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BPI OFFICERS PARENT DEPENDENTS PROGRAM

2015 IMPLEMENTING GUIDELINES


Coverage Period September 01, 2015 - August 31, 2016
I.

ELIGIBILITY
Both Single and Married Officers employees are entitled to enroll both of their parents or either parent to the
program.
No addition and deletion of enrolled dependents within the coverage period.
A.

AGE

B.

For Single Employees, they shall enroll their qualified dependent/s to Gold 1 or Silver 1 Plans only
For Married Employees, they shall enroll their qualified dependent/s to Gold 2 or Silver 2 Plans only
Shall the employee wish to enroll both parents, they have to be enrolled to one /same plan only.
No upgrading or downgrading of plan within the coverage period
Only dependents of newly hired employees maybe enrolled in the middle of the coverage within 30
days from date of hire.

PLAN, ROOM and BOARD and MAXIMUM BENEFIT LIMIT


Plan Type
Gold 1
Gold 2
Silver 1
Silver 2

III.

: up to 65 years old
: up to 65 years old

PLAN TYPE

II.

Mother
Father

Member Type
Parent/s of
Single Employees
Parent/s of
Married Employees
Parent/s of
Single Employees
Parent/s of
Married Employees

Maximum
Benefit Limit

Room and Board

ACU

100,000.
Regular Private
100,000.
Routine (Clinic)
100,000.
Semi-Private
100,000.

PROVIDER ACCESS
Nationwide access to all accredited hospitals/clinics including nine (8) major hospitals. The following are the Nine (8)
Major Hospitals:
1.
Asian Hospital & Medical Center
2.
Cardinal Santos Medical Center
3.
Makati Medical Center
4.
St. Luke's Medical Center - Quezon City
5.
The Medical City
6.
Cebu Doctors Hospital
7.
Chong Hua Hospital
8.
Davao Doctors Hospital
Moreover, Members shall have no access to Healthway Medical Clinics and St. Lukes Medical Center Global City.

IV. BENEFIT
The benefits covered which should be availed at the HMO Accredited hospitals / clinics through the Maxicare
Coordinator, are as follows:

OUT-PATIENT CARE
IN-PATIENT CARE
ANNUAL CHECK-UP
PREVENTIVE CARE
EMERGENCY CARE
DENTAL CARE

HEALTHCARE BENEFITS
A.

Coverage/Limits (FULL HMO)

OUT-PATIENT (OP) CARE

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

Subject to MBL

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 however
that the cost of diagnostic and therapeutic
procedures covered shall be limited to a specific
amount.

Subject to MBL

Minor surgery not requiring confinement prescribed


by an Accredited Physician /Specialist

Subject to MBL

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.

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

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 Accreditted Physician /Specialist

Up to Php1,000 /member /year

10

Sclerotherapy for varicose veins (except medicines


and for cosmetic purposes) as prescribed by an
Accredited Physician, to be availed through
accredited vascular surgeons.

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

11

Allergy Testing/ allergy screening and other related


examinations prescribed by an Accredited Physician

Up to Php 2,500 /member /year

12

Speech therapy (for stroke patients only)

13

Tuberculin test
B.

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 (IP) CARE

Room and Board Accommodation

Use of operating room, Intensive Care Unit (ICU),


isolation room (if prescribed by Attending
Accredited Physician) and recovery room.

Subject to the Members Room and Board limit


Subject to MBL

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 MBL

Medicines for in-patient use

Subject to MBL

Blood products transfusions and intravenous fluids,


including blood screening and cross matching.
X-Ray, laboratory examinations, routine, diagnostic
and
therapeutic
procedures
incidental
to
confinement

10
11

Subject to MBL

Subject to MBL
Subject to MBL

12

Dressings, conventional casts (plaster of Paris) and


sutures

Subject to MBL

13

Anesthesia and its administration

Subject to MBL

14

Oxygen and its administration

Subject to MBL

15

Standard Admission kit

Subject to MBL

16

All other items directly related in the medical


management of the patient, as deemed medically
necessary by the Attending Accredited Physician

Subject to MBL

C.

