MAXICARE Proposal - Wen Parker Logistics Phils.

29 October 2013
NANCY V. MARAMBA
Station Manager
Wen-Parker Logistics Phils. Co. Ltd. Inc.
G-4 Factor Warehouse, Joshua cor. Judges St., BF Martinville, Las Pinas
Thru:
Agent name,
Accredited Independent Agent
Dear Ms. Maramba
/ Health Benefit Agent
We trust this finds you in good health.

For the past twenty
-five (25) years now , Maxicare has continued its legacy of providing the most
wide Network of Medical Providers nationwide
comprehensive healthcare benefits, through our
,
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 prem
ium 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
countrys 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 countrys
Top 2,000 companies.
You will find the details of the program for referenc
e. 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.
Yours in Health,
ERWIN S. DELA CRUZ

Account Officer
Noted by:
AUBREYLEE ZAPATA
Business Development Manager
MAXICARE Proposal
Maxicare Healthcare Corporation
10/26/2013 10:21 AM
WHY IS MAXICARE THE BEST HMO FOR YOUR

COMPANY?
Extensive Healthcare Program
Vast Network of Providers
Maxicare Intelligent Card
Primary Care Centers
Extensive Customer Care Network
WHO IS MAXICARE?
* 25 Years of Solid
Healthcare Expertise
* 700,000 Cardholders
Nationwide
* Operates Nationwide
* Consistently in the Top
3 HMOs in the Country
* HMO of choice of the
Best Employers in Asia
and in the Philippines
MAXICAREs
MISSION-VISSION
To help people achieve
peace of mind through
quality healthcare service
delivery.
To be the leading health
maintenance
organization preferred by
customers because of
Superior Service.
Extensive Healthcare Program which includes the

following :
Preventive Care
Annual Check Up
Out Patient Care
In Patient Care
Emergency Care
Superior Additional Benefits
Riders : Life AD & D and Dental Riders
Vast Network of Providers

Over 1000 Accredited Hospitals and Clinics
nationwide (65% are Tertiary Hospitals)
More than 27,000 Top-Caliber Accredited

Doctors(Consultants, Fellows and Diplomates)
All Maxicare Centers are on-line with the

Head Office
Maxicare Intelligent Card

Real-time validation of membership during availments
Swipe facility using more than 800 POS units nationwide
Immediate activation & de-activation of memberships within
24 hours
Cards need not be replaced on a yearly basis
Maxicare Reimbursement Card
MAXICARE PRIMARY CARE CENTERS

were put together with your convenience in mind. These are well-appointed to give the cardholders the access to
quality health care close enough to where they work or live. Each center has its staff of Customer Service
Associates, Primary Care Physicians, who are consultants specializing in Internal Medicine and Pediatrics, and
additional services like Laboratory and ECG. Because our centers are located close to major hospitals, our
Customer Service Associates are able to facilitate easy access to quality diagnostics, specialist consultation and
hospitalization when you need it.
The Advantages of Primary Care Centers

Exclusive to Maxicare Members Only
Easy access to Internal Medicine Specialists
Quality lab exams @ the least possible cost

Unlimited number of consultations ; not treated as part of utilization
Majority are strategically & conveniently located @ major hospitals ;
LUZON AREA
Filomena Building
G/F Filomena Building Amorsolo Street Legaspi Village, Makati City

