2016 Maxicare MaxiPlus Healthcare Program for 5-99 Heads

For inquiries you may contact us at: (02) 622 8892; 0917 804 6275; proposal.omg@gmail.com
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TO: Sole Proprietors, Small Enterprise Business Owners, Family Owned Business Proprietors, Start up
Businesses Owners, Franchise Owners,
We hope this proposal finds you in good health!
As an industry forerunner, we pride ourselves of our more than 28 years of experience. With our strong financial muscle,
robust customer service and high caliber medical partners, we have turn to become the choice of the Top 2000
Corporations in the Philippines.
Companies with at least and only 5 employees can now enroll under Maxicare’s Corporate Program. Our options
and plan types have the following features:
Convenient Features
 Easy requirements. No individual medical examination. No individual application forms, all applications are
considered approved
 Access to more than 1000+ hospitals and clinics nationwide and 30,000 affiliated doctors
 Access to Maxicare’s own Primary Care Centers located in major hospitals
 Access to My Health Clinics
 Optional Access to Top Major Hospitals (Asian Hospital & Medical Center, The Medical City, St. Luke's Medical
Center QC, St. Lukes Medical Center Global City, Makati Medical Center, Cardinal Santos Medical Center,
Cebu Doctors Hospital, Chong Hua Hospital & Davao Doctors Hospital)
 Optional Access to Healthway Clinics
 Customized and lower pricing for regional accounts (North Luzon, South Luzon, Visayas & Mindanao)
 Coverage for Pre Existing Conditions subject to the package chosen:
o MaxiPlus Group (10-19 employees) & Small (20-99 employees) both Nationwide access and Provincial
access
 Covered up to Maximum Benefit Limit
o Starter Plan (Nationwide Access with 5-9 employees)
 1st
Year
 Pre Existing Non Dreaded Conditions – up to P5,000
 Pre Existing Dreaded – up to P5,000
 2nd
Year onwards
 Pre Existing Non Dreaded Conditions – up to Maximum Benefit Limit
 Pre Existing Dreaded – up to P5,000
Comprehensive Medical Care Features
 Outpatient Care and Consultations
 In Patient Care and Confinement
 Emergency Care
 Preventive Care
To proceed with the enrollment, kindly fill out the Maxicare Corporate Enrollment Sheet found at the last 3 pages
of our proposal and email those back to us. Kindly submit to us as well a copy of your BIR 2303 and company ID
of the contact person and signatory through email or fax at (02) 819-9899.
Requirements for Enrollment:
1. Filled out Maxicare Corporate Enrollment Sheet (found at the last 3 pages of this proposal). The
Enrollment Sheet has 3 sheets
a. Info Sheet (Name of Company, Nature of Business, Company TIN etc)
b. Principals/Employees to be enrolled (fullnames/ birthdates/ positions/ gender/ civil status)
c. Dependents to be enrolled (fullnames/ birthdates/ positions/ gender/ civil status )
2. BIR 2303
3. Scanned company IDs of contact person and signatory
4. KYC Requirements (to be submitted later together with the signed conforme).
Note: The package attached is only applicable to companies with 5-99 employees. For companies with 100 employees
and up (or of the combined headcount of the employees and dependents exceeds 100), a separate proposal will be
drafted.
Should you have any other questions, you may call us at (02) 622-8892 Mobile 09178046275 or email
mark.gastardo@gmail.com
Thank you.

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Office of Mark Gastardo
Accredited Agent License Code: A000494
Toasts Awards Nationwide Top 3 Best Performing AIA for 2015
TABLE OF CONTENTS
NO SECTION PAGE/S
I. Cover Letter & Requirements for Enrollment 1-2
II. Starter Plan Rates for 5-9 Employees 2-3
III. Group Plan Rates for 10-19 Employees 3-4
IV. Small Plan Rates for 20-99 Employees 5-6
V. Optional Riders for Nationwide 6-7
VI. Provincial Rates (North Luzon, South Luzon, Visayas & Mindanao) 7-9
VII. Summary of Benefits 10-19
VIII. Exclusions and Limitations Provisions 19-20
IX. Notes & Special Reminders 21
X. List of Providers 21
XI. Plan Types for Dependents 21-22
XII Provincial Access Directory 22
XIII. Rated & Ineligible Industries 22-23
XIV. Pre Existing Non Dreaded & Dreaded Conditions 23-24
XV. KYC Requirements for Employers 24-26
XVI. KYC Requirements for Employees 26
XVII. Ineligible Industries with less than 100 employees Requirements for Quotation 26-27
XVIII. All Companies & Industries with 100 employees & up Requirements for Quotation 27
XIX. Company Info Sheet 28
XX. Employees' Masterlist 29
XXI. Dependents' Masterlist 30
STARTER (5-9 EMPLOYEES)
PLAN
TYPES
ROOM MBL
STANDARD INDUSTRIES
NATIONWIDE WITHOUT
HEALTHWAY NATIONWIDE WITH HEALTHWAY
EMPLOYEES Without 9 Major With 9 Major Without 9 Major With 9 Major
Ann Semi Ann Semi Ann Semi Ann Semi
PLATINUM 1 Small Suite 220,000 16,196 8,746 21,380 11,545 17,007 9,184 22,447 12,121
PLATINUM 2 Lrg Pvt 175,000 13,370 7,220 17,558 9,481 14,038 7,581 18,434 9,954
GOLD 1 Reg Pvt 150,000 11,978 6,468 15,729 8,494 12,584 6,795 16,522 8,922
GOLD 2 Reg Pvt 100,000 11,317 6,111 14,783 7,983 11,882 6,416 15,522 8,382
SILVER 3 Semi-Pvt 80,000 9,295 5,019 12,052 6,508 9,760 5,270 12,655 6,834
SILVER Semi-Pvt 60,000 8,999 4,860 11,667 6,300 9,451 5,104 12,252 6,616
BRONZE Ward 50,000 7,523 4,062 9,663 5,218 7,899 4,265 10,148 5,480

