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  • • These benefits are paid to the accredited Health Care Institution (HCI) through All Case Rates

  • • The case rate amount shall be deducted by the HCI from the member’s total bill, which shall include professional fees of attending physicians, prior to discharge

  • • The case rate amount is inclusive of hospital charges and professional fees of attending physician

  • • Availment condition: Member must have six (6) months contributions preceding the three months qualifying contributions within the 12-month period prior to the first day of confinement

  • • Documents needed: copy of Member Data Record or PhilHealth Benefit Eligibility Form (PBEF) and duly accomplished PhilHealth Claim Form 1

  • • Where available: all accredited HCIs*
    *Different case rate amounts for selected medical conditions are being implemented when done in Primary Care facilities (PhilHealth Circular 14, s-2013)

  • • Only admissible cases shall be reimbursed

1. Day surgeries (ambulatory or outpatient surgeries) are services that include elective (non-emergency) surgical procedures ranging from minor to major operations, where patients are safely sent home within the same day for post-operative care


  • • Payments for these procedures are made to the accredited facility through All Case Rates

  • • The case rate amount shall be deducted by the HCI from the member’s total bill, which shall include professional fees of attending physicians, prior to discharge

  • • The case rate amount is inclusive of hospital charges and professional fees of attending physician

  • • Availment condition: Member must have six (6) months contributions preceding the three months qualifying contributions within the 12-month period prior to the first day of confinement

  • • Documents needed: copy of Member Data Record and duly accomplished PhilHealth Claim Form 1

  • • Where available: Accredited Ambulatory Surgical Clinics (ASCs)

2. Radiotherapy


  • • The case rate for radiotherapy using cobalt is P2,000 per session and P3,000 per session for linear accelerator

  • • Includes radiation treatment delivery using cobalt and linear accelator

  • • Claims for multiple sessions may be filed using one (1) claim form for both inpatient and outpatient radiation therapy

  • • May be availed of even as second case rate (full case rate amount)

  • • 45 days benefit limit: One session is equivalent to one day deduction from the 45 allowable days per year

  • • If procedure is done during confinement, only the total number of confinement days shall be deducted

  • • Exempted from Single Period of Confinement (SPC) rule (admissions and re-admissions due to same illness or procedure within 90-calendar day period)

  • • Availment condition: Member must have six (6) months contributions preceding the three months qualifying contributions within the 12-month period prior to the first day of confinement

  • • Where available: Accredited HCIs including Primary Care Facilities that are accredited for the said service

3. Hemodialysis


  • • The Case Rate for hemodialysis is P2,600 per session

  • • Covers both inpatient and outpatient procedures including emergency dialysis procedures for acute renal failure

  • • Claims for multiple sessions may be filed using one (1) claim form for both inpatient and outpatient hemodialysis

  • • May be availed of even as second case rate (full case rate amount)

  • • 90 days benefit limit: One session is equivalent to one day deduction from the 90 allowable days per year

  • • If procedure is done during confinement, only the total number of confinement days shall be deducted

  • • The procedure is exempted from Single Period of Confinement rule (admissions and re-admissions due to same illness or procedure within 90-calendar day period)

  • • Availment condition: Member must have six (6) months contributions preceding the three months qualifying contributions within the 12-month period prior to the first day of confinement

  • • Where available: All Accredited HCIs – this benefit is no longer restricted to hospitals and free standing dialysis centers provided that the service is within their capability as provided for in the DOH license

4. Outpatient Blood Transfusion


  • • The case rate for outpatient blood transfusion is P3,640 (one or more units)

  • • Includes Drugs & Medicine, X-ray, Lab & Others, Operating Room

  • • Covers outpatient blood transfusion only

  • • One day of transfusion of any blood or blood product, regardless of the number of bags, is equivalent to one session

  • • May be availed of as second case rate (full case rate amount)

  • • 45 days benefit limit: One session for each procedure is equivalent to one day deduction from the 45 allowable days per year Exempted from the SPC rule

  • • Where to avail: All Accredited HCIs

5. Primary Care Benefits 1


i. Preventive Services
  1. 1. Consultation
  2. 2. Visual inspection with acetic acid
  3. 3. Regular BP measurements
  4. 4. Breastfeeding program education
  5. 5. Periodic clinical breast examinations
  6. 6. Counseling for lifestyle modification
  7. 7. Counseling for smoking cessation
  8. 8. Body measurements
  9. 9. Digital rectal examination
ii. Diagnostic Examinations (as recommended by the doctor)
  1. 1. Complete blood count
  2. 2. Urinalysis
  3. 3. Fecalysis
  4. 4. Sputum microscopy
  5. 5. Fasting blood sugar
  6. 6. Lipid Profile
  7. 7. Chest x-ray
iii. Drugs and Medicines
  1. 1. Asthma including nebulisation services
  2. 2. Acute Gastroenteritis (AGE) with no or mild dehydration
  3. 3. Upper Respiratory Tract Infection (URTI)/Pneumonia (minimal and low risk)
  4. 4. Urinary Tract Infection (UTI)
  • • Payments for these services are made to the primary care provider through Per Family Payment Rate (PFPR)