ROUTINE PROCEDURES

Whether OP or IP

Blood Chemistries

100% of Actual Cost subject to MBL

Chest X-Ray

100% of Actual Cost subject to MBL

Complete Blood Count (CBC)

100% of Actual Cost subject to MBL

Fecalysis

100% of Actual Cost subject to MBL

Urinalysis

100% of Actual Cost subject to MBL

D.

DIAGNOSTIC PROCEDURES

Whether OP or IP

12-Lead Electrocardiogram (ECG)

100% of Actual Cost subject to MBL

24-hour Electroencephalogram (EEG) Monitoring

100% of Actual Cost subject to MBL

24-hour Holter Monitoring

100% of Actual Cost subject to MBL

Adrenocortical Function

100% of Actual Cost subject to MBL

Anti-Nuclear Antibody, C-Reactive Protein, Lupus


Cell Exam

100% of Actual Cost subject to MBL

Arterial Blood Gas

100% of Actual Cost subject to MBL

Arthroscopic Procedures, Orthopedic Arthroscopy

100% of Actual Cost subject to MBL

Audiograms and Tympanograms

100% of Actual Cost subject to MBL

Bone Densitometry Scan (Dexascan)

100% of Actual Cost subject to MBL

Bone Mineral Density Studies

100% of Actual Cost subject to MBL

10
11
12

Cardiac Stress Tests


(Thallium and Dipyridamole Stress Tests)
Computed Tomography (CT) Scans

100% of Actual Cost subject to MBL


100% of Actual Cost subject to MBL

Diagnostic Radiographs:
13

a. Biliary tract: Cholecystogram and Cholangiogram

100% of Actual Cost subject to MBL

14

b. Chest, ribs, sternum and clavicle

100% of Actual Cost subject to MBL

15

c. Digestive: Plain film of the abdomen, Barium


Enema, Upper Gastrointestinal (GI) Series, Lower GI
Series, Small Bowel series

100% of Actual Cost subject to MBL

16

d. Face (including sinuses), Head and Neck

100% of Actual Cost subject to MBL

17

e. Urinary: Kidney, Ureter and Bladder (KUB)


Pyelograms and Cystograms

100% of Actual Cost subject to MBL

18

f. X-ray of the extremities and pelvis

100% of Actual Cost subject to MBL

19

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

100% of Actual Cost subject to MBL

Diagnostic Ultrasounds:
20

a. 2D-Echo with Doppler

100% of Actual Cost subject to MBL

21

b. Abdomen

100% of Actual Cost subject to MBL

22

c. Duplex Scan

100% of Actual Cost subject to MBL

23

d. Digestive and Urinary Systems

100% of Actual Cost subject to MBL

24

e. Ultrasound of the Lungs

100% of Actual Cost subject to MBL

25

Electroencephalogram (EEG) Monitoring

100% of Actual Cost subject to MBL

26

Electromyelography and Nerve Conduction Studies

100% of Actual Cost subject to MBL

27

Endoscopic Procedures

100% of Actual Cost subject to MBL

28

Fluorescein Angiography

100% of Actual Cost subject to MBL

29

Impedance Plethysmography

100% of Actual Cost subject to MBL

30

Magnetic Resonance Angiography (MRA)

100% of Actual Cost subject to MBL

31

Magnetic Resonance Imaging (MRI)

100% of Actual Cost subject to MBL

32

Mammogram and Sonomammogram

100% of Actual Cost subject to MBL

33

Myelogram

100% of Actual Cost subject to MBL

34

Nuclear Radioactive Isotope Scan

100% of Actual Cost subject to MBL

35

Pap's Smear

100% of Actual Cost subject to MBL

36

Perfusion Scan

100% of Actual Cost subject to MBL

37

Plasma Urinary Cortisol, Plasma Aldosterone

100% of Actual Cost subject to MBL

38

Polysomnograms (Sleep Recording)

100% of Actual Cost subject to MBL

39

Pulmonary Function Tests

100% of Actual Cost subject to MBL

Radioisotope Scans and Function Studies:


40

a. Cardiac

100% of Actual Cost subject to MBL

41

b. Gastrointestinal

100% of Actual Cost subject to MBL

42

c. Liver

100% of Actual Cost subject to MBL

43

d. Parathyroid Bone, Pulmonary (Perfusion/


Ventilation Lung Scans)

100% of Actual Cost subject to MBL

44

e. Renal

100% of Actual Cost subject to MBL

45

f. Thyroid Scans

100% of Actual Cost subject to MBL

46

g. Total Body Scans

100% of Actual Cost subject to MBL

47

Radionuclide Ventriculography

100% of Actual Cost subject to MBL

48

Surface Electromyography (SEMG)

100% of Actual Cost subject to MBL

49

Thallium Scintigraphy

100% of Actual Cost subject to MBL

50

Treadmill Stress Test (TMST)

100% of Actual Cost subject to MBL

E.

