WELLS FARGO ENTERPRISE GLOBAL SERVICES,- LCC PHILIPPINES

Coverage Period:

February 1, 2016 to January 31, 2017

MAXICARE IS A COMPANY COMMITTED TO CONTINUOUS

PROGRESS FOR ITS CLIENTS

More than 1,000 Accredited

Hospitals & Clinics nationwide

All Maxicare centers are online

with the Head Office

Continuously growing in number

More than 43,000

doctors and specialists

nationwide

At minimum, our doctors are

Internal Medicine Specialists.

These are Maxicare-owned healthcare facilities / clinics that have its own staff of customer service representatives and primary care physicians, who

administer healthcare assistance to Maxicare members only.

Exclusive to Maxicare Members Only

Easy access to Internal Medicine Specialists

Unlimited number of FREE consultations

Strategically located in/near major hospitals

3rd Floor, Tower 1 Makati Medical Center

Lower Ground Floor, Asian Hospital Lower Civic Drive, Alabang, Muntinlupa

Ground Floor Medical Arts Bldg.,

Medical City, Ortigas Avenue, Pasig City

15th Floor, North Tower St. Lukes, Quezon City

Room 325, Medical Arts Building St. Lukes, Fort Bonifacio, Global City

10th Floor

Chinese General Hospital Medical Arts Building,

Sta Cruz Manila

Unit 933 Centuria Medical Makati, Century City, Kalayaan Ave. cor. Salamanca St. Brgy. Poblacion

Makati City

MyHealth clinics are Maxicare affiliated/accredited clinics located at selected

malls in Metro Manila, making them easily accessible.

*Clinic hours are subject to mall hours (highlight)

• SM North EDSA 2nd Level, North EDSA, Quezon City

• EDSA Shangri-La Level 1, Shangri-La Plaza Shaw Blvd., Mandaluyong City

• Festival Supermall

Level 2, Festival Supermall Filinvest, Alabang

• Robinsons Cybergate, Cebu 3rd Level, Robinsons Cybergate Fuente Osmena, Cebu City

• G/F Filomena Building Amorsolo Street Legaspi Village, Makati City

Availability beyond 5PM and during

weekends*

FREE consultation with a Maxicare

physician

Access to state-of-the-art medical

facilities

Easy access because they can be found

in malls

MAKATI MEDICAL CENTER

8th floor, Makati Medical Center

THE MEDICAL CITY

12th floor, Doctors Building

Ortigas Avenue, Pasig City

Roving Personnel or Liaison

Officers assist Maxicare

members who are confined

by thoroughly explaining

their coverage and informing

them of the documents they

need to submit before

discharge.

is a portal on the website dedicated for Maxicare

members. The member gateway aims to provide full access from one’s basic information to online LOA requests.*

*Members must register first using their card number in the

Member Gateway.

This provides the members with

the basic information about their

healthcare coverage such as:

Effective date

Expiry date

Plan Description

Benefit Limit

Room and Board Entitlement

Access to Hospitals

AVAILMENT SUMMARY

Members may track the

summary of their availment

through this portal. Availment

may be filtered per date or

availment type.

This is also a way to help the

members manage their usage.

Advantages of the ONLINE LOA facility:

is a facility under Member Gateway, which allows the members to

request their Letter Of Authorization (LOA) online.

Members may facilitate

LOA request anytime

and anywhere

Convenient and saves the

member a great amount

of time from queuing

Coverage of the HealthCare Program

STATUS

OF EMPLOYEE

ALLOWED

DEPENDENT/S

AGE RQMT

OF DEPENDENT/S

Regular employees aged 65 years old and below Dependents of regular employees

STATUS OF EMPLOYEE

ALLOWED DEPENDENT/S AGE REQT OF DEPENDENT

Married Spouse and Up to 65 years old

Children (eldest to youngest) 15 days old up to 21 years old

Single Parents Up to 65 years old

Domestic Partner Up to 65 years old

Single Parent Child/ren (eldest to youngest) and/or Parents

15 days old up to 21 years old; Up to 65 years old

Domestic Partner Up to 65 years old

*Must follow Hierarchy

PROVISION FOR DOMESTIC PARTNER

• Cover for Team Member’s domestic partner, regardless of gender • HMO premium will be collected based on the number of months

being covered. The monthly deduction is the same as existing dependents.