  • • Availment condition: Indigent and Sponsored Members, as well as migrant workers and their legal dependents should avail of these benefits within the effectivity of their coverage as indicated in their PhilHealth ID cards or Member Data Records. iGroup (Gold) members may avail themselves of these benefits within the validity of their group policy contracts, while DepEd personnel may avail themselves of the benefits as long as they are still active members of PhilHealth

  • • Documents needed: Copy of Member Data Record or PhilHealth ID

  • • Where available: accredited rural health units, health centers or outpatient departments of selected government hospitals where members are enlisted
Benefit Package and
Amount of Benefit
Selections criteria Where available
Acute Lymphocytic / Lymphoblastic Leukemia (standard risk)
P500,000
a. Signed Member Empowerment (ME) Form;

b. Age 1 to less than 10 years old;

c. White blood cell count ‹50,000/µL;

d. No CNS leukemia at diagnosis;

e. There should be no testicular involvement of male patient at diagnosis; and

f. WHO Classification: B or T lymphoblastic leukemia immunophenotype (mature B-cell ALL or Burkitt leukemia are excluded).
NCR
Philippine Children's Medical Center

UP-Philippine General Hospital

National Children’s Hospital

Region I
Ilocos Training and Regional Medical Center

CAR
Baguio General Hospital and Medical Center

Region IIIA
Angeles University Foundation Medical Center

Jose B. Lingad Memorial Regional Hospital

Region IIIB
Premiere Medical Center

Dr. Paulino J. Garcia Memorial Research & Medical Center

Region IVB
Batangas Medical Center

Region V
Bicol Regional Training and Teaching Hospital

Bicol Medical Center

Region VI
Corazon Locsin Montelibano Memorial Regional Hospital

Western Visayas Medical Center

Region VII
Perpetual Succour Hospital of Cebu, Inc.

Vicente Sotto Memorial Medical Center

Region X
Northern Mindanao Medical Center

Region XI
Davao Regional Hospital

Southern Philippines Medical Center
Breast Cancer
(stage 0 to IIIA)
P100,000
a. Signed ME Form

b. Clinical and TNM staging:
- Stage 0 TisN0M0
- Stage IA T1N0M0
- Stage IB T0,T1N1M0
- Stage IIB T2N1M0 or T3N0M0
- Stage IIIA T0, T1, T2N2M0 or T3N1N2M0
NCR
East Avenue Medical Center

Jose R. Reyes Memorial Medical Center

Quirino Memorial Medical Center

National Kidney and Transplant Institute

UP-Philippine General Hospital

Rizal Medical Center

Region I
Ilocos Training and Regional Medical Center

Region II
Cagayan Valley Medical Center

CAR
Baguio General Hospital and Medical Center

Region III A
Angeles University Foundation Medical Center

Region III B
Dr. Jose B. Lingad Memorial Regional Hospital

Dr. Paulino J. Garcia Memorial Research and Medical Center

Premiere Medical Center

Region IV B
Batangas Medical Center

St. Frances Cabrini Medical Center

Region V
Bicol Medical Center

Bicol Regional Teaching and Training Hospital

Region VI
Corazon Locsin Montelibano Memorial Hospital

Western Visayas Medical Center

Region VII
Perpetual Succour Hospital of Cebu, Inc.

Vicente Sotto Memorial Medical Center

Region X
Northern Mindanao Medical Center

Region XI
Davao Regional Hospital

Southern Philippines Medical Center
Prostate Cancer
(low to intermediate risk)
P100,000
a. Signed ME Form;

b. Male patients age up to 70 years old;

c. Clinical stage (T1a-T2c), PSA level 10 to 20 ng/ml,
Tumor Grade (Gleason’s score of 2-7)
- Low risk: T1-T2a and Gleason score 2-6, and
PSA ‹10 ng/ml
- Intermediate risk: T2b to T2c, Gleason score of 7,
and PSA 10-20 ng/ml

d. Localized prostate cancer; and

e. No uncontrolled co-morbid conditions
NCR
Quirino Memorial Hospital

National Kidney and Transplant Institute

Rizal Medical Center

UP-Philippine General Hospital

Region I
Ilocos Training and Regional Medical Center

CAR
Baguio General Hospital and Medical Center

Region IIIA
Jose B. Lingad Memorial Regional Hospital

Region IIIB
Dr. Paulino J. Garcia Memorial Research & Medical Center

Region IVB
Batangas Medical Center

Region V
Bicol Medical Center

Bicol Regional Training and Teaching Hospital

Region VI
Western Visayas Medical Center

Corazon Locsin Montelibano Memorial Regional Hospital

Region VII
Vicente Sotto Memorial Medical Center

Region X
Northern Mindanao Medical Center

End-state renal disease eligible for requiring kidney transplantation (low risk)
P600,000
a. Signed ME Form;

