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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 Benefit (PCB)


    Coverage
  • • Indigent
  • • Sponsored Members
  • • Overseas Workers Program (Land-based)
  • • Organized Groups/iGroups

  • Where to avail
  • • Accredited rural health units,
  • • Accredited health center
  • • Accredited government hospitals

  • Disease Conditions:
  • • Asthma
  • • Acute Gastroenteritis (AGE) with no or mild dehydration
  • • Upper Respiratory Tract Infection (URTI)
  • • Pneumonia (minimal and low risk)
  • • Urinary Tract Infection (UTI)

  • Benefit Inclusions:
  • • 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
  • • 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
  • • Drugs and Medicines
    1. 1. Inhaled Corticosteroids (Fluticasone)
    2. 2. Short acting beta 2 agonists/Inhalation solution or metered dose inhaler (Salbutamol)
    3. 3. Oral or systemic corticosteroids (Prednisone)
    4. 4. Oral Rehydration Salts (ORS)
    5. 5. Amoxicillin
    6. 6. Macrolide (Erythromycin)
    7. 7. Beta Lactams with beta lactamase inhibitors (Cephalexin)
    8. 8. 2nd generation cephalosporins (Cefuroxime)
    9. 9. Oral fluoroquinolones (Ofloxacin)
    10. 10. Co-trimoxazole
    How to avail:
  • 1. Assignment thru Local Health Insurance Offices (only for Indigent and Sponsored Members)
  • 2. Visit the PCB provider where you are assigned/enlisted

  • Expanded Primary Care Benefit (EPCB)


    Coverage
  • • Formal Economy (Employed)
  • • Lifetime Members
  • • Senior Citizen

  • Where to avail:
  • • Accredited EPCB Health Care Institution to include the following:
  • - OPD of Level 1, 2 and 3 government and private hospital
  • - Ambulatory Surgical Clinic
  • - Infirmaries
  • - Private medical outpatient clinics

  • Disease Conditions:
  • • Asthma
  • • Acute Gastroenteritis (AGE) with no or mild dehydration
  • • Upper Respiratory Tract Infection (URTI)
  • • Pneumonia (minimal and low risk)
  • • Urinary Tract Infection (UTI)
  • • Hypertension
  • • Diabetes Mellitus Type II
  • Benefit Inclusions:
  • • Health screening and assessment/consultation
  • • Essential Services (based on the life stage as indicated in the AO 2017-0012: Guidelines on the Adoption of Baseline Primary Health Care Guarantees for All Filipinos )
  • Lifestage group Essential Services
    0-12 months CBC
    >1-4 years CBC
    Fecalysis
    Urinalysis
    5-9 years old CBC
    Fecalysis
    Urinalysis
    10-19 years old Paps smear (as applicable)
    Urinalysis
    Fecalysis
    CBC
    Chest X-ray
    20-60 years old (female) Paps smear( as applicable)
    Chest X-ray
    Lipid Profile
    FBS (for follow up)
    Oral Glucose Tolerance Test (for initial)
    Sputum microscopy (as applicable e.g. Suspected TB)
    ECG (for 30 y/o and up)
    > 60 years old Pap smear (for female)
    Chest X-ray
    Lipid Profile
    FBS (for follow up)
    Oral Glucose Tolerance Test (for initial)
    Sputum microscopy (as applicable e.g. Suspected TB)
    ECG

  • • Drugs and Medicines
    1. 1. Amoxicillin
    2. 2. Co-Amoxiclav (Amoxicillin + Potassium Clavulanate)
    3. 3. Cotrimoxazole (Sulfamethoxazole + Trimethoprim)
    4. 4. Erythromycin
    5. 5. Fluticasone + Salmeterol
    6. 6. Ofloxacin
    7. 7. Oral Rehydration Salts
    8. 8. Prednisone
    9. 9. Salbutamol (as Sulfate) + Ipratropium Bromide
    10. 10. Salbutamol
    11. 11. Paracetamol
    12. 12. Simvastatin
    13. 13. Gliclazide
    14. 14. Metformin Hydrochloride
    15. 15. Enalapril
    16. 16. Metoprolol
    17. 17. Amlodipine
    18. 18. Hydrochlorothiazide + Losartan
    Note/s:
    • 1. FREE (only for the member or 1 of his/her dependent)
  • • Initial Health screening and assessment
  • • Initial Essential Services

    • 2. FIXED CO-PAYMENT* (applicable for member and dependents)
  • • Initial and follow-up medicines
  • • Follow-up consultation
  • • Follow-up laboratory included in the list

    • 3. REGULAR FEE
  • • Initial health screening, assessment and essential services for beneficiaries not availing of the free
  • • Other laboratory services and prescribed medicines not included in the list
  • * The HCI shall apply the same fixed co-payment rules for other disease conditions not covered by the expanded PCB that will require any of the laboratories and medicines included in the list of essential services and drugs. (e.g. CBC for suspected dengue case, chest X-ray for suspected TB, antibiotics for infected wounds, impetigo and other skin infections)