Tel: (02) 893-3898 / 893-4858
Hours: 7AM - 6PM Monday - Friday, 7AM - 4PM Saturday
Makati Medical Center
1st floor Tower One, Bldg., Amorsolo Street, Makati City
Tel: (02) 893-6064 / 893-9820 / 888-8999 local 2109/2110
Hours: 7AM - 7PM Monday - Friday
15/F Room 1501 (Out-Patient)/Room 1510 (In-Patient) North Tower
St. Lukes Medical Center
Catherdral Heights Bldg., St. Lukes Compound, E. Rodriguez St.,
Quezon City
Quezon City
Tel: (02) 723-5329 / 723-0101 local 5151
St. Lukes Medical Center
Room 325 Medical Arts Bldg., Rizal Drive Corner 5th Avenue & 32nd
Global City
Avenue, Fort Bonifacio, Global City Taguig
Tel: (02) 789-7700 local 7325
MGR04, Groundfloor, Medical Arts Tower 1, The New Medical City
The Medical City
Ortigas Ave., Pasig City
Tel: (02) 706-5080 / 706-1526 / 635-6789 local 5073
Asian Hospital & Medical
Lower Ground Floor, Asian Hospital & Medical Center 2205 Civic
Center
Drive, FCC Alabang, Muntinlupa
Tel: (02) 836-7493
Hours: 8AM - 5PM Monday - Sunday
10th Floor Medical Arts and Parking Building, Chinese General
Chinese General Hospital
Hospital, Sta. Cruz, Manila
Tel: (02) 567-6287
MyHealth Clinic EDSA Shangri- Unit 146, Level 1, Shangrila Plaza EDSA corner Shaw Blvd.,
La
Mandaluyong City
Tel: (02) 570-4325
MyHealth Clinic
Level 2 Style Boulevard, Festival Supermall Alabang, Muntinlupa City
Festival Supermall
Tel: (02) 850-4855
MyHealth Clinic North EDSA
MyHealth Clinic Calamba
2nd Floor North Link Bldg., F SM City North EDSA North Avenue,
Quezon City
Tel: (02) 441-4106
2nd Floor, Waltermart Center, Calamba Barangay, Real, Crossing
Calamba City
Tel: (049) 502-7130 to 32
VISAYAS AREA
MyHealth Clinic Cebu
3rd Level Robinson's Cybergate Mall, Fuente Osmena Street, Cebu City
Tel: (032) 268-8502 to 03
Extensive Customer Care Network

Maxicare SATELLITE OFFICES
Maxicare ROVING TEAM
Maxicare 24/7 CUSTOMER CARE
Maxicare SMS Inquiry

(0918-889-MAXI) - 6294
582-1900
798 -7777
0918-9072652
Maxicare HELPDESKS
Clinica Manila: 2nd Floor, Unit 202 Building A SM Megamall Complex
Don Julia Vargas Avenue, Mandaluyong City
Monday to Saturday Tel. No: (0632)661-7777 local 102
Mary Mediatrix Medical Center: 2nd Floor, H.B. Calleja Building Mary
Mediatrix Medical Center J.P. Laurel Highway, Lipa City, Batangas
Calamba Medical Center: Ground floor , Central Registration,

Crossing, Calamba,City
Monday to Saturday
MANILA DOCTORS HOSPITAL : Room 220, Manila Doctors Hospital

Maxicare EMAIL CUSTOMER SUPPORT
* callcenter@maxicare.com.ph
* Members can send their inquiries and concerns through Email.
Maxicare FAN PAGE
Maxicare Web-Portal
www.facebook.com/maxicarehealthcarecorp
* Members can like us on facebook and send inquires and

concerns via chat.
MAXICARE PLUS 2013 (Group 5 to 19)