b. Age ›10 and ‹70 years;

c. Single organ transplant;

d. Patient on chronic dialysis because of end stage renal disease or patient for pre-emptive kidney transplantation with the following:
i. The potential recipient should have an irreversible renal disease that has been progressive over the previous 6 – 12 months
ii. The recipient’s measured (nuclear scan) glomerular filtration rate, 24-hour urine creatinine clearance or calculated glomerular filtration rate should be less than 20 ml/min/1.73m2 in diabetics or less than 15 ml/min / 1.73m2 in patients with non-diabetic renal disease

e. Low immunologic risk defined as:
i. Past Panel Reactive Antibody (PRA) less than or equal to 20%
ii. Primary kidney transplant (no previous solid organ transplant)
iii. No donor specific antibody (DSA) in the potential recipient
iv. At least 1 HLA-DR match

f. Potential recipient has no previous history of cancer (except basal cell skin cancer), should be HIV negative, Hepatitis B surface antigen negative, and Hepatitis C antibody negative

g. Transplant candidate who is CMV-negative cannot receive an organ from a CMV-positive donor.

h. Absence of current severe illness (Congestive heart failure Class 3-4, liver cirrhosis (findings of small liver with coarse granular/heterogenous echo pattern with signs of portal hypertension), chronic lung disease requiring oxygen, etc)

i. Absence of the following: hemi-paralysis because of stroke, leg amputation because of peripheral vascular disease or diabetes, mental retardation such that informed consent cannot be made, and substance abuse for at least 6 months prior to start of transplant work-up.

j. Eligible patient for kidney transplant must have a certification from the social service of the hospital that they can maintain anti-rejection medicines for the next three (3) years.
NCR
National Kidney and Transplant Institute

UP-Philippine General Hospital

St. Luke's Medical Center - Global City

Delos Santos Medical Center

Region I
Lorma Medical Center

Region IIIA
Angeles University Foundation Medical Center

Region IVB
St. Frances Cabrini Medical Center

Batangas Medical Center

Region V
Bicol Medical Center

Region VI
St. Paul's Hospital of Iloilo, Inc.

Region VII
Vicente Sotto Memorial Medical Center

Region X
Northern Mindanao Medical Center

Region XI
Davao Regional Medical Center

Southern Philippines Medical Center

Coronary Artery Bypass Graft Surgery (standard risk)
P550,000
a. Signed ME Form

b. Age 19-70 years

c. Stable Coronary Artery Disease requiring ELECTIVE ISOLATED Coronary Artery Bypass Graft Surgery (CABG) with indication based on coronary anatomy, symptom severity, LV function, and/or viability tests; non-invasive testing completed and discussed with patient

d. Current Medical Status
i. Not in severe decompensated heart failure (NYFC IV)
ii. Not with severe angina (CCS Class III)
iii. No other cardiac/vascular procedures /interventions planned to be done with CABG during the admission

e. Past History:
i. No previous cardiac surgery such as CABG, valve surgery, etc.
ii. No previous transcutancous cardiac intervention such as coronary angioplasty or stenting
f. ONLINE EUROSCORE II and/or STS scoring predictive of low mortality risk (‹5%)
NCR
Philippine Heart Center

UP - Philippine General Hospital

Chinese General Hospital and Medical Center

Manila Doctors Hospital

Medical Center Manila

Makati Medical Center

CAR
Notre Dame de Chartres Hospital

Region IIIA
Angeles University Foundation Medical Center

The Medical City Clark, Inc.

Region IVA
De La Salle University Medical Center

Region IVB
Mary Mediatrix Medical Center

Region V
Bicol Regional Training and Teaching Hospital

Region VI
The Medical City – Iloilo

Region VII
Perpetual Succour Hospital of Cebu, Inc.

Vicente Sotto Memorial Medical Center

Region X
Northern Mindanao Medical Center

Region XI
Southern Philippines Medical Center
Surgery for Tetralogy of Fallot in Children
P320,000
a. Signed ME Form

b. Age: 1 to 10 years + 364 days

c. 2D-echocardiogram:
i. Pulmonary artery size
- McGoon’s index (Aorta/Pa ratio) ≥ 1.5
- Z score Pulmonary Valve Annulus : Acceptable if z score / BSA : ≥ 3 or better
- Z score peripheral PA’s : Acceptable if ≥ 2 or better
ii. Absence of major aortopulmonary collateral arteries (MAPCAs)

d. If cardiac catheterization / hemodynamic study available: PA size: adequate by Z score standards / BSA

e. No previous cardiac surgery (Blalock Taussig Shunt)

f. Functional Class I-II

g. No co-morbid factors, such as any of the ff:
i. Preoperative seizures
ii. Brain abscess
iii. Stroke events
iv. Bleeding disorders
v. Infective endocarditis
vi. Other congenital anomalies
NCR
Philippine Heart Center

UP - Philippine General Hospital

Region VII
Perpetual Succour Hospital of Cebu, Inc.