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DEPENDENTS
PLATINUM 2 Lrg Pvt 175,000 18,241 9,850 24,142 13,037 19,153 10,343 25,348 13,688
GOLD 1 Reg Pvt 150,000 16,325 8,815 21,604 11,666 17,148 9,260 22,689 12,252
GOLD 2 Reg Pvt 100,000 15,662 8,457 20,658 11,155 16,446 8,881 21,690 11,713
SILVER 3 Semi-Pvt 80,000 12,511 6,756 16,398 8,855 13,138 7,095 17,218 9,298
SILVER Semi-Pvt 60,000 12,213 6,595 16,012 8,647 12,825 6,926 16,815 9,080
BRONZE Ward 50,000 10,101 5,454 13,150 7,101 10,606 5,727 13,807 7,456
OPTIONAL RIDERS FOR STARTER PLAN: Ann Semi
Standard Dental (1 prophylaxis and 2 Lightcure) 369 199
Annual Check Up Routine Clinic 805 435
Life AD&D (Php25,000) 51 28
Note: Starter Plan is valid until September 30, 2017
GROUP (10-19-Employees)
PLAN TYPES ROOM MBL
STANDARD INDUSTRIES
NATIONWIDE WITHOUT HEALTHWAY NATIONWIDE WITH HEALTHWAY
PLATINUM 2 Open Pvt 230,000 16,849 9,098 22,165 11,969 17,691 9,553 23,273 12,567
PLATINUM 4 Lrg Pvt 185,000 15,877 8,574 20,849 11,258 16,669 9,001 21,891 11,821
GOLD 1 Reg Pvt 185,000 14,397 7,774 18,852 10,180 15,117 8,163 19,793 10,688
GOLD 2 Reg Pvt 130,000 13,935 7,525 18,226 9,842 14,630 7,900 19,138 10,335
GOLD 3 Reg Pvt 110,000 13,438 7,257 17,555 9,480 14,110 7,619 18,433 9,954
SILVER 1 Semi-Pvt 90,000 11,038 5,961 14,312 7,728 11,590 6,259 15,028 8,115
SILVER 2 Semi-Pvt 80,000 10,741 5,800 13,911 7,512 11,279 6,091 14,606 7,887
BRONZE Ward 70,000 8,961 4,839 11,502 6,211 9,408 5,080 12,079 6,523
DEPENDENTS
PLATINUM 4 Lrg Pvt 185,000 21,661 11,697 28,669 15,481 22,744 12,282 30,101 16,255
GOLD 1 Reg Pvt 185,000 19,559 10,562 25,827 13,947 20,536 11,089 27,117 14,643
GOLD 2 Reg Pvt 130,000 19,094 10,311 25,200 13,608 20,050 10,827 26,459 14,288
GOLD 3 Reg Pvt 110,000 18,598 10,043 24,531 13,247 19,529 10,546 25,757 13,909
SILVER 1 Semi-Pvt 90,000 14,857 8,023 19,472 10,515 15,601 8,425 20,446 11,041
SILVER 2 Semi-Pvt 80,000 14,559 7,862 19,071 10,298 15,286 8,254 20,024 10,813
BRONZE Ward 70,000 12,022 6,492 15,642 8,447 12,621 6,815 16,423 8,868
GROUP (10-19-Employees)

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PLAN TYPES ROOM MBL
RATED INDUSTRIES
PLATINUM 4 Lrg Pvt 185,000 22,059 11,912 28,970 15,644 23,162 12,507 30,417 16,425
GOLD 1 Reg Pvt 185,000 20,005 10,803 26,194 14,145 21,003 11,342 27,503 14,852
GOLD 2 Reg Pvt 130,000 19,362 10,455 25,324 13,675 20,328 10,977 26,591 14,359
GOLD 3 Reg Pvt 110,000 18,671 10,082 24,393 13,172 19,605 10,587 25,612 13,830
SILVER 1 Semi-Pvt 90,000 15,337 8,282 19,887 10,739 16,104 8,696 20,881 11,276
SILVER 2 Semi-Pvt 80,000 14,926 8,060 19,329 10,438 15,671 8,462 20,294 10,959
BRONZE Ward 70,000 12,451 6,724 15,982 8,630 13,071 7,058 16,784 9,063
DEPENDENTS
PLATINUM 4 Lrg Pvt 185,000 30,097 16,252 39,834 21,510 31,602 17,065 41,824 22,585
GOLD 1 Reg Pvt 185,000 27,179 14,677 35,886 19,378 28,535 15,409 37,678 20,346
GOLD 2 Reg Pvt 130,000 26,531 14,327 35,016 18,909 27,859 15,044 36,764 19,853
GOLD 3 Reg Pvt 110,000 25,842 13,955 34,085 18,406 27,136 14,653 35,787 19,325
SILVER 1 Semi-Pvt 90,000 20,644 11,148 27,056 14,610 21,677 11,706 28,409 15,341
SILVER 2 Semi-Pvt 80,000 20,229 10,924 26,498 14,309 21,239 11,469 27,822 15,024
BRONZE Ward 70,000 16,704 9,020 21,735 11,737 17,537 9,470 22,821 12,323

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SMALL (20-99 Employees)
PLAN TYPES ROOM MBL
STANDARD INDUSTRIES
Ann Semi Qtr Ann Semi Qtr Ann Semi Qtr Ann Semi Qtr
PLATINUM 1 Small Suite 230,000 16,163 8,728 4,526 21,334 11,520 5,974 16,972 9,165 4,752 22,402 12,097 6,273
PLATINUM 2 Open Pvt 230,000 14,159 7,646 3,965 18,626 10,058 5,215 14,865 8,027 4,162 19,556 10,560 5,476
PLATINUM 4 Lrg Pvt 185,000 13,342 7,205 3,736 17,521 9,461 4,906 14,008 7,564 3,922 18,397 9,934 5,151
GOLD 1 Reg Pvt 185,000 12,098 6,533 3,387 15,842 8,555 4,436 12,703 6,860 3,557 16,633 8,982 4,657
GOLD 2 Reg Pvt 130,000 11,709 6,323 3,279 15,316 8,271 4,288 12,295 6,639 3,443 16,081 8,684 4,503
GOLD 3 Reg Pvt 110,000 11,291 6,097 3,161 14,754 7,967 4,131 11,857 6,403 3,320 15,490 8,365 4,337
SILVER 1 Semi-Pvt 90,000 9,277 5,010 2,598 12,028 6,495 3,368 9,741 5,260 2,727 12,630 6,820 3,536
SILVER 2 Semi-Pvt 80,000 9,028 4,875 2,528 11,690 6,313 3,273 9,478 5,118 2,654 12,275 6,629 3,437
BRONZE Ward 70,000 7,528 4,065 2,108 9,666 5,220 2,706 7,906 4,269 2,214 10,150 5,481 2,842
DEPENDENTS
PLATINUM 4 Lrg Pvt 185,000 18,202 9,829 5,097 24,092 13,010 6,746 19,112 10,320 5,351 25,294 13,659 7,082
GOLD 1 Reg Pvt 185,000 16,436 8,875 4,602 21,703 11,720 6,077 17,257 9,319 4,832 22,787 12,305 6,380
GOLD 2 Reg Pvt 130,000 16,048 8,666 4,493 21,176 11,435 5,929 16,849 9,098 4,718 22,235 12,007 6,226
GOLD 3 Reg Pvt 110,000 15,629 8,440 4,376 20,614 11,132 5,772 16,411 8,862 4,595 21,646 11,689 6,061
SILVER 1 Semi-Pvt 90,000 12,485 6,742 3,496 16,363 8,836 4,582 13,109 7,079 3,671 17,181 9,278 4,811
SILVER 2 Semi-Pvt 80,000 12,234 6,606 3,426 16,025 8,654 4,487 12,845 6,936 3,597 16,827 9,087 4,712
BRONZE Ward 70,000 10,102 5,455 2,829 13,145 7,098 3,681 10,608 5,728 2,970 13,802 7,453 3,865

