PRaBESROUP HLPNES NC 200 annexe [BENEFITS SUMMARY A. BENEFITS AND COVERAGE Maxicare undertakes to arange the follwing healncare benelts and coverage for the Members en date of coverage (ho “Efectve Dat") Al procedures, examinations snd othe fe covered up to MOL wherwver Mealy Necessary nthe medica! management of Te Member ej tothe cuss, Imation, ane eondons specie Ins reset PLANTYPE | NETWORC TOUT ACCESS Dependent AL | Wasanee x Shee Logan: [MMc: Maka Medica Cntr, SLC GC: St, Luke's Medical Centr Glebal Cy, SLCC: 5: Likes Medes ‘Carter 2ucren Cy, AHMC: Asian Hospital and Nedeal Cesta, CSMC: Cardinal Sates Medial Centar CDH: Cebu Docs Hesptl. CHH- Chong Hua Hosp, {te he eda! Cay; EDM: Osmo Doctor Hepa M Healy EALTHCARE BENEFITS ‘covERAce iat “OUTPATIENT [GP CARE ‘4 Alten ant ar segs ie mal essa) Tega a ins T sutes u, 7 Aleit poesiuas [a bg ass ode ecoss [rgsesie al ir Tswectowst “TB Eye esr apy ey ena orftal hol, fen scnpat an guucoa esos BY ‘bite Pasa Eye ooedonaich ts, PK and ent anes [rcoste tal Pre Lust Pip 10.000 e/ monber yar “TA Excbecoseeaton fin esos seh arta was. ta was, perl wa io wats meio consgsur ey pal Da bed posts yan Ale Pysan/Spci Tpseaiot a Pans TuptPip 10001 nenbor yoo TE Seacoherapy ar aie vans ep esc na fr sxe upon) WeeCbe Dy aN fas antes aoe etme etna De ‘ia Pn. a ania T_ Ate esa! sly ening wd elt oes a0 Ai Py Bones Pans ‘Upto Php 2500 rembe year [7 Speen aap fo sks ats Depteabie teal Pe ‘Coord ws larg up ove (2) ssara Biel [repeat at Par [ipo Pip S007 mana CZINPATIENT CARE [eesti [ Sats i ears Ream a oad ‘Sr cone FRO OEP EDEFTS UMAR PrPROBEOROUP PLPPNES C200 22 Al citer tone arecy sed he edd manapanar oe pend deemed mely pe Aner Alaa Psesh ens tear Cope Tages at Ps Tstsscteus Aslan Conde it 2 {PRERSTING CONDITION Dopnet- ALLDEPEIOENTS. Ba orcs Constens pisedip 1 BL 2 | Nonaraded Gosane ‘Cover up 1 100.005 «FMB ‘2 Wa Wer & eal nas an Agena a dove te oie patking oars en Pa Monbar sat rt be cro a fr any o-tng corona ry Se dng he Mere bra Menber sent under_anAgoonon hal cos nat oer pe-aicg condos fr De tek, ‘woh (2) mes tne Eve ate fhe Wenbarscevarage, he he Maer 2h al be {re cy re-snntyconaon rg ta (12) rt om te Ecave Dt oe ‘Mbors coreg nd tase Agena The Manbe®preausng endo sha bs coves terete (12 ert ome Etactie Dea ote Memoera coor nde at ae Darearert prove thatthe Monet overage nds a sae Agee = contrusd ae To tT a ins ova na a a lenbor 8 ewoles user an Ayaan at coves te-ang condos ton ha tare Dal ‘te Mabe cveray ene re sal be over fry brace onan fe he Ech Daf oror coverage ude ht sane Agee “E-BAGNOSTICTHERAPEUTS PROCEDURES [spare oarraren “EA dagrase bras peaaes nea nese banat Tropica oat rian Tsweateuat [aapaious opiate ol Pane ‘pate wat Up a) coins yea oot 13__ Sota Pte Ay Pre (SP AP] Walon op Sy opieabe oa Pls ‘Up Pp 01000 manta ] Up Pp 6900 NDE yest Fyoat (ghredim tro anse)_| (res nt OF an) a Day ropteabe oma Sapare wa ‘Up wate (2) sone soo Mat 72S cnomatrap Bo cnc Vonat oy Povilla Suet HL Tp wate 92) cate nos toust “2E_ra dct atone cy Popa eal lane ‘Up Pp 62000 meme | Up Pp 698007 meMBer (chwesint ro ese) | (edit fr OF a “47 Physical oar 7 Ocapaipnal Pwrany exclu sibspocares Sx cade renebisten, opiate oa Plane ‘pate wa ‘Up ott (12) sons patos Nato: Thay of ene 0) eay ce shal be coated orenoaconaur paprnes ne. 2018 7a Tsao 23a yer ela st Pas aes Up hake (9) ease soca Ma aia eles aT Pane Se wa Up wah (2) seo sues Ma ite Un Acai Tee ele a Pre wa Up ah 2) eon sje iad Rac Ge ele a Pe at wa Tp ah 1) ee sje epee st Pos Sawa Tp a wa sje 7 Tashan Tr Pee Fepleai tPae ri Sir | Up Pip a reine xo nay | te to aie aetna elena Pere ‘pis Pp 007 ener | Ups Pap nore er yor ors oP si) | Sst Pa pelea ata ‘pis Pp 8 mar | Ops Pap 50 ana Streit xP anairy_| ed oO Ea Uae ep bens ed rls a Pe ‘pte Pro 087 marer | Ups Pop SDT menbe yer Pa Eire tnaororanim_| [red tnt oP a 2 Eehapelnonaa pleat Pare TpieFe Sia anbe | Up Pip SDT mea? Testmecoranair) | fee oo a a a waa ‘eet a Pom Tp Fo 607 mabe | Up Pp EOD maT ver ror Eretint yore) | fest 70 a2) seco al are pt Pp 5080 / nenbr | Ups Pp 0 aanBaT Birectentoror sir | Saeed tet 0 nd) “EBL Povo nin Temas PET Sean epee a Pats pie Pap 50007 mene | Up WP 00 aT rr ver fecimt oP anair) | fiestas) aan soa siete a Pe Ups Pie S00 maar | Up Pp 87 maT {aureasint oro ansie)_| tad intr OP and) Gar coe FR Ra ANDI EDEFTS SAMARPROREOROUP FHIUPPNES WE 219 Tepicaieto at Pe ‘Up Pp 60007 marie | Un Pp 0007 maneer [chredine toc oP ene) | (Sarestnt oP anh) ik Henan Raaston Fase Popieabe os Plas ‘a Pip 50007 marr? | Unt Pp 80 meer yer a [srrestnte 0° auth) | erent OP a) “RE pa Gabe Gain Going epee al Plane Ups Php 000) mane? | Up PRPSINOT arbor yes your [srr oP aan) (stars nt te OF ana) Cai Ttared Pople ransom APES Hm epee tal Pars Up Prpsp00/ mabe | Upto BEER mero? [sre tnt OP ani) {red nt fr OP an “421 Rnb Endl Grew Fade VEGF) sug (asin, Lacres, Mage) Retro, anu Deyeersion a oer Ope ears epee tat Pane Up Pip a0) wane! | Up Pip BGT martorT (shoreline oP ane) | shred nt 0° ane (22A_BCHABL by Gunite Real tne Pelyrrsns Can Repeon (ORTPOR RT-PCR) Depieae bal Fl ‘pt Pp 500 member] Up oP S60 mambar ear ver shoedine ero? gin) | [shred nt f° as 1228 a Gl San Gomi popleae oat ans ‘pls Pp S00 manta] | Upto Php 60 Fmarbar? {shed mtr oP ens) | (tered watt OP erst i Copa Bone opal Ps ‘pt Pp 650 /mantar? | Upto Php 6.0 Famer? (ared mat tc Pane) | (red mt fr OF an) opts al Plane ‘pm Pp 6007 manta | Upto Pip SIO Farber? [shed mt or oP ene) | lta rt OP as “432 Conia on Raposo Thray (RAT) Dope oa Plane ‘pt Pp 6007 manber7 | Upto Php 8000 /wambor! year ver (Seed tnt or OP ans) | (here etx OP ans) popes a Plane ‘ol Pp 500/ manta | Uplo Pip 60 manbar? {ered mt or oP ene) | (hres at OP ns) “3A Cone manoad Pumneonginas FOG PET San popes oa Plane ‘pt Pp 59007 mantar/ | Upto Php 60 manbar? [erwedim or OP we) | (share