Vicente Sotto Memorial Medical Center

Region X
Northern Mindanao Medical Center

Region XI
Southern Philippines Medical Center
Surgery for Ventricular Septal Defect in Children
P250,000
a. Signed ME Form

b. Age: 1 to 5 years + 364 days

c. 2D-echocardiography
i. Isolated VSD perimembranous, subaortic or subpulmonic
ii. No combined shunts such as atrial septal defect or patent ductus arteriosus or atrioventricular septal defect
iii. No other associated CHD’s : such as coarctation of the aorta, or moderate to severe aortic insufficiency, or moderate to severe pulmonic stenosis
iv. Pulmonary artery pressure: ‹50 mmHg or at least 2/3 systolic blood pressure
v. QP QS: > 1.5:1

d. No previous cardiac surgery (PA Banding)

e. Functional Class I-II

f. No co-morbid factors, such as any of the ff:
i. Preoperative seizures
ii. Brain abscess
iii. Stroke events
iv. Bleeding disorders
v. Infective endocarditis

g. No chromosomal abnormalities and other associated congenital defects
NCR
Philippine Heart Center

UP - Philippine General Hospital

Region IV-B
Mary Mediatrix Medical Center

Region VII
Perpetual Succour Hospital of Cebu, Inc.

Vicente Sotto Memorial Medical Center

Region X
Northern Mindanao Medical Center

Region XI
Southern Philippines Medical Center
Cervical Cancer:
Chemoradiation with Cobalt and Brachytherapy (low dose) or Primary surgery for Stage IA1, IA2 – IIA1
P120,000

Chemoradiation with Linear Accelerator and Brachytherapy (high dose)
P175,000
a. Signed ME Form;

b. No previous chemotherapy

c. No previous radiotherapy

d. No uncontrolled co-morbid conditions

e. Treatment plan from gynecologic oncologist
Region IIIA
Angeles University Foundation Medical Center

Region IIIB
Premiere Medical Center

Region IVB
St. Frances Cabrini Medical Center

Region VII
Vicente Sotto Memorial Medical Center

Region IX
Zamboanga City Medical Center
Z-MORPH (Mobility,
Orthosis, Rehabilitation, Prosthesis Help)

- first right and/or left below the knee
P15,000

- both limbs
P30,000
a. Signed ME Form;

b. No associated disabilities or co-morbidities, such as contractures, deformities, mental or behavioral incapacity, quadriparesis, cardiopulmonary disease;

c. Community ambulation with or without cane, crutches or walker;

d. At least three (3) months post-amputation, if acquired; and

e. At least 15 years and 364 days of age, if congenital.
NCR
University of the East Ramon Magsaysay Memorial Medical Center

UP - Philippine General Hospital

Region III
Kapampangan Development Foundation, Inc.

Region IX
Zamboanga City Medical Center

Region XI
Southern Philippines Medical Center
Expanded Z-MORPH NCR
University of the East Ramon Magsaysay Memorial Medical Center

Region III
Kapampangan Development Foundation, Inc.

Selected Orthopedic Implants
1. Implants for Hip Arthroplasty
- Implants Hip Prosthesis, cemented*
P103,400

- Total Hip Prosthesis, cementless**
P169,400

- Partial Hip Prosthesis, bipolar
P73,180

*cemented: 66 years old and above
** cementless: 65 years and 364 days old and below

 

 

 

 

 

 

 

 

2. Implants for Hip Fixation
- Multiple screw fixation (MSF)*** 6.5mm cannulated cancellous screws with washer
P61,500

***59 years and 364 days old and below (both displaced and undisplaced fracture); 60 years old and above (undisplaced fracture)

 

 

 

 

 

3. Implants for Pertrochanteric Fracture
- Compression Hip Screw Set (CHS)
P69,000

- Proximal Femoral Locked Plate (PFLP)
P71,000

 

 

 

 

 

4. Implants for Femoral Shaft Fracture
- Intramedullary Nail with Interlocking Screws
P48,740

- Locked Compression Plate (LCP) – Broad / Metaphyseal / Distal Femoral LC
P50,740
a. Signed ME Form

b. Clinical Features
i. hip fracture
1. with avascular necrosis of the femoral head; OR
2. neglected fracture of the hip; OR
3. hip fracture with pre-existing cox-arthritis; OR
4. displaced hip fracture
  ii. with avascular necrosis of the femoral head (FICAT Stage III and IV); OR
iii. hip dysplasia (CROWE I-IV); OR
iv. severe osteoarthritis; OR
v. severe inflammatory joint disease (rheumatoid, gout, psoriatic, ankylosing spondylitis)

c. Pre-injury status: ambulatory patients

d. With no more than two co-morbid illnesses based on: Physical status classification based on ASA (low to moderate risk)

ASA I – normal healthy patient
ASA II – Patient with mild systematic disease; no functional limitation
 
a. Signed ME Form

b. Any hip fracture not covered under the total hip package for femoral neck fracture
i. with no avascular necrosis of the femoral head; OR
ii. acute fracture of the hip; OR
iii. hip fracture with no pre-existing cox-arthritis; OR
iv. displaced hip fracture

c. Pre-injury status: ambulatory patients

d. With no more than two co-morbid illnesses based on: Physical status classification based on ASA (low to moderate risk)

