Coverage Details
MAXIMUM BENEFIT LIMIT (MBL) |
PHP 200,000.00/ILLNESS/YEAR |
PRE-EXISTING CONDITIONS |
COVERED/WAIVED, FULL |
| COVID Care Coverage |
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* PhilHealth membership is required to pay the PhilHealth portion of bill. In the case of a non-PhilHealth member, member is responsible for paying the Philhealth cost of the bill.
HIERARCHY OF DEPENDENTS |
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| FOR SINGLE PRINCIPAL MEMBERS | FOR SINGLE PARENT PRINCIPAL MEMBERS | FOR MARRIED PRINCIPAL MEMBERS |
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HIERARCHY: You are required to enroll dependents in this order: First: Your parents
ELIGIBILITY CRITERIA Parents must:
Siblings must:
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HIERARCHY: You are required to enroll dependents in this order: First: Your children (starting from oldest to youngest)
ELIGIBILITY CRITERIA Children must:
Parents must:
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HIERARCHY: You are required to enroll dependents in this order: First: Your legal spouse
ELIGIBILITY CRITERIA Legal spouse must:
Children must:
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SERVICES/BENEFITS |
COVERAGE/LIMIT |
| ANNUAL PHYSICAL EXAMINATION | |
| Taking of Medical History | Covered |
| Physical Examination | Covered |
| Chest X-Ray | Covered |
| Routine Urinalysis | Covered |
| Routine Fecalysis | Covered |
| Complete Blood Count (CBC) | Covered |
| Electrocardiogram (ECG) for members 35 years old and above or if indicated | Covered |
| Pap Smear for female members 35 years old and above or if indicated | Covered |
| Pre-employment Examination | Applicant to pay prior to availment. Reimbursable up to Php350 upon regularization |
| PREVENTIVE HEALTH CARE | |
| Health Education Counselling on diet or exercise | Covered |
| Periodic Monitoring of Health Problems | Covered |
| Family Planning Counselling | Covered |
| OUT-PATIENT (OP) CARE | |
| Consultations during regular clinic hours, except prescribed medicines | Covered |
| Pre and Post Natal consultations | Covered excluding laboratory & diagnostic procedures |
| Eye, ear, nose and throat (EENT) treatment pre-scribed by an affiliated physician/specialist | Covered |
| Treatment for minor injuries such as lacerations, mild burns, sprains and the like | Covered |
| Dressings, conventional casts (plaster of Paris) and sutures. | Covered |
| X-Ray, laboratory examinations, routine, diagnostic and therapeutic procedures prescribed by an affiliated physician/specialist, provided however that the cost of diagnostic and therapeutic procedures covered shall be limited to a specific amount. | Covered |
| Minor surgery not requiring confinement pre-scribed by an affiliated physician/specialist | Covered |
| Cauterization of Warts prescribed by an Affiliated Physician/Specialist except genital warts and condyloma acuminatum | If Medically necessary & for therapeutic purposes (e.g. plantar warts, etc.) covered up to MBL; Php2,000 reimbursable Face Down for aesthetic purposes |
| Speech Therapy | Covered up to Php10,000/member/year (ON REIMBURSE-MENT ONLY) |
| Initial treatment of Animal bites | Covered subject to MBL except cost of vaccines which is subject to a separate limit/coverage |
| Passive and active vaccines for treatment of tetanus and animal bites (including immunoglobulin) | covered up to P20,000 per member per year |
