Professional Documents
Culture Documents
Who may be enrolled into the Maxicare Program Notwithstanding any provisions to the contrary, the
and what are the requirements? following shall not be covered except otherwise
specified in Agreement:
• The age eligibility for principal and 1. Services obtained for non-emergency conditions
dependents are from 15 days old to 60
from Physicians and Hospitals in any of the
years and 5 months of age.
following circumstances:
• Eligible dependents are as follows (in
a. Non-affiliated physicians in non-affiliated
order):
✓ For single enrollees: Mother, Father, hospitals or clinics;
then Siblings 21 years and 5 months b. Non-affiliated physicians in affiliated
old and below, according to age. hospitals or clinics;
✓ For married enrollees: Spouse, then c. Affiliated physicians in non-affiliated
Children 21 years and 5 months old hospitals or other non-affiliated
and below, according to age. healthcare facilities.
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 commission of a crime whether consummated or
release of discharge order from member’s not
attending physician; e. Violation of a law or ordinance
f. Unnecessary exposure to imminent danger,
c. Fees of the assistant surgeons/ resident knowingly or unknowingly or hazard to health, by
doctors who assisted the Attending Physician the member.
in the process of rendering the above-
Note: Maxicare shall be given a copy the police or
mentioned services shall not be chargeable to
doctor's report (the “Report”), if any. To determine
the Member and/or Maxicare except for
whether or not such treatment is an exclusion under
hospitals that do not have resident physicians this paragraph, Maxicare may rely on the Report, as
to assist during surgeries subject to the prior well as on the evaluation of its own medical resource
approval of Maxicare group provided, however, that if Maxicare has yet to
d. Use of extra bed, TV, electric fan, DVD/VCD, receive the Report or the evaluation of its medical
and other similar items unless such resource group, the Member shall shoulder the
appliances and items are expenses for medical treatment subject to
necessarily and ordinarily included in Maxicare’s reimbursement should it be found, after
the Member’s Room & Board submission of pertinent documentary evidence, that
Accommodation; the treatment is not an exclusion under this
e. Extra food; paragraph. Reimbursement will be based on
f. Toilet articles like face towel, soap, toothbrush Maxicare standard rates and will be based on the
and the like; terms and conditions of this Agreement.
g. Difference in room and board, the
incremental rate differences for professional 8. Aesthetic, cosmetic and reconstructive surgery or
fees, diagnostic and laboratory any consultation or treatment for any beautification
examinations, and other ancillary medical purposes except if necessary to treat a functional
services brought about by obtaining a room defect due to accidental injury within the initial
accommodation higher than the Member’s confinement.
Room and Board Accommodation limit; 9. Oral surgery following accidental injury to teeth for
h. Services of a private or a special nurse; purposes of beautification. Dental examinations,
i. All other items not medically necessary in the extractions, fillings, other dental
medical management of the patient treatment and their complications to the extent
3. Custodial, domiciliary, convalescent and that are medically necessary for repair or
intermediate care. alleviation of damage to the m e m b e r caused
4. Long-term rehabilitation and psychiatric care solely by an accident. Medical care resulting from
and/or psychological illnesses and conditions any dental related conditions.
including neurotic and psychotic behavior 10. Maternity care and all other conditions, including
disorders; anxiety disorders. pre- and post-natal consultations, related to
5. Treatment for injury and its complications and/or resulting from pregnancy and/or delivery
which affect the conditions of the principal
resulting from self-inflicted injuries including
member and the unborn child.
infections as a result of tattoos, piercing of the ear
11. Circumcision (except for treatment of urological
or in any body part, whether self-inflicted or done
conditions), sex transformation, diagnosis,
by a third party or attempted suicide or self-
treatment and procedures related to fertility or
destruction, whether sane or insane.
infertility, artificial insemination, sterilization or
6. Developmental disorders including functional
disorders of the mind, such as but not limited to reversal of such procedures and their
Attention-Deficit Disorder complications.