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)
RATES FOR EMPLOYEES PER HEAD
Plan Type Room and Board
Annual
Check-up
Maximum
Benefit Limit
Annual
Semi-Annual
Platinum
Suite up to Php
4,000
Routine
200,000
PHP 26,602
PHP 14,365
Platinum
Small Suite
Routine
200,000
24,341
13,145
Platinum
Open Private
Routine
200,000
21,403
11,558
Platinum
Open Private
Routine
150,000
20,833
11,250
Platinum
Large Private
Routine
150,000
20,205
10,911
Gold
Regular Private
Routine
150,000
18,384
9,928
Gold
Regular Private
Routine
100,000
17,814
9,620
Gold
Regular Private
Routine
75,000
17,202
9,289
Silver
Semi-Private
Routine
75,000
14,247
7,694
Silver
Semi-Private
Routine
60,000
13,881
7,496
Bronze
Ward
Routine
50,000
11,686
6,311
RATES FOR DEPENDENTS PER HEAD
Annual
Check-up
Maximum
Benefit Limit
Annual
Semi-Annual
Platinum
Suite up to Php
4,000
Routine
200,000
PHP 36,191
PHP 19,544
Platinum
Small Suite
Routine
200,000
33,396
18,034
Platinum
Open Private
Routine
200,000
28,677
15,486
Platinum
Open Private
Routine
150,000
28,106
15,178
Platinum
Large Private
Routine
150,000
27,331
14,759
Gold
Regular Private
Routine
150,000
24,741
13,361
Gold
Regular Private
Routine
100,000
24,170
13,052
Gold
Regular Private
Routine
75,000
23,559
12,722
Silver
Semi-Private
Routine
75,000
18,949
10,233
Silver
Semi-Private
Routine
60,000
18,583
10,035
Bronze
Ward
Routine
50,000
15,459
8,348
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).
RATES FOR EMPLOYEES PER HEAD
Annual
Check-up
Maximum
Benefit Limit
Annual
Semi-Annual
Platinum
Suite up to Php
4,000
Routine
200,000
PHP 20,405
PHP 11,019
Platinum
Small Suite
Routine
200,000
18,731
10,115
Platinum
Open Private
Routine
200,000
16,558
8,942
Platinum
Open Private
Routine
150,000
16,136
8,714
Platinum
Large Private
Routine
150,000
15,672
8,463
Gold
Regular Private
Routine
150,000
14,324
7,735
Gold
Regular Private
Routine
100,000
13,903
7,508
Gold
Regular Private
Routine
75,000
13,450
7,263
Silver
Semi-Private
Routine
75,000
11,263
6,082
Silver
Semi-Private
Routine
60,000
10,993
5,937
Bronze
Ward
Routine
50,000
9,369
5,060
RATES FOR DEPENDENTS PER HEAD
Annual
Check-up
Maximum
Benefit Limit
Annual
Semi-Annual
Platinum
Suite up to Php
4,000
Routine
200,000
PHP 27,501
PHP 14,851
Platinum
Small Suite
Routine
200,000
25,435
13,735
Platinum
Open Private
Routine
200,000
21,941
11,849
Platinum
Open Private
Routine
150,000
21,519
11,621
Platinum
Large Private
Routine
150,000
20,944
11,310
Gold
Regular Private
Routine
150,000
19,029
10,276
Gold
Regular Private
Routine
100,000
18,605
10,047
Gold
Regular Private
Routine
75,000
18,153
9,803
Silver
Semi-Private
Routine
75,000
14,743
7,962
Silver
Semi-Private
Routine
60,000
14,471
7,815
Bronze
Ward
Routine
50,000
12,159
6,566
Notes:
Rates and benefits are valid up to June 30, 2013 and based on a 12-month coverage only.
Above rates are applicable for accounts beginning 5 to 19 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:
standard rates
at least 75%
+ 10% to standard rates
60% - 74.9%
40% - 59.9%
Below 40%
Riders:
Benefit
Additional Fees
Standard Dental
Inclusive in the rates
Life with AD&D - Php 25,000
Inclusive in the rates
MAXICARE PLUS (Group)

SUMMARY OF BENEFITS
HEALTHCARE BENEFITS
A.
Consultations during regular clinic hours, except prescribed medicines
Subject to MBL
Pre and Post Natal consultations
Subject to MBL
Eye, ear, nose and throat (EENT) treatment prescribed by an Accredited

Physician/Specialist
Subject to MBL
Treatment for minor injuries such as lacerations, mild burns, sprains and
the like
Dressings, conventional casts (plaster of Paris) and sutures.
Subject to MBL
4
5
6
Subject to MBL
Minor surgery not requiring confinement prescribed by an Accredited

Physician / Specialist
Subject to MBL
10
Eye laser therapy only for retinal tear, retinal hole, retinal detachment
and glaucoma prescribed by an Accredited Physician/Specialist. Eye
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 of the body, except genital warts and condyloma acuminata,
prescribed by an
Sclerotherapy
forAccredited
varicose Physician/Specialist.
veins (except medicines and for cosmetic
purposes) as prescribed by an Accredited Physician, to be availed
through accredited vascular surgeons.
11
Allergy Testing/ allergy screening and other related examinations

prescribed by an Accredited Physician
12
Speech therapy (for stroke patients only)
13
Tuberculin test
Up to Php 10,000 /eye /member /year
Up to Php 1,000 /member /year
Up to Php 5,000 / leg / member / year