| Allergy Testing/ allergy screening and other related examinations prescribed by an affiliated Physician | Covered up to Php2,500/member/year |
| IN-PATIENT (IP) SERVICES | |
| Room and Board according to the Member’s Room and Board Accommodation and subject to the maximum rate of Daily Room and Board, if any, of the plan under which the Member is enrolled. | Covered |
| Use of operating room, Intensive Care Unit (ICU), isolation room (if prescribed by attending Affiliated Physician) and recovery room. | Covered subject to MBL |
Professional fees in accordance with PhilCare Schedule of Rates
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Covered subject to MBL |
| Standard Nursing Services | Covered |
| Medicines for in-patient use | Covered subject to MBL |
| Blood products transfusions and intravenous fluids, including blood screening and cross-matching | Covered subject to MBL |
| X-Ray, laboratory examinations, routine, diagnostic and therapeutic procedures incidental to confinement | Covered subject to MBL |
| Dressings, conventional casts (plaster of Paris) and sutures | Covered subject to MBL |
| Anesthesia and its administration | Covered subject to MBL |
| Oxygen and its administration | Covered subject to MBL |
| Standard Admission Kit | Covered |
| All other items directly related to the medical management of the patient, as deemed medically necessary by the attending Affiliated Physician | Covered subject to MBL |
| Assistance in administrative requirements through a Liaison Officer | Covered |
| SPECIAL MODALITIES OF TREATMENT | |
| (Shared limit for OP and IP; Professional Fees, Hospital Bills, and other incidental expenses relative to the procedure shall form part of the limit) | |
| The following procedures and modalities are subject to the inner limits when specified, otherwise Actual Cost, subject to MBL. | |
| Laparoscopic Cholecystectomy | Subject to MBL |
| Lithotripsy | Subject to MBL, once per contract year |
| Magnetic Resonance Imaging (MRI) | Subject to MBL |
| Use of Nuclear/Radioactive Isotopes | Subject to MBL |
| Hysteroscopic Myoma Resection | Subject to MBL |
| Laparoscopic Adrenalectomy (Unilateral) | Subject to MBL |
| Laparoscopic Adrenalectomy (Bilateral) | Subject to MBL |
| Transurethral Microwave Therapy of Prostate | Subject to MBL, once per contract year |
| Hysteroscopic Guided D&C/Biopsy | Subject to MBL |
| Percutaneous Ultrasonic Nephrolithotomy | Subject to MBL, once per contract year |
| Ureterolithotripsy | Subject to MBL, once per contract year |
| Stereotactic Brain Biopsy | Subject to MBL |
| Cryosurgery | Subject to MBL |
| Sleep Study/Polysomnograms (Sleep Recording) | Subject to MBL |
| Continuous Positive Airway Pressure (CPAP) titration for sleep study | Subject to MBL, once per contract year |
| Neuroscan | Subject to MBL |
| Pelvic Laparoscopy | Subject to MBL |
| All Special Modalities of treatment and/or diagnostic procedures | Covered up to Php 5,000.00/procedure/member/year |
| Sclerotherapy for varicose veins as prescribed by an Affiliated Physician, to be availed through Affiliated vascular surgeons. | Up to Php 5,000/leg/member/year |
| If a Member avails of the special modalities of treatment and/or diagnostic tests, the liability of PhilCare shall be limited to the prevailing costs of hospital bills, professional fees, and related expenses ordinarily charged for traditionally accepted treatment modality and/or diagnostic tests.