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SMALL (20-99 Employees)
PLAN TYPES ROOM MBL
RATED INDUSTRIES
Ann Semi Qtr Ann Semi Qtr Ann Semi Qtr Ann Semi Qtr
PLATINUM 4 Lrg Pvt 185,000 18,583 10,011 5,191 24,345 13,146 6,817 19,465 10,511 5,450 25,564 13,805 7,158
GOLD 1 Reg Pvt 185,000 19,810 9,077 4,707 22,012 11,886 6,163 17,650 9,531 4,942 23,112 12,480 6,471
GOLD 2 Reg Pvt 130,000 16,270 8,786 4,556 21,281 11,492 5,959 17,084 9,225 4,784 22,344 12,066 6,256
GOLD 3 Reg Pvt 110,000 15,689 8,472 4,393 20,499 11,069 5,740 16,475 8,897 4,613 21,524 11,623 6,027
SILVER 1 Semi-Pvt 90,000 12,891 6,961 3,609 16,713 9,025 4,680 13,534 7,308 3,790 17,549 9,476 4,914
SILVER 2 Semi-Pvt 80,000 12,543 6,773 3,512 16,243 8,771 4,548 13,169 7,111 3,687 17,056 9,210 4,776
BRONZE Ward 70,000 10,460 5,648 2,929 13,430 7,252 3,760 10,986 5,932 3,076 14,103 7,616 3,949
DEPENDENTS
PLATINUM 4 Lrg Pvt 185,000 25,292 13,658 7,082 33,474 18,076 9,373 26,556 14,340 7,436 35,147 18,979 9,841
GOLD 1 Reg Pvt 185,000 22,837 12,332 6,394 30,154 16,283 8,443 23,979 12,949 6,714 31,664 17,099 8,866
GOLD 2 Reg Pvt 130,000 22,298 12,041 6,243 29,424 15,889 8,239 23,410 12,641 6,555 30,894 16,683 8,650
GOLD 3 Reg Pvt 110,000 21,716 11,727 6,080 28,643 15,467 8,020 22,802 12,313 6,385 30,076 16,241 8,421
SILVER 1 Semi-Pvt 90,000 17,347 9,367 4,857 22,736 12,277 6,366 18,215 9,836 5,100 23,874 12,892 6,685
SILVER 2 Semi-Pvt 80,000 16,999 9,179 4,760 22,267 12,024 6,235 17,848 9,638 4,997 23,381 12,626 6,547
BRONZE Ward 70,000 14,036 7,579 3,930 18,266 9,864 5,114 14,740 7,960 4,127 19,177 10,356 5,370
OPTIONAL RIDERS FOR NATIONWIDE: Ann Semi Qtr
1. Annual Check up Routine (Clinic) 805 435 225
2. Annual Check Up Routine (Mobile) 1,016 549 284
3. Standard Dental (1 oral propahylaxis) 369 199 103

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4. Life Insurance with AD&D - Php 25,000 51 28 14
5. Cancer Benefit (Php200,000) 448 242 125
6. Maternity Benefit 3,161 1,707 885
7. Semi Executive Check Up Outpatient MMC 5,781 3,122 1,619
8. Executive Check Up Outpatient MMC 17,523 9,462 4,906
9. Executive Check Up Inpatient MMC 32,516 17,559 9,104
10. Semi Executive Check Up Outpatient TMC 16,000 8,640 4,480
11. Executive Check Up Outpatient TMC 35,045 18,924 9,813
12. Executive Check Up Inpatient TMC 53,381 28,826 14,947
13. Executive Check Up OP MHC 3,604 1,946 1,009
14. Wellness Session 4,516 2,439 1,264
15. Fee for Service for Senior Citizens
P450 Network Access
Fee & 13.5% claims fee
per availment
PROVINCIAL NORTH LUZON (10-99 Employees) SOUTH LUZON (10-99 Employees)
PLAN TYPES ROOM MBL
STANDARD INDUSTRIES RATED INDUSTRIES STANDARD INDUSTRIES RATED INDUSTRIES
EMPLOYEES Ann Semi Qtr Ann Semi Qtr Ann Semi Qtr Ann Semi Qtr
PLATINUM 1 230,000 12,548 6,777 3,514 16,952 9,154 4,747 15,134 8,172 4,237 18,585 10,036 5,204
PLATINUM 2 230,000 10,958 5,916 3,069 14,803 7,994 4,145 13,212 7,135 3,700 16,227 8,763 4,544
PLATINUM 3 185,000 10,651 5,752 2,982 14,388 7,770 4,029 12,842 6,935 3,596 15,771 8,516 4,416
PLATINUM 4 185,000 10,308 5,566 2,886 13,924 7,519 3,899 12,430 6,712 3,481 15,265 8,243 4,274
GOLD 1 185,000 9,323 5,034 2,610 12,593 6,800 3,526 11,243 6,071 3,149 13,805 7,455 3,865
GOLD 2 130,000 9,014 4,868 2,524 12,177 6,576 3,410 10,870 5,870 3,044 13,349 7,208 3,738
GOLD 3 110,000 8,681 4,688 2,431 11,727 6,333 3,284 10,469 5,654 2,931 12,857 6,943 3,600
SILVER 1 90,000 7,082 3,824 1,982 9,568 5,167 2,679 8,541 4,612 2,391 10,488 5,664 2,937
SILVER 2 80,000 6,883 3,717 1,927 9,298 5,021 2,603 8,298 4,481 2,323 10,191 5,503 2,853
BRONZE 70,000 5,692 3,073 1,593 7,688 4,152 2,153 6,864 3,707 1,922 8,429 4,552 2,360
DEPENDENTS
PLATINUM 1 Small 230,000 17,457 9,427 4,888 23,583 12,735 6,603 21,050 11,367 5,894 25,851 13,960 7,238

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Suite
PLATINUM 4 Lrg Pvt 185,000 14,170 7,652 3,967 19,142 10,337 5,360 17,086 9,227 4,784 20,984 11,331 5,876
GOLD 1 Reg Pvt 185,000 12,766 6,894 3,575 17,247 9,313 4,829 15,394 8,313 4,310 18,905 10,209 5,293
GOLD 2 Reg Pvt 130,000 12,457 6,726 3,488 16,827 9,087 4,712 15,022 8,111 4,205 18,447 9,961 5,165
GOLD 3 Reg Pvt 110,000 12,125 6,548 3,396 16,380 8,845 4,586 14,623 7,897 4,095 17,957 9,697 5,028
SILVER 1 Semi-Pvt 90,000 9,628 5,200 2,696 13,006 7,023 3,642 11,611 6,270 3,251 14,259 7,700 3,993
SILVER 2 Semi-Pvt 80,000 9,429 5,092 2,640 12,738 6,879 3,567 11,368 6,139 3,184 13,962 7,539 3,909
BRONZE Ward 70,000 7,738 4,178 2,167 10,453 5,645 2,927 9,331 5,039 2,613 11,459 6,188 3,209
OPTIONAL RIDERS: Ann Semi Qtr Ann Semi Qtr Ann Semi Qtr
Standard Dental (1 prophylaxis and 2 Lightcure) 369 199 103 369 199 103
Annual Check-up (Basic 5) Clinic 1,334 720 374 1,877 1,014 526
Life AD&D (Php25,000) 51 28 14 51 28 14
Cancer Benefit (Php200,000) 448 242 125 448 242 125
PROVINCIAL VISAYAS (10-99 Employees) MINDANAO (20-99 Employees)
PLAN TYPES ROOM MBL
STANDARD INDUSTRIES RATED INDUSTRIES STANDARD INDUSTRIES RATED INDUSTRIES
EMPLOYEES Ann Semi Qtr Ann Semi Qtr Ann Semi Qtr Ann Semi Qtr
PLATINUM 1
Small
Suite 230,000 12,138 6,555 3,399 14,907 8,050 4,174 12,778 6,900 3,577 15,692 8,474 4,394
PLATINUM 4 Lrg Pvt 185,000 9,972 5,384 2,792 12,246 6,613 3,429 10,499 5,669 2,940 12,892 6,962 3,610
GOLD 1 Reg Pvt 185,000 9,019 4,869 2,525 11,075 5,981 3,101 9,493 5,126 2,658 11,657 6,295 3,264
GOLD 2 Reg Pvt 130,000 8,719 4,708 2,442 10,708 5,782 2,998 9,177 4,955 2,570 11,270 6,086 3,156
GOLD 3 Reg Pvt 110,000 8,399 4,536 2,351 10,314 5,570 2,888 8,840 4,774 2,475 10,857 5,863 3,040
SILVER 1 Semi-Pvt 90,000 6,850 3,699 1,918 8,412 4,542 2,355 7,209 3,893 2,019 8,854 4,781 2,479
SILVER 2 Semi-Pvt 80,000 6,657 3,595 1,864 8,176 4,415 2,289 7,007 3,784 1,962 8,606 4,647 2,410
BRONZE Ward 70,000 5,507 2,974 1,542 6,764 3,653 1,894 5,798 3,131 1,623 7,120 3,845 1,994
DEPENDENTS