Up to Php 2,500 / member / year
Covered as charged up to Php 10,000 / member / year (reimbursement basis)
Note: Consultations shall be part of the limit and treated as sessions
Up to Php 600 / member / year
IN-PATIENT CARE
Room and Board Accommodation
Use of operating room, Intensive Care Unit (ICU), isolation room (if
prescribed by attending Accredited Physician) and recovery room.
Professional fees in accordance with Maxicare Schedule of Rates.
a. Attending Physicians
b. Surgeons
c. Anesthesiologists
d. Cardio-pulmonary clearance before surgery and cardiac monitoring
during surgery.
Standard Nursing Services
Subject to the Member's Room and Board limit
Subject to MBL
Medicines for in-patient use

Blood products transfusions and intravenous fluids, including blood
screening and cross matching.
X-Ray, laboratory examinations, routine, diagnostic tests and therapeutic
procedures incidental to confinement
Dressings, conventional casts (plaster of Paris) and sutures
Anesthesia and its administration
Subject to MBL
10
Oxygen and its administration
Subject to MBL
11
Standard Admission kit
Subject to MBL
12
All other items directly related in the medical management of the patient,
as deemed medically necessary by the attending Accredited Physician
Subject to MBL
1
2
3
4
5
6
7
C.
Subject to MBL
X-Ray, laboratory examinations, routine, diagnostic and therapeutic

procedures prescribed by an Accredited Physician/Specialist, provided
however that the cost of diagnostic and therapeutic procedures covered
shall be limited to a specific amount.
B.
MAXICARE'S COVERAGE
OUT-PATIENT CARE
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
ROUTINE PROCEDURES (whether IP or OP)

1
2
Blood Chemistries
Chest X-Ray
100% of Actual Cost subject to MBL

Complete Blood Count (CBC)
Fecalysis
5
D.
DIAGNOSTIC PROCEDURES
1
2
12-Lead Electrocardiogram (ECG)

24-Hour Electroencephalogram (EEG) Monitoring

3
4
5
6
7
24-hour Holter Monitoring

Adrenocortical Function
Anti-Nuclear Antibody, C-Reactive Protein, Lupus Cell Exam
Arterial Blood Gas
Arthroscospic Procedures, Orthopedic Arthroscopy

8
9
Audiograms and Tympanograms

Bone Densitometry Scan (Dexascan)

10
Bone Mineral Density Studies
11
12
13
Cardiac Stress Tests (Thalium and Dipyridamole Stress Tests)

Computed Tomography Scans

Diagnostic Radiographs:
a. Biliary tract: Cholecystogram and Cholangiogram
b. Chest, ribs, sternum and clavicle

c. Digestive: Plain film of the abdomen, Barium Enema, Upper GI Series,
Lower GI Series, Small Bowel series
d. Face (including sinuses), Head and Neck
e. Urinary: Kidney, Ureter, Bladder (KUB), Pyelograms and Cystograms
f. X-ray of the extremities and pelvis

g. X-ray of the spine (cervical, thoracic, lumbo-sacral)

Diagnostic Ultrasounds:
a. 2D-Echo with Doppler
b. Abdomen

15
16
c. Duplex Scan
d. Digestive and Urinary Systems
e. Ultrasound of the Lungs
Electroencephalogram (EEG) Monitoring
Electromyelography and Nerve Conduction Studies

17
18
19
20
21
Endoscopic Procedures
Fluorescein Angiography
Impedance Plethysmography
Magnetic Resonance Angiography (MRA)
Magnetic Resonance Imaging (MRI)

22
23
24
25
26
Mammography and Sonomammogram

Myelogram
Nuclear Radioactive Isotope Scan
Pap's Smear
Perfusion Scan

27
28
29
30
Plasma Urinary Cortisol, Plasma Aldosterone

Polysomnograms (Sleep Recording)
Pulmonary Function Tests

14
E.
Urinalysis
Radioisotope Scans and Function Studies:

a. Cardiac
b. Gastrointestinal
c. Liver


d. Parathyroid Bone, Pulmonary (Perfusion/ Ventilation Lung Scans)
31
e. Renal
f. Thyroid Scans
g. Total Body Scans
Radionuclide Ventriculography

32
33
Surface Electromyography (SEMG)

Thallium Scintigraphy

34
Treadmill Stress Test (TMST)
THERAPEUTIC PROCEDURES
1
2
3
4
Arthrocentesis
Dialysis
Intravenous Chemotherapy
Phlebotomy
Up to six (6) sessions subject to MBL for OP; Up to MBL for IP