Notwithstanding this provision, PhilCare’s liability shall be limited to the amounts specified in the Schedule of Benefits of the Agreement. |
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| EMERGENCY CARE | |
| In Affiliated Hospitals | |
| a. Physician’s services – Affiliated | Subject to Maximum Benefit Limit |
| b. Emergency Room Fees | Subject to Maximum Benefit Limit |
| c. Medicines used for immediate relief during treatment | Subject to Maximum Benefit Limit |
| d. Oxygen, Intravenous fluids, and blood products | Subject to Maximum Benefit Limit |
| e. Dressings, conventional casts (plaster of Paris) and sutures | Subject to Maximum Benefit Limit |
| f. X-Rays, laboratory and diagnostic examinations, and other medical services related to the emergency treatment of the patient | Subject to Maximum Benefit Limit |
| g. Room Upgrade in case of room unavailability | Subject to Maximum Benefit Limit |
| In Non-Affiliated Hospitals | 100% of hospital bills & professional fees based on PhilCare rates up to Php 30,000 /case /member /year (Reimbursement) |
| Outside the Philippines | 100% of hospital bills & professional fees based on PhilCare rates up to Php 30,000 /case /member /year (Reimbursement) |
| Areas without Affiliated Hospital (No affiliated hospitals within 50-km radius of the location of the incident) | Covered subject to PhilCare rates up to MBL |
| Ambulance Service (Affiliated/Non-Affiliated to Affiliated) if within Metro Manila | Covered provided that case is fully coordinated with PhilCare through AeroMed |
| Ambulance Service (Affiliated/Non-Affiliated to Affiliated) if in Provincial areas | Covered up to Php 2,500 per conduction (reimbursement) |
| ADDITIONAL BENEFITS | |
| Work Related Conditions based on conditions covered by ECC | Covered |
| Motor Vehicular Accidents | Covered subject to MBL |
| Congenital diseases, except physical therapy sessions and developmental disorders | up to Php 40,000 /member /year |
| Congenital Hernia | Covered subject to MBL |
| Scoliosis (acquired cases only) including necessary procedures, except physical therapy sessions | Covered up to Php 40,000/member/year (only acquired cases) |
| Epilepsy, Seizure Disorder | Covered if acquired |
| Hepatitis B (if acquired, excluding STD) & Hepatitis C | Covered if acquired & not related to STD. Screening test is not Covered |
| Sports-related injuries | Covered; if extreme sports, not covered |
| Unprovoked Assault, including domestic violence, whether initiated by a known or unknown third party | Covered |
| Maternity Assistance (for female employees only & for delivery assistance, subject to 280 days waiting period) | Covered up to P5,000 (on reimbursement – once per contract year) |
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| DIAGNOSTIC PROCEDURES | |
| Lead Electrocardiogram | Covered as prescribed by the attending physician subject to MBL |
| 24-hour Electroencephalogram (EEG) Monitoring | Covered up to Php 5,000.00/member/year |
| 24-hour Holter Monitoring | Covered as prescribed by the attending physician subject to MBL |
| Adrenocortical Function | Covered as prescribed by the attending physician subject to MBL |
| Anti-Nuclear Antibody, C-Reactive Protein, Lupus Cell Exam | Covered as prescribed by the attending physician subject to MBL |
| Arterial Blood Gas | Covered as prescribed by the attending physician subject to MBL |
| Arthroscopic Procedures, Orthopedic Arthroscopy | Covered as prescribed by the attending physician subject to MBL |
| Audiograms and Tympanograms | Covered as prescribed by the attending physician subject to MBL |
| Bone Densitometry Scan (Dexascan) without nuclear or radioisotope | Covered as prescribed by the attending physician subject to MBL |
| Bone Mineral Density Studies | Covered as prescribed by the attending physician subject to MBL |
| Cardiac Stress Tests (Thallium and Dipyridamole Stress Tests) | Covered as prescribed by the attending physician subject to MBL |
| Diagnostic Radiographs: | Covered as prescribed by the attending physician subject to MBL |
| a. Biliary tract: Cholecystogram and Cholangiogram | Covered as prescribed by the attending physician subject to MBL |
| b. Chest, ribs, sternum, and clavicle | Covered as prescribed by the attending physician subject to MBL |
| c. Digestive: Plain film of the abdomen, Barium Enema, Upper Gastrointestinal (GI) Series, lower GI Series, Small Bowel Series | Covered as prescribed by the attending physician subject to MBL |
| d. Face (including sinuses), Head and Neck | Covered as prescribed by the attending physician subject to MBL |
