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Product Benefits
Annual Benefit Limit (ABL)
The ABL refers to the consumable limit you can use for ALL treatments/illnesses, per person, per year.
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Product Features and Benefits
CORE BENEFITS
EMERGENCY CARE
Acute care for sudden, severe conditions causing immediate
disability or death
IN-PATIENT CARE
Medical care
that requires hospital admission and strict monitoring of current health condition
OUTPATIENT CARE (Clinic-Based)
Medical care that does not require hospitalization
ADDITIONAL BENEFITS
PREVENTIVE CARE
Prevents health risk and promote wellness
MINDCARE
Support mental well-being, including mindfulness, self-care, and stress management
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Note:
Shared benefit limit
for OP, IP & ER (Core
Benefits) per year
subject to inner limits
Product Features and Benefits
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Pre-Existing Conditions
An illness or condition shall be considered pre-existing if, prior to the effective date of health coverage the pathogenesis of such illness or condition has started, whether or not the member is aware of such illness or condition. (Ex. Diabetes, Hypertension, Hemorrhoid, Chronic Diseases, etc.)
The diagnosis of the doctor/physician is the basis of if the condition is pre-existing.
PEC is covered up to Php 10,000 ABL /member/year after two months upon the start of effective date
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Out-Patient Care
Telemed consultations via HeyPhil DigiMed App 2.0 Consultations with affiliated Physicians at designated Primary Care clinics nationwide.
Laboratory and diagnostics procedure up to Php5,000 annually, including intensive laboratory exams (special modalities of treatment ex. CT Scan). Accessible in all affiliated clinics nationwide except Fortmed, TMC clinics and Healthway.
Reminders:
If services required are not available:
Secure Letter of Authorization (LOA) from PhilCare Authorized
LOA issuer in the said clinic for the required services.
Call Philcare’s hotline for assistance in availing the required lab
procedures.
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Out-Patient Care Telemedicine thru
HeyPhil DigiMed App 2.0
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Unlimited DigiMed Consultation with the following Physicians:
-Family Medicine Specialists
-Internal Medicine
-General Physician
Includes the ff:
Issuance of medical assessment and prescription
Endorsement for lab tests/procedures to clinics if
necessary
Referrals for specialty consult if necessary
Interpretation of laboratory test results
Consultations for pre-existing conditions not requiring
emergency attention
LOA GENERATION
THE
HEYPHIL APP
Memberscangenerate LOAs for Consultation or Laboratory Procedures anywhere and anytime at their convenience using their smartphone.
FIND A DOCTOR
Searchfor an accredited doctor and know which hospitals or clinics he is affiliated to. Check for the doctor’s specialization, clinic hours and address.
FIND A CLINIC/HOSPITAL
Searchforan accredited hospital or clinic and check for their address and contact details.
DIGICARD
Bypresentingthe HeyPhil DigiCard to the Coordinator, Clinic, or Hospital, members can still avail of the medical services if they forgot to bring along their NFC membership card.
VIEW DEPENDENTS
Memberscan viewtheirdependent’s details such as their benefits and historical availments. Principal members can also generate LOA for their dependents.
DIGIMED
Get instant consultation with an accredited on-line doctor in your office or at your home without queuing in hospitals or clinics.
@PHILCAREPH
Out-Patient Care Telemedicine thru HeyPhil DigiMed App 2.0
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These are illnesses requiring primary care consultation and may not need visualization and physical assessment of the doctor. Primary care is provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern not limited by problem, origin and organ system. This includes several conditions, but not limited to the following list:
- Respiratory conditions: Allergies, Asthma, Arthritis, Bronchitis, Cold or Cough,Sinusitis or Rhinitis, Pharyngitis, Laryngitis, Tonsillitis
- Cardiovascular conditions for follow up check-up: Hypertension, Medicinerefills
- Gastrointestinal Issues: Diarrhea and Vomiting, GERD, Dyspepsia
- Skin Conditions: Allergies, Rashes, Insect bites, Skin swelling/inflammations,
- CellulitisOther conditions/infections: Acne breakouts, Arthritis, Boils (Pigsa), Conjunctivitis, Ear infections, Fever, Mild injuries, Sprains and strains, UTI and bladder infections, General Pediatric conditions requiring initial consultation
Out-Patient Care Telemedicine thru HeyPhil DigiMed App 2.0
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TeleMed Limitations (DigiMed):
The exceptions of this health plan coverage are medical conditions which require in-person medical check-up for proper visualization of the case and physical exam for assessment of more appropriate treatment. These medical cases include but not limited to:
Emergency related cases
Maternity related cases
Dental Consultations
Mental health related conditions
Medical conditions related to all forms of behavioral disorders Developmental or psychiatric disorder and psychosomatic illness whether acquired or congenital
Dermatology-related cases
Illnesses needing treatments from a medical specialist
(e.g. severe cases of chronic illnesses)
“Fit to work” assessments requiring medical certification
Out-Patient Care Face to Face medical consultations and lab procedures at Affiliated providers
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Download the HeyPhil App 2.0 from Play Store or App Store
Sign up and register.