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PLATINUM 1
Small
Suite 230,000 16,886 9,119 4,728 20,738 11,199 5,807 17,775 9,598 4,977 21,828 11,787 6,112
PLATINUM 4 Lrg Pvt 185,000 13,705 7,402 3,838 16,832 9,089 4,713 14,427 7,791 4,040 17,718 9,568 4,961
GOLD 1 Reg Pvt 185,000 12,348 6,668 3,457 15,164 8,189 4,246 13,000 7,019 3,641 15,964 8,621 4,470
GOLD 2 Reg Pvt 130,000 12,051 6,508 3,375 14,799 7,991 4,144 12,684 6,850 3,551 15,576 8,411 4,361
GOLD 3 Reg Pvt 110,000 11,730 6,334 3,284 14,406 7,779 4,034 12,347 6,667 3,457 15,163 8,188 4,246
SILVER 1 Semi-Pvt 90,000 9,314 5,030 2,608 11,439 6,177 3,203 9,804 5,295 2,746 12,040 6,502 3,371
SILVER 2 Semi-Pvt 80,000 9,123 4,926 2,554 11,204 6,050 3,137 9,603 5,186 2,690 11,794 6,369 3,302
BRONZE Ward 70,000 7,482 4,041 2,095 9,190 4,963 2,573 7,878 4,254 2,206 9,675 5,225 2,709
OPTIONAL RIDERS: Ann Semi Qtr Ann Semi Qtr
Standard Dental (1 prophylaxis and 2 Lightcure) 369 199 103 369 199 103
Annual Check-up (Basic 5) 1,166 630 326 1,166 639 326
Cancer Benefit (Php200,000) 448 242 125 448 242 125
Life AD&D (Php25,000) 51 28 14 51 28 14
Executive Check Up OP - Cebu Doctors Hospital 3,604 1,946 1,009 n/a n/a n/a
Executive Check Up Ip - Cebu Doctors Hospital 31,495 17,007 8,819 n/a n/a n/a
Executive Check Up Ip - Davao Doctor's Hospital n/a n/a n/a 30,529 16,486 8,548

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SUMMARY OF BENEFITS
MAXIPLUS
HEALTHCARE BENEFITS MAXICARE'S COVERAGE
A. OUT-PATIENT CARE
1
Consultations during regular clinic hours,
except prescribed medicines
Subject to MBL
2 Pre and Post Natal consultations Subject to MBL
3
Eye, ear, nose and throat (EENT)
treatment prescribed by an Accredited
Physician/Specialist
Subject to MBL
4
Treatment for minor injuries such as
lacerations, mild burns, sprains and the
like
Subject to MBL
5
Dressings, conventional casts (plaster of
Paris) and sutures.
Subject to MBL
6
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
7
Minor surgery not requiring confinement
prescribed by an Accredited Physician /
Specialist
Subject to MBL
8
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
9
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 Accredited
Physician/Specialist.
Up to Php 1,000 /member /year
1
0
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
1
1
Allergy Testing/ allergy screening and
other related examinations prescribed by
an Accredited Physician
Up to Php 2,500 / member / year
1
2
Speech therapy (for stroke patients only)
Covered as charged up to Php 10,000 / member / year
(reimbursement basis)
Note: Consultations shall be part of the limit and
treated as sessions
1
3
Tuberculin test Up to Php 600 / member / year
B. IN-PATIENT CARE
1 Room and Board Accommodation Subject to the Member's Room and Board limit

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2
Use of operating room, Intensive Care Unit
(ICU), isolation room (if prescribed by
attending Accredited Physician) and
recovery room.
Subject to MBL
3
Professional fees in accordance with
Maxicare Schedule of Rates.
a. Attending Physicians Subject to MBL
b. Surgeons Subject to MBL
c. Anesthesiologists Subject to MBL
d. Cardio-pulmonary clearance before
surgery and cardiac monitoring during
surgery.
Subject to MBL
4 Standard Nursing Services Subject to MBL
5 Medicines for in-patient use Subject to MBL
6
Blood products transfusions and
intravenous fluids, including blood
screening and cross matching.
Subject to MBL
7
X-Ray, laboratory examinations, routine,
diagnostic tests and therapeutic
procedures incidental to confinement
Subject to MBL
8
Dressings, conventional casts (plaster of
Paris) and sutures
Subject to MBL
9 Anesthesia and its administration Subject to MBL
1
0
Oxygen and its administration Subject to MBL
1
1
Standard Admission kit Subject to MBL
1
2
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 IP or OP)
1 Blood Chemistries 100% of Actual Cost subject to MBL
2 Chest X-Ray 100% of Actual Cost subject to MBL
3 Complete Blood Count (CBC) 100% of Actual Cost subject to MBL
4 Fecalysis 100% of Actual Cost subject to MBL
5 Urinalysis 100% of Actual Cost subject to MBL
D. DIAGNOSTIC PROCEDURES
1 12-Lead Electrocardiogram (ECG) 100% of Actual Cost subject to MBL
2
24-Hour Electroencephalogram (EEG)
Monitoring
100% of Actual Cost subject to MBL
3 24-hour Holter Monitoring 100% of Actual Cost subject to MBL
4 Adrenocortical Function 100% of Actual Cost subject to MBL
5
Anti-Nuclear Antibody, C-Reactive Protein,
Lupus Cell Exam
6 Arterial Blood Gas 100% of Actual Cost subject to MBL
7
Arthroscospic Procedures, Orthopedic
Arthroscopy
8 Audiograms and Tympanograms 100% of Actual Cost subject to MBL
9 Bone Densitometry Scan (Dexascan) 100% of Actual Cost subject to MBL
1
0
Bone Mineral Density Studies 100% of Actual Cost subject to MBL
1
1
Cardiac Stress Tests (Thalium and
Dipyridamole Stress Tests)

12
1
2
Computed Tomography Scans 100% of Actual Cost subject to MBL
1
3
Diagnostic Radiographs:
a. Biliary tract: Cholecystogram and
Cholangiogram
b. Chest, ribs, sternum and clavicle 100% of Actual Cost subject to MBL
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 100% of Actual Cost subject to MBL
g. X-ray of the spine (cervical, thoracic,
lumbo-sacral)
1
4
Diagnostic Ultrasounds:
a. 2D-Echo with Doppler 100% of Actual Cost subject to MBL
b. Abdomen 100% of Actual Cost subject to MBL
c. Duplex Scan 100% of Actual Cost subject to MBL
d. Digestive and Urinary Systems 100% of Actual Cost subject to MBL
e. Ultrasound of the Lungs 100% of Actual Cost subject to MBL
1
5
Electroencephalogram (EEG) Monitoring 100% of Actual Cost subject to MBL
1
6
Electromyelography and Nerve
Conduction Studies
1
7
Endoscopic Procedures 100% of Actual Cost subject to MBL
1
8
Fluorescein Angiography 100% of Actual Cost subject to MBL
1
9
Impedance Plethysmography 100% of Actual Cost subject to MBL
2
0
Magnetic Resonance Angiography (MRA) 100% of Actual Cost subject to MBL
2
1
Magnetic Resonance Imaging (MRI) 100% of Actual Cost subject to MBL
2
2
Mammography and Sonomammogram 100% of Actual Cost subject to MBL
2
3
Myelogram 100% of Actual Cost subject to MBL
2
4
Nuclear Radioactive Isotope Scan 100% of Actual Cost subject to MBL
2
5
Pap's Smear 100% of Actual Cost subject to MBL
2
6
Perfusion Scan 100% of Actual Cost subject to MBL
2
7
Plasma Urinary Cortisol, Plasma
Aldosterone
2
8
Polysomnograms (Sleep Recording) 100% of Actual Cost subject to MBL
2
9
Pulmonary Function Tests 100% of Actual Cost subject to MBL
3
0
Radioisotope Scans and Function
Studies:
a. Cardiac 100% of Actual Cost subject to MBL
b. Gastrointestinal 100% of Actual Cost subject to MBL
c. Liver 100% of Actual Cost subject to MBL
d. Parathyroid Bone, Pulmonary 100% of Actual Cost subject to MBL