(ADD)/Attention-Deficit Hyperactivity Disorder 12. Experimental medical procedures and its
(ADHD), Autism Spectrum Disorders, Bipolar complications.
Disorders, Central Auditory Processing Disorder 13. Acupuncture and cryotherapy and o t h e r
(CAPD), Cerebral Palsy, Down Syndrome, forms of therapies, and its complications.
Neural Tube Defects, and Mental Retardation. 14. All expenses incurred in the process of
7. Treatment of any injury received when there is: organ donation and transplantation if the
member is the donor of such donation or
a. Negligence
transplantation, and its complications.
b. Unauthorized use of prohibited drugs or
regulated drugs
c. Alcoholic liquor intake
d. Direct or indirect participation in the
15. Routine physical examinations required for epidemic or pandemic by the Department of
obtaining or continuing employment, Health, World Health Organization or any
requirement in school, insurance, recognized health authority.
government licensing, health permit and 28. Hepatitis B and screening and vaccines for all types
other similar purposes. of Hepatitis.
16. Purchase or lease of durable medical 29. Benefits covered by PhilHealth and all other
equipment, oxygen dispensing equipment, and government funded healthcare entitlements
oxygen, except during in-patient care. as provided for by law.
17. Corrective appliances, prosthetics and 30. Speech therapy for developmental and
orthotics such as but not limited to eye glasses congenital diseases.
and contact lenses, hearing aids, pacemaker, 31. Weight reduction programs, surgical operation or
artificial limbs, valves, procedure for treatment of obesity, including gastric
knee-tibial insert for total knee arthroplasty, stapling or balloon procedures and liposuction
vascular grafts, titanium thread, myringotomy 32. Cost of vaccines and immunization
tube, intravascular catheters, vascular stents, including its administration.
bone screws/plates, pins, wires, balloons, 33. Cost of medico-legal cases.
orthopedic internal fixator/fixation systems, 34. Routine medical examination or check up or medical
orthopedic external fixator/fixation systems, examination for employment or medical examination
intraocular lens, braces, crutches, for travel.
herniorrhaphy mesh or mesh used for 35. Intravenous Immunoglobulin (IVIG).
herniorrhaphy. 36. Treatment of work-related injuries of high-risk
18. Take-home medicine and outpatient medicine occupations such as but not limited to construction
except workers, miners, loggers and drillers.
a. Chemotherapy m e d i c i n e ( except f o r 37. Cost of the medical services and Professional Fees
c a n c e r treatment in excess of the MBL.
b. Medicine a d m i n i s t e r e d d u ring a n emergency 38. Guillain-Barre Syndrome
treatment. 39. Multiple sclerosis, epilepsy and seizures.
19. Congenital, genetic and heredity disease and their 40. Routine, diagnostic, therapeutic and other
complications (except for hernias) affecting functions procedures of the same or similar nature not
of individuals.
otherwise specified in this Agreement
20. All physical deformities prior to enrollment.
21. Treatment of injuries/illnesses caused 41. Open heart surgeries, angioplasties, valvuloplasty,
directly or indirectly by engaging in any permanent pacemaker, balloon valvuloplasty,
professional sport or hazardous activity percutaneous intra-aortic balloon counter pulsation
such as but not limited to scuba diving, and balloon atrial septostomy.
surfing, water skiing, mountain climbing, 42. All cases of assault whether provoked or unprovoked,
rock climbing, mountaineering, whether initiated by the Member or by a known or
parachuting, airsoft, drag racing, unknown third party.
paintballing, wakeboarding and bungee 43. Home service.
jumping, except for activities under 44. Laser procedures or treatments.
company-sponsored sports activities. 45. Neurologic degenerative diseases such as but not
22. Injuries resulting from direct participation in limited to Alzheimer’s disease, Parkinson’s disease,
riots, strikes, and other civil disturbances. amyotrophic lateral sclerosis
23. Treatment of injuries or illnesses resulting from 46. All screening tests.
war or any combat-related activities while in
military service.
24. Sexually transmitted diseases, genital warts,
AIDS and AIDS related diseases.