An SMS and email confirmation shall be sent to the registered email after successful registration. Use the HeyPhil App to your convenience.
Emergency Care
Examples of Emergency: Massive bleeding, Acute Appendicitis, Fractures, Multiple injuries secondary to accidents and/or unprovoked assault, Diarrhea with severe dehydration, Syncope
Up to Php 10K per year
Emergency room fees and doctors’ services
All medicines used for immediate relief and during treatment
All charges related to the emergency management of the patient
Treatment of tetanus and animal bites on first 24 hours only. This covers the 1ˢᵗ dose of
vaccine (anti-tetanus vaccine and rabies vaccine) only within the first 24 hours.
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Availment Procedure: Out-Patient ER
In an Affiliated Hospital
Without Confinement
Go to the Emergency Room of an affiliated
hospital
Present the PhilCare Card/ DigiCard to the
ER personnel for membership verification.
Receive needed emergency care.
Sign the Emergency Treatment Form and hospital Statement of Account / Charge Slip
before discharge.
If Confinement is needed
Follow procedure for In-Patient Care
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Availment Procedure: ER Leading to Confinement
In an Affiliated Hospital
With Confinement (InPatient procedure)
Go to the Emergency Room of an affiliated
hospital
Present the PhilCare Card/DigiCard to the ER
personnel for membership verification
Go to the admitting section and make sure to
have a LOA within 24 hours.
For PhilHealth members, file for coverage
before discharge.
Sign the hospital Statement of Account upon
discharge and pay ineligible charges.
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Availment Procedure: Out-Patient ER
In a Non-Affiliated Hospital
This applies to emergency case only on identified areas without affiliated hospitals.
Without Confinement
Go to the Emergency Room of the non-
affiliated hospital
Receive needed emergency care.
Inform PhilCare Customer Service within 24
hours.
Pay hospital bills and secure an Attending
Physician’s Report or Medical Certificate
from the ER doctor.
Submit a Reimbursement Claim Form to
PhilCare
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Availment Procedure: ER Leading to Confinement In a Non-Affiliated Hospital
If Confinement is needed
Pay ER for reimbursement
Coordinate with PhilCare Customer
Service within 24 hours for transfer to
an affiliated hospital.
Follow procedure for In-Patient Care
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Reimbursement Procedure:
foravailmentsinareasWITHOUT affiliated hospitals
Reminders:
Reimbursement is applicable for ER availment ONLY, in non-affiliated hospitals in areas without affiliated hospitals.
This benefit does not apply to hospital confinement
Turn-around time for processing is 30 days upon submission of complete requirements / documents.
A letter shall be issued for denied claims, stating the reason(s) for denial.
Reimbursement benefit applies to the following identified locations where there are no affiliated providers yet:
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Region II
Isabela Province
Nueva Viscaya
Region IV-B (MIMAROPA)
Oriental Mindoro
Region V
Masbate
Region VIII
Northern Sama r
Southern Leyte
Region XIII
Surigao Del Sur
CAR
Abra
Ifugao
Kalinga Apayao
BARMM
Sulu
Reimbursement Procedure:
foravailmentsinareasWITHOUT affiliated hospitals
This applies to emergency case only on identified areas without affiliated hospitals.