Up to MBL shared limit for OP and IP
5
6
7
F.
Physical therapy / Occupational therapy excluding subspecialties such as

cardiac rehabilitation, pulmonary rehabilitation and the like.
Thoracentesis
a. Brachytherapy
b. Cobalt

Up to Php 60,000 shared limit for OP and IP
Oral Chemotherapy
Up to Php 60,000 shared limit for OP and IP
ANNUAL CHECK-UP
* The following Routine ACU program shall be conducted at a designated Maxicare Accredited Clinic once a year:
Routine (clinic) which includes:
Physical Examination
Complete Blood Count
Urinalysis
Fecalysis
Chest X-ray
ECG
Pap Smear
2
H.
Pre-employment in lieu of ACU
Applicable for members 35 years old and above

Applicable for members (women) 35 years old and above
Can be availed under Fee for Service. Billing shall be based on actual cost plus
13.5% Claims Handling Fee
PREVENTIVE CARE
1
2
3
Passive and active vaccines for treatment of tetanus and animal bites
Periodic monitoring of health problems
Health-education and counselling on diets or exercise
Health habits and Family Planning counseling
Covered up to Php 18,000 / member / year

Covered
Covered
Covered
ADDITIONAL PROCEDURES AND MODALITIES (shared limit for OP and IP; Professional Fees, Hospital Bills and other incidental expenses relative to
the procedure shall form part of the limit)
Angiography (gastrointestinal, brain, retinal and peripheral vascular)

3
4
Coronary Angiogram and/or Angioplasty/Coronary Artery Bypass

Graft
Cryosurgery
Gamma Knife Surgery
5
6
7
8
9
Hysterescopic Myoma Resection

Hysteroscopically-guided D&C
Laparoscopy
Lithotripsy
Percutaneous Ultrasonic Nephrolithotomy

10
11
12
13
Stereotactic Brain Biopsy

Conventional Hemorrhoidectomy
Scalpel Hemorrhoidectomy
Stapled Hemorrhoidectomy
14
15
16
17
18
Mammotome
4D Ultrasound except for maternity-related cases
Esophageal Manometry
Intensified Modulated Radiotheraphy
Botox which is not cosmetic in nature nor for beautification purpose
19
20
21
Positron Emission Tomography

CT Pulmonary Angiography
Photodynamic Therapy
22
Other medically necessary modalities not mentioned above and those for
which there are no comparable, conventional or traditional counterparts
23
Transurethral Microwave Therapy of Prostate
1
2
I.
Therapeutic Radiology:
c. Linear Accelerator Therapy

d. Radioactive Cesium
e. Radioactive Iodine
Continuous Positive Airway Pressure (CPAP)
G.
Shared limit of up to twelve (12) sessions/member/year subject to MBL for OP;

Up to MBL for IP.
Note: Therapy of one (1) body area shall be considered as one (1) session.
EMERGENCY CARE
1
In Accredited Hospitals


Covered up to Php 5,000 /member /year
Covered up to Php 5,000/ procedure /member /year
a. Doctors services
b. Emergency Room Fees
c. Medicines used for immediate relief during treatment
Subject to MBL
Subject to MBL
Subject to MBL
d. Oxygen, Intravenous fluids and blood products.
Subject to MBL
e. Dressings, conventional casts (plaster of Paris) and sutures.

f. X-Rays, laboratory and diagnostic examinations, and other medical
services related to the emergency treatment of the patient.
Subject to MBL
Subject to MBL
up to 24 hours
g. Room Upgrade in case of room unavailability

2
In Non-Accredited Hospitals
Outside the Philippines
Reimbursable up to 80% of hospital bills & professional fees based on

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 /
year
100% based on Maxicare rates up to MBL
Areas without Accredited Hospital
Ambulance Service
Hospital/Clinic)
Ambulance Service (Non-accredited Hospital/Clinic to Accredited

Hospital/Clinic)
Initial Treatment of Animal Bites
(Accredited
Hospital/Clinic
to
Accredited
Up to MBL
Reimbusable up to Php 2,500 per conduction
Note: The ambulance service provided herein shall be available regardless of the location within the Philippines
J.
K.
PRE-EXISTING CONDITIONS
1
Dreaded Conditions
Covered
Non-Dreaded Conditions
Covered
DENTAL CARE
1
2
Dental examination/consultation only