nt fr OP ano 36 ctsony eas Popeater ‘a Pp S007 mania | Uplo Php 6 Tranber? ed rt OP so “Eins Foran yan 01S) Tspatcabe tal Pans Luo w Pp sai0/manter’ | upto Phe Sm /wanbars COR FF POE BOATS BUA Pa waresre share tf OP an) [er int er OP a) 757_Eadoe aad pelea oat Tp Pip Sn maar? | Upto Po 8500" wanberT ad nt ro nay | [hvestnn er OF at) a, Tiber Lar Teena ‘Aapleabe al Pe ‘Up Pre 56mm! | Up Pe 50007 manber [Brxostnt tor ans | ise mite oP and “£35, Enders Laer As ‘tie wal Pas Upto Pe SnD marber! | Up w Pe 007 enka Teorcimt oor ans) | Bras itt oP an aren usar roti Vag ere (VPS Poke walls ‘Upto Pp §000/ mente] Up Php S007 member yer your Sram orenaim | feed mt OP an) “2A Ennanad utara Coroners Perabo ol Pare ‘Us Pp 58007 | Upto Pp 50 Fran? ad it eo nai | [re nae OP ant 2nd ed iusratSpal ELISPOT, As popes Pls ‘Up Pre 6007 mnt’ | Up Pe 5000 mane [Exod ime tor ans) | [Shed nite O° a 28ers Face sap (EGFR ton Aas Tost ‘Netieo a Pa Upto Pp 5000 mana | Up w Pp 50007 mente? [Suestoneror ante) | [red ttl OP dB) as Sans and OPO poole tal Pre ‘pte Pan S07 mobo? | Up PH 59007 mab Gado oP nai | frre intr OP as) 7c Ss to ponent Pere ‘ri Pre 5.0 enter! | Up Pre 500) mabe [rennet oP ast) | [shel 0° er Genie Sal Sion Tin ‘pes Pk ‘pio Pp i80 marae! | Up Pip S000 rember! (ares P ate) | fed mt OP end) AT ped Suan Raheny Peps lars ‘p= Php SOT meter? | Up oP 50007 aber art [ers nt OF an AG nae Caagdaten Foner pepo at Pant Tp Pre 6.8m abr! | Ups Pre BHO member year weer [Grae int 0° asi) | [Sheatne OP ent “i oes ermal Aepiese teal Pas Tote Pap 60 er | UP Pp 500 maar? edn OP nt | (trent OP an 2) [or me, FRO EAGER BUI Pao atPROBEOROUP PHILIPS Ne 208 ii hemmaa Umea epee oal Fare ‘Ue Pre S0007mante! | Up Php 0007 member? mtr oP at) | (ares O° ae SAR ‘soncaboa Pare ‘Toi Pip 50 marbar! | Up PRpSSOD/anEar ew ve Faea tnt oP ra m)_| {ars nt OP a) ae Kanan repeal Pare Ups Pr 500 mare! | Upto Prasat [Eisen oP anatt_| ted nt OP nc) 13 AS Te ‘epics oa Fae ‘ewe Fre Bt menba? | Upto Pp OCD maBerT hse nt OP ant) hare tr OF es “AEA_MegneiRecrancs Spears ropa al Pare ‘oe Pip Sto enh? | Upto Php ROOT meme ye yer rosin oP aed) | fed tr OF nh 7 Marcia or Vara eed ras Boon eae al Pare Ups Pip S00 merbar? | Up POON mentar7 weer ver [Brawanat ce ansmy_| Se into oP andi 56 ores Aotoay Te Aare coors ed Rraunatogea! Oieates (hte Cetin Honea Anes Pave nese pater and a eres ‘plato (ronna tbody rap nsusrmne cor nd heabape dees ch ‘SLE, etyoon sofa eu argo ‘ese a Pare ‘Up Pre 50007 mauer? | Upto Pro S000 panbarT LEtwadimetr ovat) | fred nt 0° end) 57 naga cig ops al Pant ‘Vom Pre 6000 /anber? | Upto Pp S00) nenbar7 ear ee std tt oP ans | ftarestt OP eth) “58 nsec ia ar CT eben a Pare ‘Ww Pie 50 meer! | Upte PRP HOOD mebar7 [Grccumt ror sie | {tect ant) ens at Pare Tete Sao meee | Up Pp 000 TaT {Sraes intr anaiey_|(Surestn oP a2) Cp arate Seas Pepe at Pars pie Pip 50 /mene! | Ube Pp 0007 menbar7 [rarest op ashy | aed