Reimbursement Requirements:
1.Duly accomplished Reimbursement Form
2.Original official receipt(s) of all hospital bills
3.Original official receipt(s) of the doctor’s professional fee(s)
4.Statement of Account from the hospital where the
member was treated
5.Original individual charge slips or itemized breakdown of
charges to support the Statement of Account
6.Police report, in case of accident and medico-legal cases
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In-Patient Care
Benefits
Upto Php 50K Annual Benefit Limit (ABL) per year Ward Room Only Not applicable for dependent enrollment
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Can be availed at more than 500 affiliated hospitals nationwide No admission deposit in any of the affiliated hospitals
Use of operating, ICU and recovery rooms
Professional fees of Attending physicians
Standard nursing services
Drugs & medicines for in-patient use
Coverable procedures directly related in the medical management of the patient as deemed medically necessary by the attending affiliated physician
No access to Major Hospitals (Asian Hospital Medical Center, St. Luke’s Quezon City, St. Luke’s Global City, Makati Medical Center, Cardinal Santos Medical Center, and The Medical City )
Availment Procedure: In-Patient / Hospital Confinement
Go to the admitting section of the hospital and present the COC and LOA.
The room type indicated for the specific plan shall be assigned for confinement, unless an upgrade has been requested by the patient.
Upon discharge, submit PhilCare requirements, check
final billing, and pay any amount not covered by the plan and PhilHealth, if applicable.
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Availment Procedure:
In-Patient Care Room Upgrade
If the patient prefers to upgrade his / her hospital room, please take note that:
Additional room cost shall be shouldered by the patient
Medical fees are linked to hospital room class – the more
expensive the room, the higher the fees for the medical
services
Higher medical fees may exceed your plan’s ABL and may
not be covered by PhilCare
Tip: In some hospitals, you may actually get the privacy you
need even in a semi-private room
Tip: If there are no available ward / semi-private rooms,
you might get upgraded at no extra cost
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Preventive Care
Annual Physical Examination by designated APE providers/clinics nationwide. Covers the following Basic 5 procedures:
Physical Examination
Chest X-Ray
Urinalysis
Fecalysis
CBC
Review of Medical History
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Availment Procedure: Annual Physical Exam (APE)
All Annual Physical Exam (APE) availments are strictly by appointment. Secure an APE request and submit to clientservicing@philcare.com.ph one (1) week before the preferred day of availment.
A Letter of Endorsement (LOE) shall be issued by PhilCare Client Servicing via email.
Call the accredited clinic one (1) day before the scheduled APE for confirmation. Present the LOE to the clinic on the day of availment.
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Mind Care
Mental health assessment in relation to the perceived stress, anxiety and depression.
24/7 Chat support from mental health associates. 24/7 Helpline where members can get an instant call from our mental health associates.
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Non-coverable Medical Availments
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An illness or condition shall be considered pre-existing if, prior to the effective date of health coverage the pathogenesis of such illness or condition has started, whether or
not the member is aware of such illness or condition. (Ex. Diabetes, Hypertension,
Hemorrhoid, Chronic Diseases, etc.)
Congenital conditions are not covered.
An illness, abnormality or defects present from birth (Ex. Mental retardation,
malformation of the body organs, down syndrome, etc.)
Maternity and related conditions are not covered.
All pregnancy and pregnancy related conditions
Standard general exclusions are not covered.
Note: Refer to the expounded Exclusion List in the proposal.
For HealthCare Availment Concerns . . .
We’re HERE for you 24/7
For urgentconcerns,pleasecall the following numbers:
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8462-1800
PhilCare’s Call Center Hotline Number
Toll Free Hotline1-800-1-888-3230
PhilCare’s Mobile Hotline Numbers
Smart Line: (0998) 562 1800
Globe Line: (0917) 592 1800
24/7 Covid Help Hotline8462-1810 PhilCare’s Call Center Email Address
For advance LOA Approval
callcenter@philcare.com.ph
For HealthCare Availment Concerns . . .