ASA I – normal healthy patient
ASA II – Patient with mild systematic disease; no functional limitation
 
a. Signed ME Form

b. CHS: stable fracture of the intertrochanteric area (AO Classification Type A1 fracture)

c. PFLP: unstable/comminuted pertrochanteric fracture (AO Classification Type A2 and A3 fracture)

d. Pre-injury status: ambulatory patients
e. With no more than two co-morbid illnesses based on: Physical status classification based on ASA (low to moderate risk)

ASA I- normal healthy patient
ASA II – Patient with mild systemic disease; no functional limitation
 
a. Signed ME Form

b. Femoral shaft fracture
i. without malignant/metastatic pathologic fracture: AND
ii. with any complete fracture of the femur
Pre-injury status: ambulatory patients

c. Physical status classification based on ASA (low to moderate risk)

ASA I – normal healthy patient
ASA II – Patient with mild systemic disease: no functional limitation
NCR
Philippine Orthopedic Center

CAR
Baguio General Hospital and Medical Center

Region IIIB
Dr. Paulino J. Garcia Memorial Research & Medical Center

Region VI
Corazon Locsin Montelibano Memorial Regional Hospital

Region VII
Vicente Sotto Memorial Medical Center

Region IX
Zamboanga City Medical Center

Region X
Northern Mindanao Medical Center

Region XI
Southern Philippines Medical Center
“PD First” - for End-Stage Renal Disease Requiring Peritoneal Dialysis
P270,000 per year
a. Signed ME Form (to be submitted annually together with the pre-authorization)

b. Patients must have a permanent Tenckhoff peritoneal dialysis catheter properly placed in the abdominal cavity;

c. Patients must have completed PD initiation in an accredited healthcare institution so that the patient is no longer uremic, with stable vital signs and adequately trained (patient himself/herself or a caregiver) to perform PD at home using manual exchanges;

Clinical Criteria
i. Must be at least 10 years of age;

ii. Diagnosed to have end-stage renal disease requiring renal replacement therapy;

iii. No previous history of cancer other than a successfully and completely treated cutaneous squamous cell or basal cell carcinoma or carcinoma in-situ of the cervix , within the past 5 years;

iv. HIV-negative;

v. No mental incapacity such that informed consent cannot be made or that would interfere with the patient’s ability to comply with the PD prescription;

vi. For pediatric patients, aged 10 to 18 years and 364 days, informed consent from the parents or when appropriate, from the guardian, must be secured;

vii. Absence of current severe illness, including congestive heart failure Class IV, liver cirrhosis (findings of small liver with coarse granular/heterogeneous echo pattern with signs of portal hypertension) and chronic lung disease requiring oxygen;

viii. Absence of hemiparalysis and leg amputation because of peripheral vascular disease;

ix. No history of substance abuse for at least 3 months prior to start of chronic dialysis treatment;

x. Absence of any disease of the abdominal wall, such as injury or surgery, burns, hernia, extensive dermatitis involving the abdomen;

xi. Absence of any inflammatory bowel diseases (ex. Crohn’s disease, ulcerative colitis or diverticulitis)

xii. Absence of any intra-abdominal tumors or intestinal obstruction;

xiii. Absence of active serositis;

xiv. Absence of known or suspected allergy to PD solutions
NCR
National Kidney Transplant Institute

Kidney Solutions, Inc.

Rizal Provincial Hospital System – Binangonan – Rizal)

Valenzuela Citycare Medical Center

Antipolo City Hospital System

Region III
Tarlac Provincial Hospital

Region IVA
Nephrocare

New Hope Peritoneal Dialysis Clinic

Region VI
Corazon Locsin Montelibano Memorial Regional Hospital

St. Paul's Hospital of Iloilo, Inc.

Region XI
Southern Philippines Medical Center
Colon and Rectum Cancer
Colon Cancer
Stage I-II (low risk) – P150,000
Stage II (high risk) – III – P300,00

Rectum Cancer
Stage I (clinical and pathologic) – P150,000
Pre-operative clinical stage I
but with post-operative pathologic
stage II-III
- using linear accelerator as mode of radiotherapy) - P400,000
- using cobalt as mode of radiotherapy - P320,000

Clinical Stage II-III
- using linear accelerator as mode of radiotherapy) - P400,000
- using cobalt as mode of radiotherapy -P320,000
1. Signed Member Empowerment (ME) Form
For Colon Cancer
a. Clinical and TNM Staging from stage I to III (Clinically T1-T4, N0-2, M0)

b. Pre-operative physical risk classification
ASA I – normal health patient OR
ASA II – patient with mild systemic disease

c. ECOG Performance Status

d. Mandatory and other services (procedures, diagnostics, medicines & others)

e. See Table 1 of Circular No. 028-2015

For Rectum Cancer
a. Biopsy proven rectum cancer stages I to III (clinically T1-4, N0-2, M0)

b. No previous pelvic radiation

c. Pre-operative physical risk protection
ASA I – normal health patient OR
ASA II – patient with mild systemic disease

d. ECOG Performance Status
e. Mandatory and other services ( procedures, diagnostics, medicines & others)
See Tables 6, 7, 8 of Circular No. 028-2015
NCR
UP-Philippine General Hospital

IIIA
Angeles University Foundation Medical Center

IVB
St. Frances Cabrini Medical Center

VII
Perpetual Succour Hospital of Cebu, Inc.