Oral prophylaxis
3
4
6
7
8
9
Uncomplicated tooth extraction (anterior tooth, posterior tooth, )

Temporary Fillings
Desensitization of hypersensitive teeth (limited to the application of
necessary medicament to the affected teeth)
Simple denture adjustment and repair
Recementation of loose jacket crowns, bridges, inlays and onlays
Palliative treatment for simple mouth sores and blisters
Open incision and drainage (intraoral)
10
11
12
13
Dental Nutrition and Dietary Counseling

Dental Health Education
Pre-natal consultation on teeth and gums
Temporo Mandibular Joint Consultation
14
Permanent Fillings
L.
Covered for the first 24 hrs. from the time of bite subject to MBL
Covered
Covered - Once a year
Covered
Covered, as advised by Dentist
Up to 2 teeth
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Initial Consultation -Covered
2 teeth per year
GROUP LIFE INSURANCE WITH ACCIDENTAL DEATH AND DISABLEMENT (AD&D) BENEFITS
1
2
3
Insurance Provider
Death (amount of insurance)
Corporate Personal Accidental Death & Dismemberment (AD&D)
A. Schedule of Losses for AD&D Coverage
i.) Loss of Life
The Philippine American Life & General Insurance Company

up to Php 25,000 /member
100% of amount of insurance
ii.) Accidental Death, Dismemberment & Disablement or Loss of Use of Limbs

Both Hands
Both Feet
One hand and One foot
One hand
Arm between elbow and wrist

Arm at or above elbow

Leg below knee
Leg at or above knee
iii.) Loss of sight

Both eyes
One eye
iv.) Loss of speech
v.) Loss of hearing


Both ears
One ear
vi.) Accidental Dismemberment or Loss of Use of Fingers
All of one hand
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
Injury due to homicide or any attempt thereof not occasioned by
provocation of Insured member
ix.) Flying Coverage
100% of amount of insurance (but not exceeding 250,000)

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.
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.
General Guidelines
A. Eligibility Age
Benefits:
Life
Principals, Spouse / Parent: 18 to 69 years old; Children / Sibling: 14 days to 26

years old
AD&D
Principals, Spouse / Parent: 18 to 65 years old; Children / Sibling: 14 days to 26

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
ii.) Dependents of Single Employees
Siblings who are single, unemployed and fully dependent on the principal for
support
iii.) Dependents of Single Parent 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
Parents who are actively performing the daily normal chores of life
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

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

Motor Vehicular Accidents
Provoked and Unprovoked Assault, including domestic violence,

whether initiated by the Member or by a known or unknown third party
Up to MBL
Scoliosis, including necessary procedures, except physical therapy

sessions, whether congenital, pre-existing, developmental or acquired
Up to Php 20,000 /member /year (shared limit for OP and IP)

Note: Physical Therapy sessions shall form part of the Physical therapy
/Occupational therapy limits.
Congenital Conditions
developmental disorders
up to Php 20,000 /member /year (shared limit for OP and IP)

Note: Physical Therapy sessions shall form part of the Physical therapy
/Occupational therapy limits.
6
7
Chronic Dermatoses
Scabies
Congenital Hernia
except
physical
therapy
sessions
and
Covered up to MBL
Consultations only
Consultations and treatments
N.
Exclusion #25
Hepatitis B
ADDED PROGRAM FEATURES

1
2
3
24-Hour/7 Days a Week Customer Care Hotline

Roving Customer Care Representative
Manner of Access:
a. Hospitals
b. Clinics
c. Primary Care Centers
O.
Covered up to MBL
Covered up to MBL (if acquired)
4
5
d. Maxicare Centers
e. Accredited Doctors
PayorLink System
Orientations
VAT Charges
ID Processing Fee
Booklets & Summary of Coverage (SOC)
more than 1,000 Hospitals (65% are tertiary hospitals) and Clinics
Maxicare Primary Care Centers at Makati Medical Center, Filomena Bldg., St.
Luke's Medical Center - Quezon City, The Medical City, Chinese General
Hospital, Asian Hospital, My Health Clinic - Festival Mall, My Health Clinic EDSA Shangri-La Plaza
Cebu, Bacolod, Iloilo, General Santos & Davao
over 27,000 accredited doctors (composed of Fellows, Diplomates)
Inclusive (12% of the VATable portion) of the membership fees