THERAPEUTIC PROCEDURES

Arthrocentesis

Up to six (6) sessions subject to MBL for OP; Up to MBL for IP

Dialysis

Up to twelve (12) sessions subject to MBL for OP; Up to MBL


for IP

Intravenous Chemotherapy

Up to twelve (12) sessions subject to MBL for OP; Up to MBL


for IP

Phlebotomy

Up to six (6) sessions subject to MBL for OP; Up to MBL for IP


or Based on TOR

Physical therapy / Occupational therapy excluding


subspecialties such as cardiac rehabilitation,
pulmonary rehabilitation and the like.

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]

Thoracentesis

Continuous Positive Airway Pressure (CPAP) titration


for sleep study

Up to six (6) sessions subject to MBL for OP; Up to MBL for IP


Up to Php 60,000 shared limit for OP and IP

Oral chemotherapy

Up to Php 60,000 shared limit for OP and IP

Therapeutic Radiology:
a. Brachytherapy

Up to twelve (12) sessions subject to MBL for OP; Up to MBL


for IP

10

b. Cobalt

Up to twelve (12) sessions subject to MBL for OP; Up to MBL


for IP

11

c. Linear Accelerator Therapy

Up to twelve (12) sessions subject to MBL for OP; Up to MBL


for IP

12

d. Radioactive Cesium

Up to twelve (12) sessions subject to MBL for OP; Up to MBL


for IP

13

e. Radioactive Iodine

Up to twelve (12) sessions subject to MBL for OP; Up to MBL


for IP

F.

PREVENTIVE CARE

Routine Immunization except cost of vaccines

Passive and active vaccines for treatment of tetanus


and animal bites

Periodic monitoring of health problems

Health-education
exercise

Health habits and Family Planning counseling

G.
1
2

and

counseling

Not Covered
Up to Php18,000 /member /year
Covered

on

diets

or

ADDITIONAL PROCEDURES AND MODALITIES


Angiography (gastrointestinal, brain, retinal and
peripheral vascular)
Coronary Angiogram and/or Angioplasty/Coronary
Artery Bypass Graft

Covered
Covered

Shared limit for OP and IP; Professional Fees, Hospital Bills


and other incidental expenses relative to the procedure
shall form part of the limit
100% of Actual Cost subject to MBL
100% of Actual Cost subject to MBL (shared limit)

Cryosurgery

100% of Actual Cost subject to MBL

Gamma Knife Surgery

100% of Actual Cost subject to MBL

Hysteroscopic Myoma Resection

100% of Actual Cost subject to MBL

Hysteroscopically-guided D&C

100% of Actual Cost subject to MBL

Laparoscopy

100% of Actual Cost subject to MBL

Lithotripsy

100% of Actual Cost subject to MBL

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

Up to Php 5,000 /member /year

14

Mammotome

Up to Php 5,000 /member /year

15

4D Ultrasound except for maternity-related cases

Up to Php 5,000 /member /year

16

Esophageal Manometry

Up to Php 5,000 /member /year

17

Intensified Modulated Radiotheraphy

Up to Php 5,000 /member /year

18

Botox which is not cosmetic in nature nor for


beautification purpose

Up to Php 5,000 /member /year

19

Positron Emission Tomography (PET) Scan

Up to Php 5,000 /member /year

20

CT Pulmonary Angiography

Up to Php 5,000 /member /year

21

Photodynamic Therapy

Up to Php 5,000 /member /year

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


H.