Vicente Sotto Memorial Medical Center
Prevention of Preterm Delivery

1.Prevention of preterm delivery with severe pre-eclampsia/eclampsia - 3,000.00

2.Prevention of preterm delivery, with preterm pre-labor rupture of membrane (pPROM) - 1,500.00

3. Prevention of preterm delivery without pre-eclampsia/eclampsia or rupture of membranes but with labor or vaginal bleeding or multifetal pregnancy - 600.00

4. With coordinated referral and transfer from a lower level of facility - 4,000.00
The following benefits shall be available for pregnant women who are in their 24 to 36 and 6/7 weeks of gestation, at risk of preterm delivery. The packages for the prevention of preterm delivery are availed exclusive of each other, with or without the coordinated referral and transfer package.
Preterm and Small Newborns
(24 to < 32 weeks)

1. Essential interventions for 24 to < 32 weeks - 35,000.00

2. Essential intervention with minor ventilator support and Kangaroo Care for 24 weeks to < 32 weeks - 85,000.00

3. Essential interventions with major ventilatory support and Kangaroo Care for 24 weeks to < 32 weeks - 135,000.00
The following benefits shall be available for pregnant women who are in their 24 to 36 and 6/7 weeks of gestation, at risk of preterm delivery. The packages for the prevention of preterm delivery are availed exclusive of each other, with or without the coordinated referral and transfer package.
Preterm and Small Newborns
(32 to < 37 weeks)

1. Essential interventions for 32weeks to < 37 weeks - 24,000.00

2. Essential interventions with mechanical ventilation and Kangaroo Care for 32 weeks to < 37 weeks - 71,000.00
The following benefits shall be available for premature newborns who are visually small or very small, 24 weeks to < 37 weeks by fetal aging or 500g to ≤ 2,499g fetal weight
Children with Developmental Disabilities

Assessment and discharge assessment ranges from P3,626.00 – P5,276.00

Rehabilitation Therapy Sessions P5,000.00 per set*

*Eligible children with developmental disability can only avail of a maximum of nine sets of therapies. Each set of therapies has a maximum of 10 sessions

a. Chronological age must be zero to 17 years and 364 days old; and

b. A child presents with functional problems secondary to delays, regressions, or deviations in any of the following developmental domains: cognitive-adaptive, sensorimotor, communication, social, emotional, or behavioral
Children with Mobility Impairment

Requiring assistive devices ranges from P13,110.00 – P163,540.00

Requiring seating device, basic and intermediate wheelchair ranges from P12,730.00 – P29,450.00

Yearly services and replacement of devices ranges from P1,590.00 – P13,690.00
a. General Criteria
i. Age must be 0 to 17 years and 364 days old;

ii. Absence of conditions that will compromise safety and functionality with the use of prosthesis, orthosis,

iii. On physical examination: no fresh or non-healing wound on body part of interest

iv. At least three months-post-surgery, if acquired amputation

b. With mobility impairment, presenting with any of the following:

i. Disorders resulting to mobility impairment:
a.) Musculoskeletal conditions characterized with any of the following: limb loss (amputation), limb deficiency, limb deformity and spine deformity (Cobb’s angle ≥ 20 degrees and Risser ˂ 4) classified into:

i.) Gross motor function classification system (GMFCS) 1 and 2 for prosthesis and orthoses

ii.) GMFCS 3, 4, and 5 for seating device, wheelchair, prosthesis and orthosis (note: For seating device, a child must be six months to six years & 364 days),

iii.) Talipes equinovarus (clubfoot)

b.) Neuromuscular conditions characterized with any of the following: weakness or paralysis, imbalance, incoordination, sensory deficits classified into:

i.) GMFCS 1 and 2 for prosthesis and orthosis, OR

ii.) GMFCS-3, 4, and 5 for seating device, wheelchair and orthosis

ii. Presence of cardiopulmonary, behavioral or cognitive conditions that impairs a child’s mobility
Children With Visual Disabilities

Package code and rates for initial assessment and intervention

Initial assessment and intervention (i.e. rehabilitation and training) for Category 1 Visual impairment - 25,920.00

Initial assessment and intervention (i.e. electronic assistive device, rehabilitation and training) for Categories 2, 3, and 4 Visual impairment - 31,920.00

Initial assessment and intervention (i.e. electronic assistive device, rehabilitation and training) for Category 5 Visual impairment - 9,070.00

Optical Aid 1: Low Power Distance, Categories 1, 2, 3 and 4 visual impairment eyeglasses + low power optical device - 7,350.00

Optical Aid 2: High power Distance, Categories 1, 2, 3 and 4 visual impairment progressive eyeglasses + high optical device - 13,820.00

Optical Aid 3: Colored Filter, Categories 1, 2, 3 and 4 visual impairment - 2,940.00

White cane, Category 5 visual impairment - 1,000.00

Description for add-on* devices

*These add-on assistive devices are availed of on top of the benefits for initial assessment and intervention for the Z Benefits for visual disabilities.

