HMO Coverage With PhilCare Voluntary Dependent Plan
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1 PHILIPPINES HMO With PhilCare Voluntary Dependent Plan As part of our commitment of providing your health security through quality health care, it is our pleasure to present to you our health care guidelines for your reference. This provides information on your medical benefits under Teletech Customer Care Management Philippines, Inc. PhilCare s network of accredited providers nationwide gives members an advantage of experiencing the medical service enjoyed by the largest and best corporations in the country. You also get to maximize technology s benefits with the use of NFC- equipped card, smartphone-enabled applications and a web-based database system. The Voluntary Dependent Plan is a standalone plan that gives single and married employees the ability to enroll their dependent parents and over-aged siblings/children in health care coverage. COVERAGE CLASSIFICATION Dependents coverage are classified according to the following table. DEPENDENT/S CLASSIFICATION Classification Room Accommodation Maximum Daily/ Room & Board Maximum Benefit Limit (MBL) All Levels - Dependents of Directors, Managers, Supervisors and Rank and File Regular Private 1, , ELIGIBILITY Adult Dependents (parents): father and/or mother, up to 65 years old. Over-aged child/sibling dependents 22 to 25 years old, single and unemployed. COVERAGE OVER PROCEDURES Plan benefits and covered services are consistent with those offered to Rank and File employees on the company -sponsored plan, with the exception of eye laser therapy. Upon consultation and availment, a working diagnosis will be identified by a medical personnel to proceed with procedures. Below are the procedures covered under our plan.
2 Outpatient (Op) Care Inpatient (Ip) Care Consultations during regular clinic hours, except prescribed medicines Room and Board Accommodation Pre and Post Natal consultations. Eye, ear, nose and throat (EENT) treatment prescribed by an Accredited Physician/Specialist Treatment for minor injuries such as lacerations, mild burns, sprains and the like Dressings, conventional casts (plaster of Paris) and sutures. Covered up to 14 sessions subject to MBL Use of operating room, Intensive Care Unit (ICU), isolation room (if prescribed by Attending Accredited Physician) and recovery room. Professional fees in accordance with HMO Schedule of Rates. a. Attending Physicians b. Surgeons c. Anesthesiologists d. Cardio-pulmonary clearance before surgery and cardiac monitoring during surgery. 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. Standard Nursing Services Medicines for inpatient use Minor surgery not requiring confinement prescribed by an Accredited Physician /Specialist Blood products transfusions and intravenous fluids, including blood screening and cross matching. Cauterization 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 Accredited Physician/Specialist. Sclerotherapy for varicose veins (except medicines and for cosmetic purposes) as prescribed by an Accredited Physician, to be availed through accredited vascular surgeons. Allergy Testing/ allergy screening and other related examinations prescribed by an Accredited Physician Covered up to Php1,000.00/ member /year 30,000.00/member/year 10,000.00/member/year Covered up to Php2,500.00/ member/year X-ray, laboratory examinations, routine, diagnostic and therapeutic procedures incidental to confinement Dressings, conventional casts (plaster of Paris) and sutures Anesthesia and its administration Oxygen and its administration Standard Admission kit Speech therapy (for stroke patients only) Tuberculin test Principal: Covered up to 16 sessions/ member/year (reimbursement basis). Note: Consultations shall be part of the limit and treated as sessions Covered up to Php600.00/ member/year All other items directly related in the medical management of the patient, as deemed medically necessary by the Attending Accredited Physician Blood Chemistries Chest X-ray Routine Procedures (Whether Op Or Ip)