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

Up to Php 25,000 /member /year

EMERGENCY CARE
In Accredited Hospitals
a. Doctors 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
f. X-Rays, laboratory and diagnostic examinations,
and other medical services related to the
emergency treatment of the patient
g. Room Upgrade in case of room unavailability
2

In Non-Accredited Hospitals

Outside the Philippines

Areas without Accredited Hospital


Ambulance Service (Accredited Hospital/Clinic to
Accredited Hospital/Clinic)
Ambulance Service (Non-Accredited Hospital/Clinic
to Accredited Hospital/Clinic)

5
6

Subject to MBL
Subject to MBL
up to 24 hours
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 Php 30,000
/availment /member /year
100% based on Maxicare rates up to MBL
Subject to MBL
Reimbursable up to Php 2,500 per conduction

Note: The ambulance service provided herein shall be available regardless of the location within the Philippines.
7

Initial treatment of Animal bites

I.

PRE-EXISTING CONDITIONS

Dreaded Conditions

Non-Dreaded Conditions

J.

Covered for the first 24 hrs. from the time of bite subject to
MBL

Covered up to Php 50,000 per member per year


subject to MBL.
Covered up to Php 50,000 per member per year
subject to MBL.

CONDITIONS WITH SPECIFIC LIMITATIONS

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

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)

Congenital Conditions except physical therapy


sessions and developmental disorders

Up to Php 20,000 /member /year (shared limit for OP and


IP)

Congenital Hernia

Chronic Dermatoses

Scabies

Exclusion #25

Up to MBL
Subject to MBL and exclusions and limitations
Up to MBL

Up to MBL
Consultations only
Consultations and treatments
Up to MBL (if acquired) and subject to Dreaded Preexisting provision (if Pre-existing)

10

Hepatitis B except vaccines

11

Hepatitis B Screening

K.

Up to MBL (if acquired)


Not Covered

ANNUAL CHECK-UP

The following Routine ACU program shall be conducted at a designated Maxicare Accredited Clinic once a year:
1

Physical Examination

Covered

Complete Blood Count

Covered

Urinalysis

Covered

Fecalysis

Covered

Chest X-ray

Covered

Electrocardiogram (ECG)

Pap's Smear

Other ACU Tests

For members 35 years old and above


For female members 35 years old and above
None

L. DENTAL CARE
Dental Provider

Maxicare Dental Hub

Annual Dental examination and consultation

Covered

Emergency out-patient dental treatment - to be


availed at accredited dental clinics only

Covered

Oral Prophylaxis)

Simple tooth extractions.

Covered

Restorative and prosthodontic treatment planning

Covered

Temporary fillings.

Unlimited

Desensitization of hypersensitive teeth.

Simple adjustment and repair of dentures.

Covered

Re-cementation of loose crowns,bridges, inlays and


onlays.

Covered

10

Dental nutrition and dietary counseling.

Covered

11

Dental health education.

Covered

12

Permanent fillings

13

Palliative treatment for simple mouth sores and blisters

Covered

14

Open incision and drainage (intraoral)

Covered

15

Pre-natal check of teeth and gums

Covered

16

Temporo Mandibular Joint Consultation (Initial consult


only, referral to specialist not covered)

Covered

17

Gum Treatment for cases like inflammation or


bleeding

Covered

Covered - once a year

Up to 2 Teeth per year

2 Teeth Per Year

V.

APPLICABLE MEMBERSHIP FEES (PER HEAD)

Plan Type

Member Type

MEMBERSHIP FEES PER HEAD


(Inclusive of VAT and Net of Philhealth)
Annual

Gold 1

Parent/s of Single Employees

Gold 2

Semi-Annual

Quarterly

P 37,939.

P 20,487.

P 10,623.

Parent/s of Married Employees

45,435.

24,535.

12,722.

Silver 1

Parent/s of Single Employees

30,714.

16,586.

8,600.

Silver 2

Parent/s of Married Employees

36,764.

19,852.

10,294.

Note:

Rates are Inclusive of 12 % VAT


Coverage is Net of Philhealth

VI. MODE OF PAYMENT


A.