| e. Urinary: Kidney, Ureter, and Bladder (KUB) Pyelograms and Cystograms | Covered as prescribed by the attending physician subject to MBL |
| f. X-ray of the extremities and pelvis | Covered as prescribed by the attending physician subject to MBL |
| g. X-ray of the spine (cervical, thoracic, lumbosacral) | Covered as prescribed by the attending physician subject to MBL |
| Diagnostic Ultrasounds: | Covered as prescribed by the attending physician subject to MBL |
| a. 2D-Echo with Doppler | Covered as prescribed by the attending physician subject to MBL |
| b. Abdomen | Covered as prescribed by the attending physician subject to MBL |
| c. Duplex Scan | Covered as prescribed by the attending physician subject to MBL |
| d. Digestive and Urinary Systems | Covered as prescribed by the attending physician subject to MBL |
| e. Ultrasound of the Lungs | Covered as prescribed by the attending physician subject to MBL |
| Electromyelography and Nerve Conduction Studies | Covered as prescribed by the attending physician subject to MBL |
| Computed Tomography Scans | Covered as prescribed by the attending physician subject to MBL |
| Electroencephalogram (EEG) Monitoring | Covered as prescribed by the attending physician subject to MBL |
| Endoscopic Procedures | Covered as prescribed by the attending physician subject to MBL |
| Esophageal Manometry | Covered up to Php 5,000.00/member/year |
| Fluorescein Angiography | Covered as prescribed by the attending physician subject to MBL |
| Impedance Plethysmography | Covered as prescribed by the attending physician subject to MBL |
| Magnetic Resonance Angiography (MRA) | Covered as prescribed by the attending physician subject to MBL |
| Magnetic Resonance Imaging (MRI) | Covered as prescribed by the attending physician subject to MBL |
| Mammogram and Sonomammogram | Covered as prescribed by the attending physician subject to MBL |
| Myelogram | Covered as prescribed by the attending physician subject to MBL |
| Neuroscan | Covered subject to MBL |
| Nuclear/Radioactive Isotope Scan | Covered subject to MBL |
| Pap’s Smear | Covered as prescribed by the attending physician subject to MBL |
| Perfusion Scan | Covered as prescribed by the attending physician subject to MBL |
| Plasma Urinary Cortisol, Plasma Aldosterone | Covered as prescribed by the attending physician subject to MBL |
| Polysomnograms (Sleep Recording) | Covered as prescribed by the attending physician subject to MBL |
| Positron Emission Tomography (PET) Scan | Covered up to Php 5,000.00/member/year |
| Pulmonary Function Tests | Covered as prescribed by the attending physician subject to MBL |
| Radioisotope Scans and Function Studies: | Covered as prescribed by the attending physician subject to MBL |
| a. Cardiac | Covered as prescribed by the attending physician subject to MBL |
| b. Gastrointestinal | Covered as prescribed by the attending physician subject to MBL |
| c. | Covered as prescribed by the attending physician subject to MBL |
| d. Parathyroid Bone, Pulmonary (Perfusion/ Ventilation Lung Scans) | Covered as prescribed by the attending physician subject to MBL |
| e. Renal | Covered as prescribed by the attending physician subject to MBL |
| f. Thyroid Scans | Covered as prescribed by the attending physician subject to MBL |
| g. Total Body Scans | Covered as prescribed by the attending physician subject to MBL |
| Radionuclide Ventriculography | Covered as prescribed by the attending physician subject to MBL |
| Surface Electromyography (SEMG) | Covered as prescribed by the attending physician subject to MBL |
| Thallium Scintigraphy | Covered as prescribed by the attending physician subject to MBL |
| Treadmill Stress test (All types except Cardiac and Nuclear Treadmill Stress Tests) | Covered as prescribed by the attending physician subject to MBL |
| THERAPEUTIC PROCEDURES | |
| Anti-neoplastic Chemotherapy (IM/IV) | Covered subject to MBL |
| Continuous Positive Airway Pressure (CPAP) titration for sleep study | Covered up to Php 5,000.00 if related to dread disease |
| Conventional Hemorrhoidectomy | Covered subject to MBL |
| Dialysis | Covered subject to MBL |
| Oral anti-neoplastic chemotherapy | Covered subject to MBL |
| Physical Therapy/Occupational Therapy | (IP) Covered subject to MBL excluding subspecialties such as cardiac rehabilitation, pulmonary rehabilitation, and the like (OP) Covered up to shared/aggregate limit up to 12 sessions for PT and OT or up to available MBL whichever comes first.