3 Routine Procedures (Whether Op Or Ip) Diagnostic Procedures (Whether Op Or Ip) Complete Blood Count (CBC) Fecalysis Urinalysis Diagnostic Procedures (Whether Op Or Ip) Diagnostic Ultrasounds: a. 2D-Echo with Doppler b. Abdomen c. Duplex Scan d. Digestive and Urinary Systems e. Ultrasound of the Lungs 12-Lead Electrocardiogram (ECG) Electroencephalogram (EEG) Monitoring 24-hour Electroencephalogram (EEG) Monitoring Electromyelography and Nerve Conduction Studies 24-hour Holter Monitoring Endoscopic Procedures Adrenocortical Function Fluorescein Angiography Anti-Nuclear Antibody, C-Reactive Protein, Lupus Cell Exam Impedance Plethysmography Arterial Blood Gas Magnetic Resonance Angiography (MRA) Arthroscopic Procedures, Orthopedic Arthroscopy Magnetic Resonance Imaging (MRI) Audiograms and Tympanograms Mammogram and Sonomammogram Bone Densitometry Scan (Dexascan) Myelogram Bone Mineral Density Studies Nuclear Radioactive Isotope Scan Cardiac Stress Tests (Thallium and Dipyridamole Stress Tests) Pap Smear Computed Tomography (CT) Scans Perfusion Scan Diagnostic Radiographs: Plasma Urinary Cortisol, Plasma Aldosterone a. Biliary tract: Cholecystogram and Cholangiogram b. Chest, ribs, sternum and clavicle c. Digestive: Plain film of the abdomen, Barium Enema, Upper Gastrointestinal (GI) Polysomnograms (Sleep Recording) Pulmonary Function Tests Series, Lower GI Series, Small Bowel series d. Face (including sinuses), Head and Neck e. Urinary: Kidney, Ureter and Bladder (KUB) Pyelograms and Cystograms f. X-ray of the extremities and pelvis g. X-ray of the spine (cervical, thoracic, lumbo-sacral) Radioisotope Scans And Function Studies: a. Cardiac b. Gastrointestinal c. Liver d. Parathyroid Bone, Pulmonary (Perfusion/ Ventilation Lung Scans) e. Renal
4 Diagnostic Procedures (Whether Op Or Ip) Therapeutic Procedures f. Thyroid Scans g. Total Body Scans Radionuclide Ventriculography Surface Electromyography (SEMG) Thallium Scintigraphy Treadmill Stress Test (TMST) Physical therapy/occupational therapy excluding subspecialties such as cardiac rehabilitation, pulmonary rehabilitation and the like. Principal: Shared limit of up to 16 subject to MBL for OP; for IP Dependent: Shared limit of up to 10 subject to MBL for OP; for IP Note: Therapy of one (1) body area shall be considered as one (1) session Therapeutic Procedures Arthrocentesis Continuous Positive Airway Pressure (CPAP) titration for sleep study Dialysis Intravenous Chemotherapy Oral chemotherapy Phlebotomy Covered up to six (6) sessions subject to MBL for OP; Covered subject to MBL for IP Covered up to Php60, shared limit for OP and IP Covered subject MBL for IP; Dependent: Covered up 10 sessions/ for IP Principal: Covered up 18 sessions/ for IP; subject to MBL for OP; for IP Covered up to Php60, shared limit for OP and IP Covered up to six (6) sessions subject to MBL for OP; Covered subject to MBL for IP Thoracentesis Therapeutic Radiology: a. Brachytherapy b. Cobalt c. Linear Accelerator Therapy d. Radioactive Cesium Covered up to six (6) sessions subject to MBL for OP; for IP Principal: Covered up to 18 subject to MBL for OP; for IP; for IP for IP; for IP Principal: Covered up to 18 subject to MBL for OP; for IP; for IP for IP; for IP
5 e. Radioactive Iodine Therapeutic Procedures Preventive Care for IP; for IP 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) Lithotripsy Percutaneous Ultrasonic Nephrolithotomy to MBL: Dependent: Covered up to to MBL; Dependent: Covered up to Passive and active vaccines for treatment of tetanus and animal bites Covered up to Php15,000.00/member/year Stereotactic Brain Biopsy Periodic monitoring of health problems Covered Conventional Hemorrhoidectomy Health-education and counseling on diets or exercise Covered Scalpel Hemorrhoidectomy Health habits and family planning counseling Covered Stapled Hemorrhoidectomy Covered up to Php5,000.00/member/year 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) Mammotome 10,000.00/procedure/member /year Coronary Angiogram and/or Angioplasty/Coronary Artery Bypass Graft Cryosurgery Gamma Knife Surgery (shared limit) to MBL 40,000.00/member/year 4D Ultrasound except for maternity-related cases Esophageal Manometry Hysteroscopic Myoma Resection to MBL; Dependent: Covered up to Intensified Modulated Radiotheraphy Hysteroscopically-guided D&C Laparoscopy to MBL; Dependent: Covered up to Botox which is not cosmetic in nature nor for beautification purpose Positron Emission Tomography (PET) Scan