ANNUAL

Total premium shall be paid by the principal member on an annual basis. Premium of all enrolled
members shall be paid in full on or before November 11, 2014

Payments can be made via cash, cheque or credit card directly to Maxicare Healthcare Corporation,
3/F Maxicare Tower, 203 Salcedo St. Legaspi Village, Makati City

Cash and cheque payments can be made through BPI Payment Facility with Reference#:
BPI0000001000 (Payment Slip must be attached as proof of payment with name of dependent)

Proof of payment such as the Official Receipt or Machine Validated Deposit Slip must be attached to
the application form. Kindly indicate member/s name and contact numbers to the deposit slip.

No Payment, No Processing of application.

B.

SEMI-ANNUAL
First-Half Premium

Total First half premium shall be paid by the member on or before November 11, 2014
Payments can be made via cash, cheque or credit card directly to Maxicare Healthcare Corporation,
3/F Maxicare Tower, 203 Salcedo St. Legaspi Village, Makati City
Cash and cheque payments can be made through BPI Payment Facility with Reference #:
BPI0000001000 (Payment Slip must be attached as proof of payment with name of dependent)
Proof of payment such as the Official Receipt or Machine Validated Deposit Slip must be attached to
the application form. Kindly indicate member/s name and contact numbers to the deposit slip.
No Payment, No Processing of application.

Second-Half Premium

Total second half premium (balance) shall be paid on or before January 15 , 2015
Payment can be made via auto debit to credit card or post-dated cheque (PDC) only.
Post-dated cheques shall be payable to Maxicare Healthcare Corporation. This should be submitted
together with the initial payment and completed application form
For credit card payments, any unsuccessful deduction due to insufficient limit, card suspension and
cancellation, or any other reasons that may cause disapproval of the transaction, Maxicare shall
automatically suspend its healthcare services. Suspension an only lifted upon payment of the total
amount due and corresponding penalty fee, if any. Credit card deduction form shall be submitted
together with the initial payment and completed application form.

C.

QUARTERLY
First-Quarter Premium

Total First Quarter premium shall be paid by the member on or before November 11, 2014
Payments can be made via cash, cheque or credit card directly to Maxicare Healthcare Corporation,
3/F Maxicare Tower, 203 Salcedo St. Legaspi Village, Makati City
Cash and cheque payments can be made through BPI Payment Facility with Reference#:
BPI0000001000 (Payment Slip must be attached as proof of payment with name of dependent)
No Payment, No Processing of application.

2nd 4th Quarter Premium

Payment can be made via auto debit to credit card or post-dated cheque (PDC) only.
Payment due date is the 15th day of the month before the new quarter
o
January 15, 2015
o
April 15, 2015
o
July 15, 2015
Post-dated cheques shall be payable to Maxicare Healthcare Corporation. This should be submitted
together with the initial payment and completed application form
For credit card payments, any unsuccessful deduction due to insufficient limit, card suspension and
cancellation, or any other reasons that may cause disapproval of the transaction, Maxicare shall
automatically suspend its healthcare services. Suspension an only lifted upon payment of the total
amount due and corresponding penalty fee, if any. Credit card deduction form shall be submitted
together with the initial payment and completed application form.

** Premiums for parent dependents of newly promoted employee to be enrolled in the middle of the coverage shall be subject to
Pro-rated premiums.
PARTICIPATION REQUIREMENT: Minimum Headcount requirement is 40 enrollees only.
VII. EXCLUSIONS
Notwithstanding any provisions to the contrary, the following shall not be covered except otherwise specified in List of
Benefits
Services obtained for non-emergency conditions from Physicians and Hospitals in any of the following
circumstances:
1

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.

Additional hospital charges and physicians professional fees resulting from:


room-upgrading beyond Members allowable time during emergency care
extension of hospital stay despite release of discharge order from Members attending physician
fees of the assistant surgeons / resident doctors who assisted the Attending Physician in the process of rendering
the medical 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
use of extra bed, TV, electric fan, DVD/ VCD, and other similar items unless such appliances and items are
necessarily and ordinarily included in the Members Room & Board Accommodation
extra food
toilet articles like face towel, soap, toothbrush and the like
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 Members Room and Board Accommodation limit
services of a private or a special nurse
all other items not medically necessary in the medical management of the patient.

Custodial, domiciliary, convalescent and intermediate care.