nt 0° ani SL Piers Pte ‘epee a Pans pie Pip 500 marba™ | Up Pp EDV manber7 [torent oP aey_| [Shae tao” ar Ae Pecans Dac CT Giedaradecal Eeronema Aton Teche (DED, pepsi Pe ‘Upto Pp 500/ member! ‘Upto Pe 5009 nba? Pa reti [iscsi or aaie) [presiater oP aah 1ai9_Povional ae Adon Tek Potent esile al Plne| ‘ps Pp 5tb0 mare | Up Pp SDIOT menber? {Gres to 0P ord 1)_| (Saosin 0° ard 265 “pink piabaoes = rosie mallPiane ‘pt Pp 56007 marer! | Up Po 5007 arbor? oor re [chr tnt for ari) | (hae ifr 0° ar i Pharmacy ‘raison Pa pia Pep 500 marbarT | Upto Pp 6007 mabe {Grrl fr andi) | es tito 09 ar 57 Phinda ‘plea al Pans ‘Upto Pe 5000 /morbar/ | Up Pip S001 member? ye yor [stores int fr? ansi)_| [aes intr 0° a Hit Phstaanis Guonde Some arpiess eal Pane ‘Upto Pre Sat /marber! | Up Pip BO member! {shred tint fr? ansi)_| aes batt 0° ar £5 Fist Agrgaton Tt ‘Apical Pane ‘Upto Pe 5000 merber/ | Up Pie 600 mene? oor ver [srr it fo OP ani)_| [aos ifr 0° ard “£70 Polmeraa Can Reon (PORTH and po ‘opie oa Pars Upto Pep 5000) marbarl | Up Pp 5tHO/ area [erred tnt fr OP ondiP)_| [aes i 0° ar {L71_Fayarse Chain Reason Ga rand CortnsonPoymorgtem PERSP ‘epics oa Ps Ut mp 5000! mame’ | Up © Pp 5007 manter/ your Yee {Ghetto OP a iP)_| (Saad itr OP ae “AE GimreROn Tapas (GFTSL ‘ples oa Pae ‘pe Pp 50507 erie | Up @ Pp S007 mater [Giuedtint oP anti) | eatint OP 9x 1 Radieguncy ASR BER) ad at RF proces ‘Apical Pa ‘Upto Pp 50007 member | Up Pip SDt0/ mentee? [Gtreatm ror ane) | (red mt tr OP ane) ‘apical Pans ‘Us Pp 6000/menterl | Up Php 60 maar? yoo [starectmt tr oP sie) | {sired itt OP sn) “a Tacit Petes Gian Reston -PCR) ‘esate Pane ‘Upto Pp 5000/ mantarT] Up Pp S000 mabe? (teresimt te OP ens | [Seed tf OP an “Gs ote Sago Rebel Postale al Pls ‘Upto Pp 600 /montar/[ Up Prp 800 /manborT resi fr OP ans)_| [tare kf OP ans) (AF G05 FRAG NOEL EDEFTSOIMUARY Poor tetPROBEGROUP PHILFPIES NE, 2018 rl Sng iso Laproca ‘Up Pp 500 abe? {chee tr OP ene) ‘po Pp 6007 manBer? yoo [etre int bP ed) 7a Sora angen epics oal Pa Tle Pp SGOT marie | Upto Pip SIO menaeT {eres tnat oro eth) | (hres fr OP enP) 7a Seresaris naa Bap opie oa Plane ‘Up Pp 6000/ marber | Unt Pp 50007 member! Year yeu edt OP ae )_| {ered it fr OP a) “aa _Sereuazis Redaten eran! Sereda Rasp peptic Pla Ui Pp 80007 mare | Up Pp tO / maroer [erwin 0° ete) | (srrestet OP sh) 281 Supanagets nana SP rr Popes al Plane ‘Upto Pip 5000) mare! | Unt» Pp BUD maTBeT your toro and) | tras nt or a) “AEE “Terese eran Dstt TAD) Pepa oal Plane Upto Pip 5000) mara | Unio PpSUIO/ mare [Ghost or 0° ese) | (ered wt OP an aes Temecs ima ‘ope al Plane ‘Uw Pip 50007 marber | Up Pp ON0/ marie yer yeu [Shs or 0° ane) [share fr OP an P) “AEA Th Dinero! Conbnal Radar SOCRT, Popes ol Plane ‘Up Pip 500) mabe | Up Pp tN0/ marae [Shaestnt or ene) | [red rtf OP an at Taree Donets oa Pane pw ip 6007 mare | Upto Pp OHO7 maBeT yeor ral editor OP ans) | (ed ir OP an) Dope oa Pane ‘pie Pp 550 mania | Up Pip S00 Fanta? (Sraseumt nr oP ee) | (sees mt OP ens opens ‘Upto Prp 6 350/ manta? | Upto Php 5.0/7 eed tor OP and) | (ae rt fr OP ans) “2 iat Eocon Baan Cong Tomar Dopieae oa Plan ‘Ups Pp S007 manta | Up io Pip SNF mabar? (shred nate OP ansiy_| (ved it OP ans 288 io enero Manet ‘epleabe oat Fae ‘Opt Pp 83007 manbar? | Upto Pho S00 J manber? ear ye ed itr OP andi) {eared bn OP ans) Se Soer FR AE BERETS SUNNPROBESROUP PENS NC 208 Fonte at Ps ‘Upto Pp 50007 montar/| Up Pp 60007 reribr? [eswesint oro? ane) | [ned mtr OP and) BY Doctor seve, Ra ray (“Dieses ag Tagaieaae gnosis tamales, and er adel awa elo BE intn ites Hosp ein , opiate malls Rorburasho wp w 80% of hapa le ard pesos fee tved on Mao rte cred dung fe 24 oars resent pi Pp 30000! ana) mare G5 Suse ha Paippres Raimbasare rosie mal Pre Famborsia uo 0h oso cost apo Pre 300007 Afshar ina Trost mallPie Tawieaiewa GEL rsinee Seve (Afiied Hepa Aas Nese, Rebun Tagsesie mais Tswiestoma __ Artseroe Senin (in Ann Hogan lo tied HeapatSIn) Tegstie aie Ta The antuance seve proded Fron shat to all rapeess ofthe eaten win a Prins 6. CONDITIONS Wil SPEGHC LMNTATIONS [—~weanenr | ~“oureanenr opie al Pls Sejeato MOL ‘apa wa ag oat of vcs ‘sega aio raha ops allie Sujet MBL “ip wt op coat azo) a asec ns dant bins caig ee but using ER Fe Peshsle al Pre ‘Upto Php 18000 menae | Up Prp 18000 member (chwrestmt or OP mse) | red itr OP ans ng. dors oases A Saslode pabaing raeany pocedues, exept physeal NEOPY seers, wheter congon, poptsto ma Plans ‘Upto Pp 200007mere | Up» Pp 20000 mono (chest rOP ani) | tre tf OP an) Nat Phy Trespy | Heo PrysealTeepy Seaton sal lm pra | sebdone shal em pat the Pryce! tap! | Re Paes aap! ‘aipteral ven tts _| Osmond Pato le 55 Cogent Gonos cpp 5 eens and dovaopranal Seo Popleale a Plans ‘Upto Pp 20000 mentor | Up Pre 20007 waar ye ye (ahem fr OP anti) | hast oP ar) Nat Pryseal Therapy | Note Pays Try sso sal fom par of | satsons sha fem part of Be Pryses soapy! | ho Physes! hort Ceagatoral orp te | Occupations Herp ie “Sa Comune of Cone Demat ‘SOR FR RSMO. SOIEATE SUNT Pagan[este oan Titov Tecate Tsp excer adnes an sro (asa) Popa al lars Sujet NOL aan Four scares [Lapse tat rams [ns ore — T.BENTAL CARE = ALL DEPENDENTS Shar 7 | Deri Power RESTA 2 Gum Tennant For Coes Lhe | Coed S.Sneenc Dei Times! | Conrad “Oslin ana a ‘cone 5. Om Pepryase pte San 5 Sep Toon eas ove 7 Tengery Fina ‘ond 1 Smole Reps Ad Suazo OF | Covered Denese isp, iy And On 10 Palio Twestnow OF Smo | Conse 1, Desensraten OF parse | Un wo Tenor ye=™ Seat 73 | oner Processes eva Tae “The coverage fe the Spedal agnosie Procediros is sbjct othe recommendation ofthe [Afiates Physcan # made neeaeemy and he provisions of fhe dreaded and or deaded preecaing endtors EXCLUSIONS AND LIMITATIONS. Netwitsanding ary previson the contay te ftzwing shat nt be covered 1. 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