25. Pre-existing Conditions
a. Dreaded
b. Non-dreaded
Note: Please refer to the Dreaded and
Non-dreaded above provision
26. Treatment for Chronic Dermatoses, except
Scabies.
27. Infectious diseases (i.e. Avian Flu,
Meningococcemia, etc.) that are declared
OTHER PROVISIONS:
LAPSATION
REACTIVATION
NOTES:
• Above rates are inclusive of 12% VAT
• With access to all affiliated hospitals and clinics EXCEPT Healthway Clinics
• Status quo benefits and arrangements including the following:
a. ACU/ECU type: ACU Basic 5 only (applicable to ALL plan types)
b. Philhealth provision: Required to file Philhealth. Non-Philhealth members will pay for the Philhealth
portion.
c. Riders: Built-in on Rates
• International Assistance Program
• Group Life Insurance with Accidental Death, Dismemberment & Disablement (ADD&D)
up to Php 50,000
Separate
e Fee
e
Rider 2023 Rates
Annual Semi-Annual
NOTES:
• Above rates are inclusive of 12% VAT
• With access to all affiliated hospitals and clinics EXCEPT Healthway Clinics
• Status quo benefits and arrangements including the following:
a. ACU/ECU type: ACU Basic 5 only (applicable to ALL plan types)
b. Philhealth provision: Required to file Philhealth. Non-Philhealth members will pay for the Philhealth
portion.
c. Riders: Built-in on Rates
• International Assistance Program
• Group Life Insurance with Accidental Death, Dismemberment & Disablement (ADD&D)
up to Php 50,000
Separate
e Fee
e
Rider 2023 Rates
Annual Semi-Annual
BACOLOD IMUS
G/F LOPUES MANDALAGAN Building, Lacson St., Metro MPC Building, Imus, Cavite
Mandalagan, Bacolod City Contact No: (046) 419-8017
Contact No: (034) 458 6715 Email: pcc.imus@maxicare.com.ph
Email: pcc.bacolod@maxicare.com.ph
ILOILO
BAGUIO Retail 4, Three Techno Place, Iloilo Business Park
G/F Patria de Baguio, Porta Vaga Mall, Session Road, Megaworld ILO, Mandurriao, IloIlo City, IloIlo Contact
Baguio City No: (033) 323 9254
Contact No: (074) 661 8833 Email: pcc.iloilo@maxicare.com.ph
Email: pcc.baguio@maxicare.com.ph
SOLENAD LAGUNA
G/F Solenad 2, Nuvali, Sta. Rosa, Laguna Contact
BRIDGETOWNE
2FM Exxa Tower C-5 Road, Barangay Ugong Norte, Libis No: (049) 559 8008
Quezon City Email: pcc.laguna@maxicare.com.ph
Contact No: 8908-6959
Email: pcc.bridgetowne@maxicare.com.ph VV SOLIVEN
GF-SOL1 (Centro Del Sol), VV Soliven Shopping
Complex, EDSA Greenhills, San Juan City Contact
CAGAYAN DE ORO
No: (02) 7798 7788, (02)7798 7739
G/F Primavera City Citta Verde, Pueblo De Oro, Upper
Carmen, Cagayan De Oro Email: pcc.vvsoliven@maxicare.com.ph
Contact No: (088) 864 8804
W CITY CENTER
Email: pcc.cdo@maxicare.com.ph
Ground Floor, W City Center, 7 th Avenue cor. 30th St.,
Bonifacio Global City, Taguig
Contact Nos: 8908-6957
Email: pcc.bgc@maxicare.com.ph
MY HEALTH CLINIC – TAGUIG CITY GENERAL SANTOS
2nd Floor, Venice Grand Canal Mall, McKinley General Santos Doctors’ Hospital Engineering Office
Hills, Taguig City Ground Floor near 1B Station National Highway,
Tel Nos: (+632)8784-6930 General Santos City
Clinic Hours: Open 24 hours daily Tel. Nos: (083) 8553-3963