A. Long-term rehabilitation.

B. Psychiatric and/or psychological illnesses and conditions including neurotic and psychotic behavior disorders;
anxiety disorders.

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.

Developmental disorders including functional disorders of the mind, such as but not limited to Attention-Deficit
Disorder (ADD)/Attention-Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorders, Bipolar Disorders,
Central Auditory Processing Disorder (CAPD), Cerebral Palsy, Down Syndrome, Neural Tube Defects, and Mental
Retardation.
Treatment of any injury received when there is:
A. Negligence
B. unauthorized use of prohibited drugs or regulated drugs

C. alcoholic liquor intake


D. direct or indirect participation in the commission of a crime whether consummated or not
E. violation of a law or ordinance
F. unnecessary exposure to imminent danger, knowingly or unknowingly or hazard to health, by the member
Note: Maxicare may require the Member to submit Police or Doctor's report to evaluate such claim.

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.
A. Oral surgery following accidental injury to teeth for purposes of beautification.

B. 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.
C. 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.
A. Circumcision (except for treatment of urological conditions).
B. Sex transformation

11

C. Diagnosis, treatment and procedures related to fertility or infertility


D. Artificial insemination
E. Sterilization or reversal of such and their complications.

12

Experimental medical procedures and its complications.


A. Acupuncture and its complications.

13

B. Chirotherapy and its complications.


C. 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.
A. Corrective appliances
B. Artificial aids

17

B. 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 screw/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


chemotherapy medicine
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

A. Sexually transmitted diseases and genital warts.


B. AIDS and AIDS related diseases.
A. Valvular heart disease (congenital and/or acquired) including Cardiomyopathies
B. Chronic Glomerulonephritis
C. previous craniotomy sequelae
D. hearing impairment
E. Neurologic disease
F. Spinal Stenosis (if pre-existing)

25

G. Poliomyelitis
H. Slipped disc (if pre-existing)
I. Guillain-Barre Syndrome
J. Diabetes and its complications (if pre-existing)
K. Complicated Hypertension (e.g. those with history of stroke, myocardial ischemia or infarction and poor kidney
function)
L. 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.
A. Pre-existing Hepatitis B

28

B. Screening for all types of Hepatitis


C. 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.


A. Weight reduction programs

33

B. 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.

37

All screening tests.

38

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

39

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

40.

Intravenous Immunoglobulin (IVG)

IMPORTANT REMINDERS:

The program is on a voluntary enrolment basis

All principal members must submit the following Enrolment Forms:


o
Application Form
o
Photocopy of BPI Machine-validated Payment Slip as proof of payment with name of dependent
using Reference#: BPI0000001000 via BPI SBA.
o
3 Original completed Credit Card Deduction Form (for credit card payments only)
o
Photocopy of Parent/ss birth certificate

Incomplete Application Form and Credit Card Deduction Forms (for credit card payments) will not be processed

Maxicare Premium cards will be issued to all qualified enrolled dependents 10 working days after the effective date.

All dependents of the same principal member must be enrolled under one plan only.

No additional enrolment and disenrollment within the coverage period except for newly hired officers and newly
promoted staff (to officer)-employees.

Initial membership fees were based on a 10-month coverage period only. Subject to recomputation for annual rates for
the renewal period.

Coverage shall be cancelled upon resignation /termination of the employee.

Completed Application forms may be submitted to the following:


o
o

BPI CCRs located at 5/F BPI head Office Bldg. Ayala Avenue Makati City or 7th fl. Maxicare Tower Salcedo
St. Legaspi Village Makati City (for deposit transactions)
For over-the-counter cash and cheque payments or credit card payments please forward the application
forms to 7th fl. Maxicare Tower Salcedo St. Legaspi Village Makati City

For Enrolment Inquiries / benefit Clarifications and Enrolment submission, please contact the following:
o
Emma Flor Dulay emma.dulay@maxicare.com.ph
o
Arianne May De Leon arianne.deleon@maxicare.com.ph
o
Jennifer de Leon jennifer.deleon@maxicare.com.ph
o
Hannah Llorente hannah.llorente@maxicare.com.ph
o
Tel Nos. (02) 9086900 local 1110, 1105 or 1125. Group Email: bpi.enrollment@maxicare.com.ph

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