Therapy of one (1) body area shall be considered as one (1) session excluding subspecialties such as cardiac rehabilitation, pulmonary rehabilitation, and the like |
| Radiotherapy | Covered subject to MBL |
| Therapeutic Radiology: | Covered subject to MBL |
| a. Brachytherapy | Covered subject to MBL |
| b. Cobalt | Covered subject to MBL |
| c. Linear Accelerator Therapy | Covered subject to MBL |
| d. Radioactive Cesium | Covered subject to MBL |
| e. Radioactive Iodine | Covered subject to MBL |
| Intensified Modulated Radiotherapy | Covered up to Php 5,000.00/member/year |
| THERAPEUTIC PROCEDURES | |
| Anti-neoplastic Chemotherapy (IM/IV) | Covered subject to MBL |
| Continuous Positive Airway Pressure (CPAP) titration for sleep study | Covered up to Php 5,000.00 if related to dread disease |
| Conventional Hemorrhoidectomy | Covered subject to MBL |
| Dialysis | Covered subject to MBL |
| Oral anti-neoplastic chemotherapy | Covered subject to MBL |
| Physical Therapy/Occupational Therapy |
(IP) Covered subject to MBL excluding subspecialties such as cardiac rehabilitation, pulmonary rehabilitation, and the like (OP) Covered up to shared/aggregate limit up to 12 sessions for PT and OT or up to available MBL whichever comes first. Therapy of one (1) body area shall be considered as one (1) session excluding subspecialties such as cardiac rehabilitation, pulmonary rehabilitation, and the like |
| Radiotherapy | Covered subject to MBL |
| Therapeutic Radiology: | Covered subject to MBL |
| a. Brachytherapy | Covered subject to MBL |
| b. Cobalt | Covered subject to MBL |
| c. Linear Accelerator Therapy | Covered subject to MBL |
| d. Radioactive Cesium | Covered subject to MBL |
| e. Radioactive Iodine | Covered subject to MBL |
| Intensified Modulated Radiotherapy | Covered up to Php 5,000.00/member/year |
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| 280-DAY WAITING PERIOD | COVERED FOR ALL FEMALE MEMBERS |
| COVERED MEMBERS | ALL FEMALE EMPLOYEES |
| PhilCare shall cover the hospital bills and professional fees incurred by covered Member for maternity services/procedures, up to the following limit: | |
| In Network | |
| · Normal Delivery | Php 5,000.00 |
| · Caesarian Delivery | Php 5,000.00 |
| · Miscarriage | Php 0.00 |
| · Abortion | Php 0.00 |
| · Complication of Pregnancy | Php 0.00 |
| · Abnormal Pregnancies | Php 0.00 |
| · Other Limit | Php 5,000.00 |
| Out Network | |
| · Normal Delivery | Php 5,000.00 |
| · Caesarian Delivery | Php 5,000.00 |
| · Miscarriage | Php 0.00 |
| · Abortion | Php 0.00 |
| · Complication of Pregnancy | Php 0.00 |
| · Abnormal Pregnancies | Php 0.00 |
| · Other Limit | Php 5,000.00 |
| Type of Availment |
Maternity Assistance (Covered on reimbursement basis once per contract year) |
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280 days Waiting Period. Maternity benefit shall only be available to eligible Member after she has been continuously covered under the agreement for a period of 280 days |
Applicable |
| Laboratory procedures/workups | Not Covered |
| Charges incurred by the newborn child are not covered. | |
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| No reimbursement. To be availed only through PhilCare accredited dental clinics. |
| Annual dental exam and consultation |
| Emergency OP dental treatment is to be availed at accredited dental clinics only. |
| Oral prophylaxis once a year |
| Simple tooth extractions |
| Restorative and prosthodontic treatment planning |
| Temporary fillings- unlimited as needed |
| Desensitization of hypersensitive teeth |
| Simple adjustment of dentures |
| Recementation of loose crowns, inlays, and onlays |
| Dental nutrition and dietary counseling |
| Dental health education |
| Pre-natal check of teeth and gums |
| Temporo mandibular joint consultation |
| Gum treatment for Cases like inflammation or bleeding |
| (2) light cure filling per tooth |
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