For advance LOA approval From Mondays to Fridays 9AM to 4PM
inVisayas and Mindanao Regions, please send a message to the assigned number per region or email the stated email addresses:
QA Cebu: Mr. Jan Edward Ibanez
Office Landline: (032) 512-7514
Mobile/Viber: (0998) 964-6853
Email: QACebu@philcare.com.ph
QA Mindanao/Davao: Ms. Arlyn Enriquez
Office Landline: (082) 225-1442
Mobile/Viber: (0916) 312-6587 /(0928) 719-0019 Email: arlyn.enriquez@philcare.com.ph
QA Dumaguete / GenSan/ Bohol: Ms. Krystel Joy Gale
Mobile/Viber: (0998) 965-3275
Email: krystel.gale@philcare.com.ph
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QA Iloilo / Aklan / Capiz/ Antique/ Bacolod: Ms. Rowena Garcia
Mobile/ Viber: (0998)965-3296. Email: QAiloilo@philcare.com.ph
Standard Exclusion List
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Standard Exclusion List
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Medical services availed from a non-affiliated provider and / or not covered in the provider contract
Homecare after hospital confinement
Benefits covered by PhilHealth and all other government funded healthcare entitlements as provided for by law
Extra charges demanded by the providers
Diseases declared as epidemic by the Department of Health and any other recognized health agencies
Cost of the medical services and professional fees in excess of the MBL and applicable inner limits of the Plan
Standard Exclusion List
Extra services that are not related to the medical management of the patient
Additional hospital charges and physician’s professional feesnot medically necessary in the medical management of the Member Routine physical examinations required for obtaining or continuing employment, requirement in school, insurance / travel or government licensing, health permit and other similar purposes
Medical Certificates
Professional fees of medico-legal officer(s)
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Standard Exclusion List
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Uncoverable medical services
Organ donation
Purchase or lease of any Durable Medical Equipment, oxygen dispensing equipment, and oxygen except during covered in-patient care
Procurement or use of corrective appliances, prosthesis, artificial aids and durable equipment (ex. Hearing aid, crutches, eyeglasses, contact lens, etc.)
Circumcision, sterilization of either sex or reversal of such, artificial insemination, sex transformation or diagnosis and treatment of infertility
Cosmetic procedure and surgery and oral surgery solely for purpose of beautification
Weight reducing programs, surgical operation or procedure for treatment of obesity, including but not limited to gastric stapling
Dental procedures unless otherwise taken as a rider benefit
Medical or surgical procedures that are experimental in nature and those that are not generally accepted as standard medical treatment (ex. Accupuncture) Take-home medicines, preventive and / or non-therapeutic drugs
Standard Exclusion List
Uncoverable medical cases and / or illnesses
Pregnancy/Maternity-relatedconditionsand their complications. Any cause or condition arising out of or during any one pregnancy, childbirth, miscarriage or abortion or any complications arising from the same.
Sexually Transmitted Diseases such as but not limited to herpes, gonorrhea, syphilis and conditions such as vulvar warts
Hepatitis B, C and D
All forms of behavioral disorders whether congenital or acquired; developmental or psychiatric disorder, psychosomatic illness
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Standard Exclusion List
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Uncoverable medical procedures
Procedures and / or services considered screening; Blood screening, blood typing, cross-matching for potential donors
Allergens used for hypersensitivity testing regardless if administered as an out-patient or in-patient procedures
Executive check-ups and confinement which are for purely diagnostic purposes except as specified in the Agreement
Out-patient medicines with the exception of intravenous chemotherapy medicine and those administered during an emergency treatment Vaccines, whether elective or administered during an emergency treatment Diagnosis and treatment of Error of Refraction conditions such as myopia, astigmatism, and the like, including laser treatment for the purpose of corrective eye refraction
Out-Patient Pain Management is not covered except in cases of emergency Complications arising from non-covered procedures and surgery
Standard Exclusion List
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Cases that are attributable self-inflicted harm and misconduct
Any injury, illnessor conditionwhich theMember maysuffer afterhe /
she has taken intoxicating drugs or alcoholic beverage
Treatment of injuries or illnesses resulting from voluntary participation of a Member in any hazardous sport or activity (ex. Bungee jumping, scuba diving, hang-gliding, mountain climbing, parachuting, surfing, rock- climbing, etc.)
Treatment of injuries or illnesses due to military service or suffered under conditions of war
Treatment of any injury which is proven to be attributable to the Member’s own misconduct and / or negligence
Cases of assault perpetrated by the Member including domestic
violence which result in harm or injury to the Member perpetrator
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