Description for yearly diagnostics, after the first year of enrolment

Yearly Diagnostics for Categories 1, 2, 3 and 4 - 3,220.00

Yearly follow up consultation for Category 5 - 780.00

Description for other benefits

Electronic Aid Replacement done every 5 years - 6,000.00

Ocular Prosthesis, per eye - 20,250.00

** Ocular prosthesis may be availed of exclusively or with any of the benefits for visual disabilities if the child fulfills the inclusion criteria stated in Item VII.1. c of PhilHealth Circular 2018-0010
a. General Criteria
1. Chronological age must be equal to 0 to 17 years and 364 days old;

2. AND any of the following:

i. The child must have undergone a visual disabilities assessment from an ophthalmologist where the child was categorized into Category 1, 2, 3, 4, or 5 visual disability and determined to need assistive devices with prescribed appropriate rehabilitation plan

ii. Children needing an ocular prosthesis should fulfill the following criteria:
a. The child has enucleated eye
b. Other clinical indications determined by ophthalmologists

3. Must be eligible at the time of pre-authorization

PhilHealth is in the process of contracting health care institutions for the provision of the Z Benefits for children with visual impairment.
Children With Hearing Impairment

Description for assessment and hearing aid provision of children 0 to less than 3 years old at the time of approval of pre-authorization

Assessment and hearing aid provision, with moderate hearing loss

Assessment: Otoacoustic Emission Screening and Auditory Brainstem Response (ABR)

Habilitation: Hearing Aid fitting, hearing aid device, batteries good for 5 years, ear mold, hearing aid verification

Ear mold refitting every six months for five years

53,460.00

Assessment and hearing aid provision, with severe to profound hearing loss

Assessment: Otoacoustic Emission Screening and Auditory Brainstem Response (ABR)

Habilitation: Hearing Aid fitting, hearing aid device, batteries good for 5 years, ear mold, hearing aid verification

67,100.00

Description for assessment and habilitation of children 3 to less than 6 years old at the time of pre-authorization

Assessment and hearing aid provision, with moderate hearing loss

Assessment: Age Appropriate Behavioral Audiometry

Habilitation: Hearing Aid fitting, hearing aid device, batteries good for 5 years, ear mold, hearing aid verification

Ear mold refitting once a year for five year

45,400.00

Assessment and hearing aid provision, with severe to profound hearing loss

Assessment: Age Appropriate Behavioral Audiometry

Habilitation: Hearing Aid fitting, hearing aid device, batteries good for 5 years, ear mold, hearing aid verification

Ear mold refitting once a year for five years

54,100.00

Description for assessment and habilitation of children 6 to less than 18 years old at the time of approval of pre-authorization

Assessment and habilitation, with moderate hearing loss

Assessment: Diagnostic Pure Tone Audiometry

Habilitation: Hearing Aid fitting, hearing aid device, batteries good for 5 years, ear mold, hearing aid verification

Ear mold refitting once a year for three years

43,880.00

Description for speech therapy assessment and sessions

Speech therapy assessment and sessions for moderate hearing loss

Include speech evaluation, speech therapy sessions and counselling

22,100.00

Speech therapy assessment and sessions for severe to profound hearing loss

Include speech evaluation, speech therapy sessions and counselling

63,420.00

Description for hearing aid replacement (The rates mentioned cover the hearing aid, its prescription, fitting, and fitting evaluation for one ear only)

Replacement of hearing aid for moderate hearing loss, 5 to less than 18 years old

Includes hearing aid fitting, hearing aid, batteries good for five years , ear mold and hearing aid fitting verification

43,670.00

Replacement of hearing aid for severe to profound hearing loss, 5 to less than 18 years old This is only available to those who have been enrolled prior to the age of six years old and availed of hearing aid. This require a new application for pre-authorization. Includes hearing aid fitting, hearing aid batteries good for five years, ear mold and hearing aid fitting verification 48,670.00
Children presenting with the following are entitled to avail themselves of the benefit package:

1. Age must be equal to 0 to 17 years and 364 days old

2. A child must have undergone professional assessment and is deemed to have ALL of the following:
i. Presence of delay on auditory milestones and/or communication issues at home/school

ii. Sensorineural hearing loss presenting with either moderate or severe to profound hearing loss described as:
a. Moderate hearing loss – three frequency (500 Hz, 1000Hz, 2000Hz) average threshold between 41 dBHL to 60 dBHL or
b. Severe to profound hearing loss –three frequency (500Hz, 1000Hz, 2000Hz) average threshold greater than or equal to 61 dBHL

iii. Absence of signs and symptoms of an active ear infection (e.g. otalgia, otorrhea, fever and tenderness)
PhilHealth is in the process of contracting health care institutions for the provision of the Z Benefits for children with hearing impairment.
As of August 2018
Benefit Package and
Amount of Benefit
Services included Where available Conditions
Outpatient Malaria Package
P600.00
Diagnostic malaria smears and other laboratory procedures; drugs and medicines & consultation services, including patient education & counseling. Initial providers are the accredited facilities for the Outpatient benefit for the indigent members, i.e Rural Health Units (RHUs) Patients diagnosed with malaria confirmed either through:
a. Microscopy-detection of malaria parasites in Giemsa- stained blood smear; or
b. Rapid Diagnostic Test (RDT) in areas with no access to microscopy centers or during outbreaks.
Outpatient HIV-AIDS Package
P30,000.00 per year
(P7,500/quarter)
Drugs and medicines, laboratory examinations, including Cluster Difference 4 (CD4) level determination test and test for monitoring of anti-retro viral drugs (ARV) toxicity and professional fees of providers DOH-designated treatment hubs Cases confirmed by STD/AIDS Central Cooperative Laboratory (SACCL) or Research Institute for Tropical Medicine (RITM).
Outpatient Anti-Tuberculosis Treatment through Directly-Observed Treatment Short-course (DOTS) Package
P4,000

P2,500 – Intensive phase

P1,500 – Maintenance Phase
Diagnostic exams, consultation services, drugs, health education and counseling during treatment Accredited TB-DOTS Centers • TB cases that are susceptible to 1st line anti-TB drugs
• Covers adult and children under the following registration groups:
• New
– Retreatment
• Relapse
• Treatment After Failure
• Treatment After Lost to Follow-up
(Return After Default)
• Previous Treatment Outcome Unknown
• Transfer-in
Voluntary Surgical Contraception Procedures
P4,000.00
Healthcare facility fee component to cover all applicable health facility charges inclusive of any of the following:

• Room and Board
• Drugs and medicines used during surgery or confinement
• X-ray, laboratory and other ancillary procedures
• Supplies used during surgery or confinement
• Use of special rooms e.g., operating room, recovery room

Physician fee component to cover any of the following:

• Family planning counseling and client assessment
• Intra-operative services including provision of anesthesia
Postoperative consultation within 90 days from day of surgery including dressing changes, local incision care, removal of sutures, management of complications that do not require hospitalization
Accredited hospitals, ambulatory surgical clinics (ASCs) and Primary care facilities (For Non-scalpel vasectomy only) Vasectomy including non-scalpel vasectomy Ligation or transection of fallopian tube (s), abdominal or vaginal approach
Animal Bite Treatment Package
P3,000.00
i. Rabies vaccine
• Purified Vero Cell Rabies Vaccine (PVRV) or
• Purified Chick: Embryo Vaccine (PCECV)

ii. Rabies Immune Globulin (RIG)
• Human Rabies Immune Globulin (HRIG) or
• Purified Equine Rabies Immune Globulin (pERIG)

iii. Local wound care
iv. Tetanus toxoid and anti-tetanus serum (ATS)
v. Antibiotics
vi. Supplies such as, but not limited to, syringes, cotton, alcohol and other antiseptics
PhilHealth accredited Animal Bite Treatment Centers This package shall cover the following:

a. The cost of providing Post-exposure Prophylaxis (PEP) services. The following are identified as reimbursable PEP service items:
i. Rabies vaccine
• Purified Vero Cell Rabies Vaccine (PVRV) or
• Purified Chick: Embryo Vaccine (PCECV

ii. Rabies Immune Globulin (RIG)
• Human Rabies Immune Globulin (HR1G) or
• Purified Equine Rubies Immune Globulin (pERIG)

iii. Local wound care
iv. Tetanus toxoid and anti-tetanus serum (ATS)
v. Antibiotics
vi. Supplies such as, but not limited to, syringes, cotton, alcohol and other antiseptics
b. Dog bites primarily. However, persons bitten by other domestic animals (cats) and livestock (cows, pigs, horses, goats) as well as wild animals (bats, monkeys) may be covered.

c. Category III Rabies exposure
i. Trans dermal bite (puncture wounds, lacerations, avulsions) or scratches/abrasions with spontaneous bleeding
ii. Exposure to a rabies patient through bites, contamination of mucous membranes (eyes, oral/nasal mucosa, genital/anal Mucous membrane or open skin lesions with body fluids through splattering and mouth-to-mouth Resuscitation
iii. Handling of infected carcass or ingestion of raw infected meat iv. Category II Rabies exposure involving the head and neck c. Patients with repeat exposure
Documents needed: copy of Member Data Record and PhilHealth Claim Form 1