at no additional cost
1 per principal member
MEMBERSHIP GUIDELINES
1 Age Eligibility
Principals
*
*
*
2
18 up to 65 years old
Adult Dependents
Minor Dependents
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.
Hierarchy of Enrollment to be followed:
18 up to 65 years old
15 days old up to 21 years old
Married Employees
Legal spouse must be enrolled first, followed by the eldest to the youngest
child.
Single Employees
Both parents (anyone ahead of the other) and then the siblings (eldest to the
youngest)
Single Parent Employees
Children (eldest to youngest) and/or Parents (anyone ahead of the other) and
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
a. Non-contributory accounts
100% of all eligible employees should enroll all the eligible dependents under
the program or the number of dependents should reach 75% of the total
number of principals.
b. Contributory accounts
At least 75% of all eligible employees should enroll all the eligible dependents
under the program or the number of dependents should reach 75% of the total
number of principals.
4 Philhealth Integration
MBL on top of Philhealth. Philhealth portion not deductible to the member's

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%
2
3
4
60% - 74.9%
40% - 59.9%
Below 40%
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 noncontributory. 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
2
3
Masterlist of Enrollees
Medical Requirements* (at the applicant's account)
Other medical requirements if deemed necessary
Waived
Maxicare Format
Waived
Waived
NOTES:
1
The coverage for the Special Diagnostic Procedures are subject to the recommendation of the accredited physician if medically necessary and the provisions
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
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.

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29 October 2013

Dear Ms. Maramba

/ Health Benefit Agent

We trust this finds you in good health.

forward to seeing you soon.

ERWIN S. DELA CRUZ

WHY IS MAXICARE THE BEST HMO FOR YOUR

Extensive Healthcare Program which includes the

Vast Network of Providers

More than 27,000 Top-Caliber Accredited

All Maxicare Centers are on-line with the

Maxicare Intelligent Card

MAXICARE PRIMARY CARE CENTERS

The Advantages of Primary Care Centers

Easy access to Internal Medicine Specialists

Quality lab exams @ the least possible cost

G/F Filomena Building Amorsolo Street Legaspi Village, Makati City

MyHealth Clinic North EDSA

MyHealth Clinic Calamba

MyHealth Clinic Cebu

Extensive Customer Care Network

Maxicare 24/7 CUSTOMER CARE

Maxicare SMS Inquiry

Calamba Medical Center: Ground floor , Central Registration,

MANILA DOCTORS HOSPITAL : Room 220, Manila Doctors Hospital

Maxicare EMAIL CUSTOMER SUPPORT

Maxicare FAN PAGE

* Members can like us on facebook and send inquires and

MAXICARE PLUS 2013 (Group 5 to 19)

Nationwide access to all accredited hospitals/clinics including 9 major hospitals (Asian

Plan Type Room and Board

RATES FOR DEPENDENTS PER HEAD

Plan Type Room and Board

Plan Type Room and Board

RATES FOR DEPENDENTS PER HEAD

Plan Type Room and Board

Inclusive in the rates

Life with AD&D - Php 25,000

Inclusive in the rates

MAXICARE PLUS (Group)

Consultations during regular clinic hours, except prescribed medicines

Pre and Post Natal consultations

Eye, ear, nose and throat (EENT) treatment prescribed by an Accredited

Minor surgery not requiring confinement prescribed by an Accredited

Allergy Testing/ allergy screening and other related examinations

Speech therapy (for stroke patients only)

Up to Php 10,000 /eye /member /year

Up to Php 1,000 /member /year

Up to Php 5,000 / leg / member / year

Subject to the Member's Room and Board limit

Medicines for in-patient use

Anesthesia and its administration

Oxygen and its administration

Standard Admission kit

X-Ray, laboratory examinations, routine, diagnostic and therapeutic

ROUTINE PROCEDURES (whether IP or OP)

100% of Actual Cost subject to MBL

Complete Blood Count (CBC)