13
(Perfusion/ Ventilation Lung Scans)
e. Renal 100% of Actual Cost subject to MBL
f. Thyroid Scans 100% of Actual Cost subject to MBL
g. Total Body Scans 100% of Actual Cost subject to MBL
3
1
Radionuclide Ventriculography 100% of Actual Cost subject to MBL
3
2
Surface Electromyography (SEMG) 100% of Actual Cost subject to MBL
3
3
Thallium Scintigraphy 100% of Actual Cost subject to MBL
3
4
Treadmill Stress Test (TMST) 100% of Actual Cost subject to MBL
E. THERAPEUTIC PROCEDURES
1 Arthrocentesis
Up to six (6) sessions subject to MBL for OP; Up to
MBL for IP
2 Dialysis Up to MBL shared limit for OP and IP
3 Intravenous Chemotherapy Up to MBL shared limit for OP and IP
4 Phlebotomy
MBL for IP
5
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.
6 Thoracentesis
MBL for IP
7 Therapeutic Radiology:
a. Brachytherapy Up to MBL shared limit for OP and IP
b. Cobalt Up to MBL shared limit for OP and IP
c. Linear Accelerator Therapy Up to MBL shared limit for OP and IP
d. Radioactive Cesium Up to MBL shared limit for OP and IP
e. Radioactive Iodine Up to MBL shared limit for OP and IP
8
Continuous Positive Airway Pressure
(CPAP)
Up to Php 60,000 shared limit for OP and IP
9 Oral Chemotherapy Up to Php 60,000 shared limit for OP and IP
F. ANNUAL CHECK-UP Optional
*
The following Routine ACU program shall be conducted at a designated Maxicare Accredited Clinic once
a year:
1 Routine (clinic) which includes:
Physical Examination √
Complete Blood Count √
Urinalysis √
Fecalysis √
Chest X-ray √
ECG Applicable for members 35 years old and above
Pap Smear
Applicable for members (women) 35 years old and
above
2 Pre-employment in lieu of ACU
Can be availed under Fee for Service. Billing shall be
based on actual cost plus 13.5% Claims Handling Fee
G. PREVENTIVE CARE

14
1
Passive and active vaccines for treatment
of tetanus and animal bites
Covered up to Php 40,000 / member / year
2 Periodic monitoring of health problems Covered
3
Health-education and counselling on diets
or exercise
Covered
4
Health habits and Family Planning
counseling
Covered
H.
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)
1
Angiography (gastrointestinal, brain,
retinal and peripheral vascular)
2
Coronary Angiogram and/or
Angioplasty/Coronary Artery Bypass Graft
3 Cryosurgery 100% of Actual Cost subject to MBL
4 Gamma Knife Surgery 100% of Actual Cost subject to MBL
5 Hysterescopic Myoma Resection 100% of Actual Cost subject to MBL
6 Hysteroscopically-guided D&C 100% of Actual Cost subject to MBL
7 Laparoscopy 100% of Actual Cost subject to MBL
8 Lithotripsy 100% of Actual Cost subject to MBL
9 Percutaneous Ultrasonic Nephrolithotomy 100% of Actual Cost subject to MBL
1
0
Stereotactic Brain Biopsy 100% of Actual Cost subject to MBL
1
1
Conventional Hemorrhoidectomy 100% of Actual Cost subject to MBL
1
2
Scalpel Hemorrhoidectomy 100% of Actual Cost subject to MBL
1
3
Stapled Hemorrhoidectomy Covered up to Php 5,000 /member /year
1
4
Mammotome Covered up to Php 5,000 /member /year
1
5
4D Ultrasound except for maternity-related
cases
Covered up to Php 5,000 /member /year
1
6
Esophageal Manometry Covered up to Php 5,000 /member /year
1
7
Intensified Modulated Radiotheraphy Covered up to Php 5,000 /member /year
1
8
Botox which is not cosmetic in nature nor
for beautification purpose
1
9
Positron Emission Tomography Covered up to Php 5,000 /member /year
2
0
CT Pulmonary Angiography Covered up to Php 5,000 /member /year
2
1
Photodynamic Therapy Covered up to Php 5,000 /member /year
2
2
Other medically necessary modalities not
mentioned above and those for which
there are no comparable, conventional or
traditional counterparts
Covered up to Php 5,000/ procedure /member /year
2
3
Transurethral Microwave Therapy of
Prostate
I. EMERGENCY CARE
1 In Accredited Hospitals
a. Doctor’s services Subject to MBL
b. Emergency Room Fees Subject to MBL
c. Medicines used for immediate relief Subject to MBL

15
during treatment
d. Oxygen, Intravenous fluids and blood
products.
Subject to MBL
e. Dressings, conventional casts (plaster
of Paris) and sutures.
Subject to MBL
f. X-Rays, laboratory and diagnostic
examinations, and other medical services
related to the emergency treatment of the
patient.
Subject to MBL
g. Room Upgrade in case of room
unavailability
up to 24 hours
2 In Non-Accredited Hospitals
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
3 Outside the Philippines
Reimbursable up to 100% of actual cost up to
Php30,000 / availment / member / year
4 Areas without Accredited Hospital 100% based on Maxicare rates up to MBL
5
Ambulance Service (Accredited
Hospital/Clinic to Accredited
Hospital/Clinic)
Up to MBL
6
Ambulance Service (Non-accredited
Hospital/Clinic to Accredited
Hospital/Clinic)
Reimbusable 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
Covered for the first 24 hrs. from the time of bite
subject to MBL
J. PRE-EXISTING CONDITIONS
1 Dreaded Conditions Covered depending on the type of Product
2 Non-Dreaded Conditions Covered depending on the type of Product
K. DENTAL CARE Optional
1 Dental examination/consultation only Covered
2 Oral prophylaxis Covered - Once a year
3
Uncomplicated tooth extraction (anterior
tooth, posterior tooth, )
Covered
4 Temporary Fillings Covered, as advised by Dentist
5
Desensitization of hypersensitive teeth
(limited to the application of necessary
medicament to the affected teeth)
Up to 2 teeth
6 Simple denture adjustment and repair Covered
7
Recementation of loose jacket crowns,
bridges, inlays and onlays
Covered
8
Palliative treatment for simple mouth sores
and blisters
Covered
9 Open incision and drainage (intraoral) Covered
1
0
Dental Nutrition and Dietary Counseling Covered
1
1
Dental Health Education Covered
1
2
Pre-natal consultation on teeth and gums Covered
1
3
Temporo Mandibular Joint Consultation Initial Consultation -Covered

