composed of Fellows, Diplomates)
4 PayorLink System √
5 Orientations √

6 VAT Charges Inclusive (12% of the VATable portion) of the membership fees

7 ID Processing Fee at no additional cost

8 Booklets & Summary of Coverage (SOC) 1 per principal member

O. MEMBERSHIP GUIDELINES
1 Age Eligibility
Principals 18 up to 65 years old
Adult Dependents 18 up to 65 years old
Minor Dependents 15 days old up to 21 years old
* Enrollees age 66 years old & above shall not be covered
* Dependents should be the same plan or lower than the Principals, on a per level basis.
* No coverage for extended dependents.
2 Hierarchy of Enrollment to be followed:
Legal spouse must be enrolled first, followed by the eldest to the youngest
Married Employees
child.
Both parents (anyone ahead of the other) and then the siblings (eldest to the
Single Employees
youngest)
Children (eldest to youngest) and/or Parents (anyone ahead of the other) and
Single Parent Employees
siblings (eldest to youngest)
There will be a thirty (30) days grace period to enroll their eligible dependents. Otherwise, only newly wed, newly born and dependents of newly
*
regularized employees shall be considered for enrollment after the 30 days grace period.
3 Participation Requirement

100% of all eligible employees should enroll all the eligible dependents under
a. Non-contributory accounts the program or the number of dependents should reach 75% of the total
number of principals.

At least 75% of all eligible employees should enroll all the eligible dependents
b. Contributory accounts under the program or the number of dependents should reach 75% of the total
number of principals.

MBL on top of Philhealth. Philhealth portion not deductible to the member's

4 Philhealth Integration
MBL. Required to file Philhealth
* Additional Philhealth fee on the onset of enrollment: Php 1,800 per Non-Philhealth member per year (applicable for expat members only)

P. ESCALATION CLAUSE:
1 at least 75% standard rates
2 60% - 74.9% + 10% to standard rates
3 40% - 59.9% + 20% to standard rates
4 Below 40% + 35% to standard rates
Above escalation clause shall apply and subject to change to the following cases:
a. If there is a significant decrease from initial count to actual number of enrollees. Participation requirement is computed as total number of actual enrollees
divided by total number of initial count prior effectivity of the account.
b. If enrollment of dependents is open to all employees then participation requirement is below 75%. This is regardless if account is contributory or non-
contributory. Participation requirement is computed as total number of eligible dependents divided by the number of principals that has eligible dependents
only.
c. If the account limits the dependent's enrollment on a per rank classification, participation requirement is computed as total number of eligible dependents
divided by the total number of principals of the account.

Q. ENROLLMENT GUIDELINES
1 Application Forms Waived
2 Masterlist of Enrollees Maxicare Format
3 Medical Requirements* (at the applicant's account) Waived
4 Other medical requirements if deemed necessary Waived

NOTES:
 The coverage for the Special Diagnostic Procedures are subject to the recommendation of the accredited physician if medically necessary and the provisions
1
of the dreaded and non dreaded pre-existing conditions.

Above limits are inclusive of room & board, operating room charges, professional fees and other incidental expenses relative to the procedure. The
2 maximum benefit limit shall be inclusive of consultations, routine procedures, diagnostic and therapeutic procedures and hospitalization. All procedures or
benefits are subject to the limitations on pre-existing conditions as stated in this proposal.
 EXCLUSIONS AND LIMITATIONS PROVISIONS

“Notwithstanding any provisions to the contrary, the following shall not be covered except otherwise specified in Maxicare Benefits”

1 Services obtained for non-emergency conditions from Physicians and Hospitals in any of the following circumstances
a. non-Accredited Physicians in non-Accredited Hospitals
b. non-Accredited Physicians in Accredited Hospitals
c. Accredited Physicians in non-Accredited Hospitals or other non accredited healthcare facility.

2 Additional hospital charges and physician's professional fees resulting from:

a. room-upgrading beyond Member's allowable time during emergency care
b. extension of hospital stay despite release of discharge order from Member's attending physician
c. fees of the assistant surgeons / resident doctors who assisteed the Attending Physician in the process of rendering the above mentioned services shall not be
chargeable to the Member and/or Maxicare except for hospitals that do not have resident physicians to assist during surgeries subject to the prior approval of
Maxicare

d. use or extra bed, TV, electric fan, DVD/VCD, and other similar items unless such appliances and items are necessarily and ordinarily medical services brought
about by obtaining a room accommodation higher than the Member's Room and Board Accommodation limit
e. extra food
f. toilet articles like face towel, soap, toothbrush and the like
g. difference in room and board, the incremental rate differences for professional fees, diagnostic and laboratory examinations, and other ancillary medical
services brought about by obtaining a room accommodation higher than the Member's Room and Board Accommodation limit;
h. services of a private or a special nurse;
i. all other items not medically necessary in the medical management of the patient.

3 Custodial, domiciliary, convalescent and intermediate care.

4
Long-term rehabilitation and psychiatric and/or psychological illnesses and conditions including neurotic and psychotic behavior disorders; anxiety disorders/

5 Treatment for injury and its complications resulting from self-inflicted injuries including infections as a result of tattoos, piercing of the ear or in any body part,
whether self-inflicted or done by a third party or attempted suicide or self-destruction, whether sane or insane.

6 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.

7 Treatment of any injury received when there is negligence, unauthorized use of prohibited drugs or regulated drugs, alcoholic liquor intake, direct or indirect
participation in the commission of a crime whether consummated or not, violation of a law or ordinance or unnecessary exposure to imminent danger, knowingly
or unknowingly or hazard to health, by the Member. Maxicare may rely on the Police or Doctor's report to evaluate such claim.

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.

38 Intravenous Immunoglobulin (IVIG).

39 Treatment of work-related injuries of high-risk occupations such as but not limited to construction workers, miners, loggers and drillers.

40 Cost of the medical services and professional fees in excess of the MBL/ABL.