6 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) CT Pulmonary Angiography Photodynamic Therapy Other medically necessary modalities not mentioned above and those for which there are no comparable, conventional or traditional counterparts Transurethral Microwave Therapy of Prostate Conditions With Specific Limitations: 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 Congenital Conditions except physical therapy sessions and developmental disorders Congenital Hernia Chronic Dermatoses Scabies 10,000.00/procedure/member /year Principal: 40,000.00/member/year 30,000.00/member /year 20,000.00/member /year 30,000.00/member /year 20,000.00/member /year Consultations only Consultations and treatments 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). Hepatitis B except vaccines and screening Prosthetic Device DENTAL BENEFITS Diagnostic Procedures (Whether Op Or Ip) 1. Annual dental examinations and consultations; 2. Emergency outpatient dental treatment to be availed at accredited dental clinics; Up to MBL (if acquired) and subject to dreaded pre-existing provision (if pre-existing) If acquired, covered subject to MBL; If pre-existing, covered subject to MBL as long as not STD-related 20,000.00/member/year Dependent: Not Covered 3. Unlimited, with flouride brushing oral scaling and polishing (prophylaxis) for senior managers to directors; 4. Two (2) oral scaling and polishing (prophylaxis) with flouride brushing per year for rank and file to managers; Simple tooth extraction; 5. Restorative and prosthodontic treatment planning; 6. Temporary fillings-unlimited as needed 7. Desensitization of hypersensitive teeth up to two (2) teeth; 8. Simple adjustment of dentures; 9. Recementation of loose crowns, inlays and onlays; 10. Dental nutrition and dietary counseling; 11. Dental health education; 12. Pre-natal check of teeth and gums; 13. Temporo mandibular joint consultation; 14. Gum treatment for cases like inflammation or bleeding; 15. Lightcure fillings up to four (4) teeth (per contract year); and 16. Guaranteed Dental discount at all HMO Dental Network accredited clinics (specify amount, e.g. 25%).
7 PRE-EXISTING CONDITIONS The pre-existing conditions (PEC) are covered under this plan. A pre-existing condition is an illness, injury or condition shall be considered pre-existing if prior to the effective date of the member s coverage and within the first 12 months from the effective date of the coverage: NO-COPAY CLINICS See list of PhilCare accredited clinics that don t require copayments. Sta. Rosa Lipa Pampanga Dumaguete Bacolod Iloilo Novaliches Cebu1 Cebu2 EBloc Site Roxas 5Ecom Roxas 2ECom Aseana One Ayala (FGU) Makati Ecoplaza Cainta Pioneer Quezon City Araneta Clinic PMP Diagnostic Clinic, CygnetMed Health System, Wellcare Clinic and Laguna Industrial Health Clinic Inc. - SM Sta Rosa St. Joseph Healthcare Inc. Lipa, MD Link Healthcare Stotsenberg Medical Center, Hematech Diagnostic Center, R.A.C.H.F Diagnostic Lab, Parian Diagnostic Laboratory and Hi-Precision clinic Angeles City Negros Oriental Hospital and Health Services Cooperative, Metro Dumaguete Diagnostics Care and Laboratory Services -Maria Cristina, Metro Dumaguete Diagnostics Care and Laboratory Services Maxima Limquiaco MP Analysis & Laboratory Inc.. MCS Diagnostics and Villanueva Clinics Statlab Clinical Laboratory, Medicus Clinic -Main, Jara, La Paz, Manduriao, Oton, Molo, Tabuc-Suba, Balasan, Passi, Sara, -Sta. Barbara branches) Friendly Care Foundation Inc. Lagro, Family Care Clinic - Lagro LH Prime Medical Clinic Consolacion LH Prime Medical Clinic Mandaue Hi Precision Clinics (Mandaue, Cebu City, Lapu-Lapu City, Talisay Branches) Lifelab diagnostics, Cebu St. Lukes Clinic, LH Prime Mactan Borough Medical Clinics MOA branch Hi-Precision clinics Manila, Philcare Clinic (VIP, Manila), Evergreen Medical & Diagnostic Center, Hi-Precision Clinics (Paranaque), Inter-Industrial Physicians Medical Services, Inc., SMS Laboratory Health Services MMC Quick Assist (Consult only) Biomedix Makati, Healthlab, Inc. -Makati Hi=Precision Clinics Global City, TMC Quick Assist (Consultation only) Megaclinic, Hi-Precision Clinics - Pioneer Hi-Precision Plus Alabang I.M Health Medical and Dialysis Wellness Center Polymed Laboratory - Lakandula Polymed Laboratory Hermosa Dasma PMP Medical Center 2016 COPAY OUTRIGHT COLLECTION: Availment on the following providers will require Teletech members to pay the copay amount outright: The Medical City Makati Medical Center 02867r
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