16
1
4
Permanent Fillings 2 teeth per year
L.
GROUP LIFE INSURANCE WITH
ACCIDENTAL DEATH AND DISABLEMENT
(AD&D) BENEFITS
Optional
1 Insurance Provider
The Philippine American Life & General Insurance
Company
2 Death (amount of insurance) up to Php 25,000 /member
3 Corporate Personal Accidental Death & Dismemberment (AD&D)
A. Schedule of Losses for AD&D Coverage
i.) Loss of Life 100% of amount of insurance
ii.) Accidental Death, Dismemberment & Disablement or Loss of Use of Limbs
Both Hands 100% of amount of insurance
Both Feet 100% of amount of insurance
One hand and One foot 100% of amount of insurance
One hand 50% of amount of insurance
Arm between elbow and wrist 60% of amount of insurance
Arm at or above elbow 70% of amount of insurance
Leg below knee 60% of amount of insurance
Leg at or above knee 70% of amount of insurance
iii.) Loss of sight
Both eyes 100% of amount of insurance
One eye 50% of amount of insurance
iv.) Loss of speech 100% of amount of insurance
v.) Loss of hearing
Both ears 100% of amount of insurance
One ear 50% of amount of insurance
vi.) Accidental Dismemberment or Loss of
Use of Fingers
All of one hand 50% of amount of insurance
4 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.
5 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
i.) Dependents of Married employees
Legal spouse who are actively performing the daily
normal chores of life
Children who are single, unemployed and fully
dependent on the principal for support
ii.) Dependents of Single Employees
Parents who are actively performing the daily normal
chores of life

17
Siblings who are single, unemployed and fully
iii.) Dependents of Single Parent
Employees
Parents who are actively performing the daily normal
chores of life
Children who are single, unemployed and fully
M. CONDITIONS WITH SPECIFIC LIMITATIONS
1
Work Related Conditions based on
conditions covered by ECC
Up to MBL (Principal only)
2 Motor Vehicular Accidents
Covered subject to MBL and Exclusions and
Limitations Provisions
3
Provoked and Unprovoked Assault,
including domestic violence, whether
initiated by the Member or by a known or
unknown third party
Up to MBL
4
Scoliosis, including necessary procedures,
except physical therapy sessions, whether
congenital, pre-existing, developmental or
acquired
Up to Php 60,000 /member /year (shared limit for OP
and IP)
Note: Physical Therapy sessions shall form part of the
Physical therapy /Occupational therapy limits.
5
Congenital Conditions except physical
therapy sessions and developmental
disorders
up to Php 60,000 /member /year (shared limit for OP
and IP) Note: Physical Therapy
sessions shall form part of the Physical therapy
/Occupational therapy limits.
Congenital Hernia Covered up to MBL
6 Chronic Dermatoses Consultations only
7 Scabies Consultations and treatments
8 Exclusion #25 Covered up to MBL
9 Hepatitis B Covered up to MBL (if acquired)
N. ADDED PROGRAM FEATURES
1
24-Hour/7 Days a Week Customer Care
Hotline
√
2 Roving Customer Care Representative √
3 Manner of Access:
a. Hospitals more than 1,000 Hospitals (65% are tertiary hospitals)
and Clinicsb. Clinics
c. Primary Care Centers
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,
MyHealth Clinic Walter-mart Calamba, MyHealth Clinic
Robinson's Cybergate Cebu
d. Maxicare Centers
Pampanga, Baguio, Batangas, Cebu, Bacolod, Iloilo,
General Santos & Davao
e. Maxicare Helpdesks
Clinica Manila, Manila Doctors Hospital, Capitol
Medical Cnter, Mary Mediatrix Medical Center, Calamba
Medical Center. Soon to open: UST Hospital and De La
Salle Hospital
e. Accredited Doctors
over 30,000 accredited doctors (composed of Fellows,
Diplomates)
4 PayorLink System √
5 Orientation √
6 VAT Charges Inclusive of 12% VAT
7 ID Processing Fee at no additional cost

18
8 Booklets & Summary of Coverage (SOC) 1 per principal member
O. MEMBERSHIP GUIDELINES
1 Age Eligibility
Principals 18 up to 65 years old
Adult Dependents 18 up to 65 years old
Minor Dependents 15 days old up to 21 years old
* 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.
2 Hierarchy of Enrollment to be followed:
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 expatriate enrollees only)
P. ESCALATION CLAUSE:
1 at least 75% standard rates
2 60% - 74.9% + 10% to standard rates
3 40% - 59.9% + 20% to standard rates
4 Below 40% + 35% to 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 non-contributory. 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.

19
Q. ENROLLMENT GUIDELINES
1 Application Forms Waived
2 Masterlist of Enrollees Maxicare Format
3
Medical Requirements* (at the applicant's
account)
Waived
4
Other medical requirements if deemed
necessary
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.
2
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.

20
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.

21
Notes & Special Reminders:
 Rates are only applicable for virgin accounts or those with no previous enrollment with Maxicare.
 Rates and benefits are valid until December 31, 2016 and based on a 12-month coverage only. Rates for
Starter Plan are valid until September 30, 2017
 Rates presented are inclusive of 12% VAT. For VAT Exempt companies, they must present a PEZA Certicate to
be exempted for VAT
 Effectivity date, id number and ID card issuance shall be 5 days after OR date including subsequent addition
 Bronze Plan has no access to Makati Medical Center for Inpatient
 ACU Annual Check up can only be availed at designated ACU Providers
 Enrollment of Dependents must follow hierarchy
 There will be a 30 days grace period from the date of effectivity 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.
 Rated rates will apply to companies whose nature of business falls under Rated Industries. Companies whose
nature of business falls under Ineligible will not be allowed to enroll under this program. A separate proposal will
be drafted.
 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.
 All terms not mentioned are assumed to be based on Maxicare standard provisions.
LIST OF PROVIDERS
You may download the lists of providers at these links
DOCUMENT TINYURL LINK
List of Hospitals & Clinics http://tinyurl.com/maxicarehospitalsclinics
List of Doctors http://tinyurl.com/maxicaredoctors
List of Dentists thru Dental Hub http://tinyurl.com/maxicaredentalhub
List of ACU Annual Check Up Providers http://tinyurl.com/maxicareacuproviders
PLAN TYPES FOR DEPENDENTS
a) The dependents’ plan could be uniform with respect to the categories or ranks within the company.
Level Employees Plan Type Dependents Plan Type Comments
Executives Platinum 1 Platinum 1 Same plan with employee
Managers Gold 1 Gold 1 Same plan with employee
Staff Silver 1 Silver 1 Same plan with employee
b) The dependents’ plan can be 1 plan lower (only) but must be uniform across all levels
Level Employees Plan Type Dependents Plan Type Comments
Executives Platinum 1 Platinum 2 1 plan lower from Platinum 1
Managers Gold 1 Gold 2 1 plan lower from Gold 1
Staff Silver 1 Silver 2 1 plan lower from Silver 2
c) The dependents’ plan for all dependents can be the same plan with that of the lowest plan assigned to the employees
Level Employees Plan
Type
Dependents Plan
Type
Comments