  • How to avail:
  • 1. Membership Data Record (MDR) Updating
  • 2. Online assignment thru any of the following:
  • Member Online Inquiry
  • • PhilHealth Call Center (02-4417442)*for further announcement
  • • Local Health Insurance Office (LHIO)
  • • PhilHealth Customer Assistance, Relations and Empowerment Staff (PCARES)
  • • Employer via Electronic Premium Remittance System (EPRS)

  • 3. Acquire Authorization Transaction Code (ATC) through any of the following:
  • Member Online Inquiry
  • • PhilHealth Call Center (02-4417442)*for further announcement
  • • Local Health Insurance Office (LHIO)
  • • PhilHealth Customer Assistance, Relations and Empowerment Staff (PCARES)

  • 4. Visit the EPCB HCI where you are assigned
  • 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
    National Children’s Hospital

    Philippine Children's Medical Center

    UP-Philippine General Hospital

    CAR
    Baguio General Hospital and Medical Center

    Region I
    Ilocos Training and Regional Medical Center

    Region IIIA
    Angeles University Foundation Medical Center

    Jose B. Lingad Memorial Regional Hospital

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

    Premiere Medical Center

    Region IVB
    Batangas Medical Center

    Region V
    Bicol Medical Center

    Bicol Regional Training and Teaching Hospital

    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 Medical Center

    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

    National Kidney and Transplant Institute

    Quirino Memorial Medical Center

    Rizal Medical Center

    UP-Philippine General Hospital

    CAR
    Baguio General Hospital and Medical Center

    Region I
    Ilocos Training and Regional Medical Center

    Region II
    Cagayan Valley Medical Center

    Region III A
    Angeles University Foundation Medical Center

    Region III B
    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 Medical Center

    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
    National Kidney and Transplant Institute

    Quirino Memorial Medical Center

    Rizal Medical Center

    UP-Philippine General Hospital

    CAR
    Baguio General Hospital and Medical Center

    Region I
    Ilocos Training and Regional 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
    Corazon Locsin Montelibano Memorial Regional Hospital

    Western Visayas Medical Center

    Region VII
    Vicente Sotto Memorial Medical Center

    Region X
    Northern Mindanao Medical Center

    End-stage 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
    Delos Santos Medical Center

    National Kidney and Transplant Institute

    St. Luke's Medical Center - Global City

    UP-Philippine General Hospital

    Region I
    Lorma Medical Center

    Region IIIA
    Angeles University Foundation Medical Center

    Region IVB
    St. Frances Cabrini 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 Doctors Hospital

    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
    Chinese General Hospital and Medical Center

    Makati Medical Center

    Manila Doctors Hospital

    Medical Center Manila

    Ospital ng Muntinlupa

    Philippine Heart Center

    UP - Philippine General Hospital

    CAR
    Notre Dame de Chartres Hospital

    Region IIIA
    Angeles University Foundation Medical Center

    The Medical City - Clark

    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

    Vicente Sotto Memorial Medical Center

    Region X
    Northern Mindanao Medical Center

    Region XI
    Davao Doctors Hospital

    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
    Philippine Orthopedic Center

    University of the East Ramon Magsaysay Memorial Medical Center, Inc.

    UP - Philippine General Hospital

    Region IIIA
    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, Inc.

    Region IIIA
    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 IVB
    Batangas 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
    Antipolo City Hospital System - Cabading

    Kidney Foundation of the Philippines

    Kidney Solutions, Inc.

    K-Matters Taguig

    Makati Medical Center

    National Kidney Transplant Institute

    Rizal Provincial Hospital System – Binangonan

    UP - Philippine General Hospital

    Valenzuela Citycare Medical Center

    Region I
    Ilocos Training and Regional Medical Center

    Region III
    Tarlac Provincial Hospital

    Region IVA
    K-Matters Dasmariñas

    Nephrocare

    New Hope Peritoneal Dialysis Clinic

    Region V
    Bicol Peritoneal Dialysis Center, Inc.

    Region VI
    Corazon Locsin Montelibano Memorial Regional Hospital

    St. Paul's Hospital of Iloilo, Inc.

    Region VII
    Cebu Provincial Hospital – Carcar

    Region VIII
    Eastern Visayas Regional Medical Center

    Region IX
    Zamboanga City Medical Center

    Zamboanga Dialysis Clinic

    Region XI
    Davao Doctors Hospital

    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
    The Medical City – Ortigas

    UP-Philippine General Hospital

    Region IIIA
    Angeles University Foundation Medical Center

    Region IVB
    St. Frances Cabrini Medical Center

    Region VII
    Perpetual Succour Hospital of Cebu, Inc.

    Region IX
    Southern Philippines Medical Center

    PREMATURE and SMALL NEWBORN
    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. Region VII
    Gov. Celestino Gallares Memorial Hospital
    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. Region VII
    Gov. Celestino Gallares Memorial Hospital
    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 March 31, 2019
    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