22
Executives Platinum 1 Silver 1 Silver 1 is the lowest plan assigned to the
employeesManagers Gold 1 Silver 1
Staff Silver 1 Silver 1
d) The dependents’ plan for all dependents can be the same plan 1 plan lower (only) with that of the lowest plan
assigned to the employees
Level Employees Plan
Type
Dependents Plan
Type
Comments
Executives Platinum 1 Silver 2 Silver 2 is 1 plan lower from the lowest plan of the
employeeManagers Gold 1 Silver 2
Staff Silver 1 Silver 2
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:
at least 75% standard rates
60% - 74.9% + 10% to standard rates
40% - 59.9% + 20% to standard rates
Below 40% + 35% to standard rates
PROVINCIAL ACCESS
NORTHERN LUZON WITHOUT NCR & BAGUIO
● Members may avail to any accredited hospital/clinics within the following provinces:
a) CAR: Abra, Apayao, Benguet (except Baguio), Ifugao, Kalinga, Mountain Province
b) Region 1: Ilocos Norte, Ilocos Sur, La Union, Pangasinan
c) Region 2: Batanes, Cagayan, Isabela, Nueva Vizcaya, Quirino
d) Region 3: Aurora, Bataan, Bulacan, Nueva Ecija, Pampanga, Tarlac, Zambales
Note: Accounts requesting for Baguio access should enroll under our Nationwide Program
SOUTHERN LUZON WITHOUT NCR & BAGUIO
● Members may avail to any accredited hospital/clinics within the following provinces:
a) Region IV-A: Batangas, Cavite, Laguna, Quezon, Rizal
b) Region IV-B: Marinduque, Occidental Mindoro, Oriental Mindoro, Romblon, Palawan c) Region V: Albay,
Camarines Norte, Camarines Sur, Catanduanes, Masbate, Sorsogon
Note: Accounts located in Batangas will not be allowed to enroll in this program and should enroll under Nationwide
VISAYAS
●Members may avail to any accredited hospital/clinics within Visayas regions only.
MINDANAO
●Members may avail to any accredited hospital/clinics within Mindanao regions only.
INDUSTRIES
CATEGORY INDUSTRIES
Rated
Construction (Office Based)
Education (except pre schools, tutorials & review centers)
Law Firms
Media
Pharmaceuticals (Distributors)
Sauna, Turkish bath, massage parlors (except spa, salons)

23
Ineligible
"Ineligible" Groups
Construction (Field Based or combined)
Drillers (oil/water/gas)
Firemen
Full Time athletes
Government Institutions
Groups involving special hazards
Logging or Forestry
Manufacturers of Ammunitions
Medical Groups or any healthcare related
Mining / Underground mine workers
NGO, Foundations, Cooperatives, Associations (if enrolling with members, if
employees only yes)
Oil production
Pharmaceutical (manufacturing)
Political groups
Private households
Protection services (security guards)
PRE EXISTING NON DREADED & DREADED CONDITIONS
Non-dreaded conditions are as follows, but not limited to:
a. All benign tumors
b. Anal Fistulae
c. Cervical Polyps (if benign biopsy)
d. Conjunctivitis (except chemical, complicated)
e. Endometrioses/Controlled Dysfunctional Uterine Bleeding (except if caused by uterine malignancies)
f. Hemorrhoids
g. Hepatitis A
h. Gastritis, Duodenitis or Uncomplicated Gastric / Duodenal Ulcer
i. Inactive Pulmonary Tuberculosis
j. Migraine
k. Non-surgical Ear-Nose-Throat conditions such as but not limited to Sinusitis, Rhinitis, Tonsillopharyngitis, Laryngitis,
Parotitis, Otitis Media, Otitis Externa and Surgical Ear-Nose-Throat conditions such as but not limited to Tonsillectomy,
Nasal Polypectomy, Tympanoplasty, Sialolithotomy, Sialodochoplasty.
l. Non-Toxic Goiter (if uncomplicated)
m. Ovarian cysts Uncomplicated Cholecystitis, Cholelithiasis
n. Uncomplicated Hernias (Congenital Hernia will have coverage as listed in the Congenital Clause)
o. Uncomplicated Hypertension
p. Uncomplicated Urinary Tract Infection, Stones/Calculi
q. Urinary Incontinence
Dreaded conditions are as follows, but not limited to:
a. All malignancies (including indicated chemotheraphy or radiotheraphy)
b. Arthritis
c. Blood Dyscrasias such as but not limited to Leukemia, Idiopathic Thrombocytopenic Purpura
d. Chronic Cardiovascular Diseases and its complications such as but not limited to Uncontrolled Hypertension of
whatever etiology, Aortic Dissection, Abdominal Aortic Aneurysm, Myocardial infarction, Cardiac Arrest, Congestive
Heart Failure, Cardiac Arrhythmia, Cardiac Tamponade, Coronary Artery Disease, Cardiomyopathies and Valvular Heart
Disease, Aortic Dissection, Abdominal Aortic Aneurysm and Peripheral Vascular Disease and its complications such as
but not limited to Buerger’s Disease
e. Cataract and Glaucoma

24
f. Cerebrovascular Diseases such as but not limited to Stroke, Cerebral, Cerebellar, Thrombosis, Embolism and
Ruptured aneurysm and all Intracranial Hemorrhage and related conditions
g. Cholecystolithiasis and Choledocholithiasis
h. Chronic Endocrine Disorders and its complications such as but not limited to Dyslipidemia, Obesity, Diabetes Mellitus,
Hormonal Dysfunctions excluding surgical treatment/procedures for obesity
i. Chronic Gastrointestinal Diseases such as but not limited to Irritable Bowel Syndrome, Crohn’s disease
j. Chronic Genito-urinary Disorders
k. Chronic Kidney Disease/Failure & its complications
l. Chronic Liver Parenchymal Diseases such as but not limited to Liver Cirrhosis, Chronic hepatitis, Non-alcoholic Fatty
Liver Disease/Steatohepatisis (NASH)
m. Chronic Pulmonary Diseases such as but not limited to Bronchial Asthma, Chronic Obstructive Pulmonary Disease
(COPD), emphysema, and other chronic lung disease
n. Collagen Vascular/Connective Tissue/Immunologic Disorders such as but not limited to Systemic Lupus
Erythematosus and its complications
o. Complications of immuno-compromised clinical conditions except HIV/AIDS
p. Extrapulmonary Tuberculosis including Pott’s disease and Multi-Drug Resistance Case (MDR) case
q. Multiple Organ Failure
r. Muscular Dystrophies such as but not limited to Duchenne, Becker, limb girdle, facioscapulohumeral, myotonic,
oculopharyngeal, distal, and Emery-Dreifuss
s. Neuro-surgical interventions and/or major neurological diseases such as but not limited to
Poliomyelitis/Meningitis/Encephalitides, Demyelinating Neurologic diseases and its complications/sequelae and
Peripheral Nervous System Disorders/Diseases
t. Thyroid Dysfunctions due to disease of thyroid such as but not limited to Hypothyroidism and Hyperthyroidism
u. Any illness other than above which would require Critical Care/Intensive Care Unit (ICU) Confinement
v. All complications resulting from above list of conditions
KYC REQUIREMENTS FOR EMPLOYERS
CORPORATIONS
AND ORGANIZED
UNDER FOREIGN
LAWS
1. Mayor's Permit
2. SEC Certificate
3. Articles of Incorporation
4. General Information Sheet
5. Photocopy of Company ID of Signatory
6. Photocopy of at least one (1) valid Government issued ID of owner/authorized signatory. Any
of the ff:
i. Driver's
ii. GSIS-E Card
iii. Passport
iv. Philhealth
v. PRC
vi. SSS
vii. TIN
viiii. UMID
ix. Voter's
7. Signed Maxicare Masterlist (to be provided by the agent upon submission of final masterlist)
ADDITIONAL REQUIREMENTS FOR SPECIAL CASES:
A. If Signatory is not the President / CEO or the highest ranking officer, any of the following as
proof of authority to sign in behalf of the entity:
i. Board Resolution duly certified by the Corporate Secretary
ii. Notarized Appointment Letter
iii. Special Power of Attorney or similar document
B. For entities registered outside of the Philippines:

25
i. similar documents and/or information shall be obtained duly authenticated by the Philippine
Consulate where said entities are registered
C. For companies with that are VAT Exempt or Zero Rated:
i. Philippine Economic Zone Authority (PEZA) and/or Board of investments (BOI) certificate
ii. BIR Certificate of Registration (BIR 2303)
PARTNERSHIPS
1. Mayor's Permit
2. SEC Certificate
3. Articles of Partnership
5. Photocopy of at least one (1) valid Government issued ID of owner/authorized signatory
(Drivers, GSIS-E Card, Passport, Philhealth, PRC, SSS, TIN, UMID, Voter's)
C. For companes with that are VAT Exempt or Zero Rated
NON GOVERNMENT
ORGANIZATIONS /
COOPERATIVES
1. Mayor's Permit
2. SEC Certificate or Certificate of Registration issued by Cooperative Development Authority
(CDA)
4. Articles of Incorporation
4. Latest General Information Sheet
C. For companes with that are VAT Exempt or Zero Rated:
SOLE
PROPRIETORSHIP
1. Mayor's Permit
2. DTI Certificate

26
A. If Signatory is not the President / CEO or the highest ranking officer, proof of authority to sign
in behalf of the entity
i. Notarized appointment letter
ii. Special Power of Attorney or similar document
B. For companies that are VAT-Exempt or Zero-Rated
GOVERNMENT
AGENCIES / LOCAL
GOVERNMENT
1. Chartered Document
3. Maxicare Questionnaire for Rated Accounts
A. If signatory is not the procurement head, head of the agency or head of the local Government,
proof of authority of the signatory
i. Resolution duly certified by the managing body, or
ii. Notarized appointment letter
EMBASSY
1. Letter credence for their representative stating
KYC REQUIREMENTS FOR EMPLOYEES & SUBSEQUENT ADDITIONS
Employees
a. BIR Form 2316 duly signed by the authorized signatories of Employer
b. BIR 1604 / Alphabetical List (latest with stamped received by the BIR), or
c. Philhealth ER2
d. SSS R5 and R3 Contribution List
Board Members a. General Information Sheet
Consultants
a. BIR Form 2316 duly signed by the authorized signatories of Employer
b. BIR 1604 / Alphabetical List (latest with stamped received by the BIR), or
c. Philhealth Members Data Form (MDR), or
d. SSS Contribution List or General Information Sheet
e. Notarized Sworn Certification signed by the authorized signatory
Foreign Nationals
(Expats)
a. Alien Employment Permit issued by the Department of Labor and Employment
b. Photocopy of Alien Certificate of Registration Identity I-card issued by the Bureayu of Immigration
INELIGIBLE INDUSTRIES WITH LESS THAN 100 EMPLOYEES
Requirements for Quotation:
All Ineligible Industries mentioned
NGOs, Foundations, Churches, Associations, Cooperatives,
Associations
1. minimum of 10 employees enrolling 1. minimum of 10 employees enrolling
2. Signed Maxicare Prospective Account
Form. You may download the form at
http://tinyurl.com/maxicarepcaf
2. Signed Maxicare Prospective Account Form. You may download
the form at http://tinyurl.com/maxicarepcaf
3. SEC Registration Certificate and/or Cooperative Developing
Authority Certificate of Registration (for Cooperatives)

27
3. BIR 2303
4. Signed Questionnaire for Rated Accounts. You may download the
form here http://tinyurl.com/maxicarequestionnaire
4. Filled out Corporate Enrollment Sheet
(found at the last 3 pages of this initial
proposal)
5. 2 Year Audited Financial Statements
6. Detailed Master list with Rank Classification, Job Designation and
Description, Birthdays / Age, Gender. You may download the
template here http://tinyurl.com/maxicaredetailed
HOW TO SUBMIT THE REQUIREMENTS:
Option 1: (Via Email) You may scan the document and email it back to us.
Option 2: (Via Fax) You may also fax it to us at (02) 819-9899
ALL COMPANIES & INDUSTRIES WITH 100 EMPLOYEES & UP (OR EMPLOYEES AND DEPENDENTS IF
COMBINED REACHES 100)
Mandatory Requirements to Generate a Pricing Proposal:
All companies with 100 employees & up
NGOs/Foundations/Cooperatives/Associations with
100 employees and up
1. Signed Maxicare Prospective Account Form. You may
download the form at http://tinyurl.com/maxicarepcaf
1. Signed Maxicare Prospective Account Form. You
may download the form at
http://tinyurl.com/maxicarepcaf
2. SEC Registration Certificate and/or Cooperative
Developing Authority Certificate of Registration (for
Cooperatives)
2. Excel Softcopy of Company Masterlist (with birthdates or
age, gender, ranks/classification)
3. Signed Questionnaire for Rated Accounts. You may
download the form here
http://tinyurl.com/maxicarequestionnaire
4. 2 Year Audited Financial Statements
3. Filled out Maxicare Product Mix Survey Form. You may
download the form here
http://tinyurl.com/maxicareproductmix
5. Detailed Master list with Rank Classification, Job
Designation and Description, Birthdays / Age, Gender
6. Filled out Maxicare Product Mix Survey Form. You
may download the form here
http://tinyurl.com/maxicareproductmix
HOW TO SUBMIT THE REQUIREMENTS:
Option 1: (Via Email) You may scan the document and email it back to us.
Option 2: (Via Fax) You may also fax it to us at (02) 819-9899

28
COMPANY INFO SHEET
Company Name:
Nature of Business:
Address:
Telephone Number/s:
Company TIN:
Company Signatory (Name and
Designation)
Contact Person (Name and
Designation)
Contact Person Email Address:
Contact Person Mobile Number:
Term of Payment
(Annual/Semi/Quarterly)
Note: Quarterly option is not available for
Starter & Group Plans and for Provincial
companies with less than 20 employees
Provider Access (With 9 Major) (Yes or
No)
Note: Not Available for Provincial Plans
With Healthway Access (Yes or No)
Note: Not Available for Provincial Plans
Optional Riders (pls enumerate)
Note: Riders cannot be selectively
assigned but must be applied to all
employees or all dependents or both
except for Executive Check Ups which can
be assigned to Executives / Officers only

29
EMPLOYEES
Last Name First Name MI Extension Employee no. Position Date of Birth Sex Civil Status Plan
Legend:
1 First Name
2 Middle Name
3 Last Name
4 Extension Name Jr. / Sr. / I, II, III, IV etc.
5 Employee No
6 Position
7 Date of Birth mm/dd/yyyy format
8 Sex Either F for female or M for male
9 Civil Status Single / Married / Separated / Widowed / Divorced
10 Plan Platinum1, Gold2, Silver2 , Bronze

30
DEPENDENTS
First Name Middle Initial /Name
Last
Name
Extension Relationship Principal/Employee
Date of
Birth
Sex
Civil
Status
Plan
Legend:
1 First Name
2 Middle Name
3 Last Name
4 Extension Name Jr. / Sr. / I, II, III, IV etc.
5 Relationship Either as spouse, child, siblings or parent
6 Principal Name of the employee
7 Date of Birth mm/dd/yyyy format
8 Sex Either F for female or M for male
9 Civil Status Single / Married / Separated / Widowed / Divorced
10 Plan Platinum1, Gold2, Silver2 , Bronze

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