• Maximum Benefit Limit for 2016 will remain in full for Domestic Partners enrolled in August.

• Standard hierarchy rules shall apply • Both the Team Member and Domestic Partner must be of legal age,

but be no more than 65 years of age and have no legal impediment to marry; have not contracted marriage in the Philippines or elsewhere; are not related by blood whether legitimate or illegitimate, up to fourth degree.

• Both the Team Member and Domestic Partner have shared a single, intimate, committed relationship of mutual caring for at least 12 months; intend to remain as each other’s sole domestic partner indefinitely.

PROVISION FOR DOMESTIC PARTNER

• Both have resided together in the same residence for at least 12 months. • Both are mentally competent to consent or contract. • Must be able to provide all of the following required documentation: A joint Affidavit of Domestic Partnership certifying that all criteria are met Barangay Certification of Co-Habitation stating that Team Member

and Domestic Partner live in the same address including the duration of their residence therein

Certified copy/ Statistics Office (NSO) copy of birth certificate Certified copy/NSO copy of No Marriage

• Team Members are encouraged to share program guidelines with their

domestic partner before enrolling them to ensure they fully understand and meet all eligibility requirements.

MBL or Maximum Benefit Limit - per illness/injury/member/year

*no access to Healthway clinics

MAXIMUM

BENEFIT

LIMIT

ROOM & BOARD

ACCOMODATION

PLAN TYPE

of EMPLOYEE/

DEPENDENTS

Employees Hired before

March 1, 2013

PLATINUM

P250,000 Open Private

Employees Hired

after March 1, 2013

GOLD P180,000 Small Private

PLAN TYPE

OF

EMPLOYEE/

DEPENDENTS

MAXIMUM

BENEFIT

LIMIT

ROOM AND BOARD

ACCOMODATION

EMPLOYEE

CLASSIFICATIO

N

Periodic Monitoring of Health Problems

Health Education & Counseling on diet and exercise

Family Planning Counseling

Wellness Programs

* May be availed during the regular consultations.

Physical Examination

Urinalysis

Fecalysis

Chest X-ray

Complete Blood Count

FBS and Cholesterol

ECG for members 30 yrs. old and above

Pap Smear for female members 35 yrs. old & above

Regular Consultations (except prescribed Medicines)

Up to MBL

Eye Laser Therapy (including cataract removal except

cost of lens; Lasik/PRK treatment

not covered

Up to P10,000 per member/year

Pre and Post Natal Consultations Up to MBL

Ears, Nose, Throat

Treatment

Up to MBL

Treatment of minor injuries

Minor surgeries not requiring

confinement

X-ray, Laboratory exams,

Routine and other diagnostic

Procedures

COVERAGE LIST

Sclerotherapy – removal of Varicose veins Up to MBL

Cauterization of Warts (except genital warts)

P1,000 per member per year

Speech Therapy

(outright coverage; for stroke patients only)

Up to MBL

Tuberculin Test P600 per member per year

Therapeutic Procedure (IV Chemotherapy, Dialysis, etc.)

Up to MBL

Physical/Occupational Therapy (Shared Limit)

Up to 25 sessions/member/year subject to MBL (Note: Therapy of one (1) body area shall be considered as one (1) session)

COVERAGE LIST

Room and Board accommodation (based on your plan type and entitlement)

Use of Recovery Room and Intensive Care Unit (ICU)

Professional Fee of attending doctors & nursing services

Drugs and medicines for use in the Hospital

Whole blood/human blood products & IV fluids transfusion

Anesthesia, oxygen and its administration

Standard hospital admission kit

Dressings, casts, sutures, and other supplies/services directly related to the medical management of the patient

Doctor’s services

Emergency room fees

Medicines used for immediate relief and during

treatment

Initial treatment of animal bites up to MBL

(For the first 24 hours from the time of bite)

Passive and active vaccines for animal bites up to MBL

Ambulance services up to MBL if within the network,

reimbursable up to P2,500 if outside the network

Coverage for room upgrade – first 24 hours

Availment in Non-accredited hospital within the Philippines

-Maxicare shall reimburse 100% of the hospital bills and professional

fees, based on Maxicare standard rates up to

MBL/availment/member/year for the first 24 hours

-If patient is not medically stable after 24 hours, reimbursement shall be

allowed

Outside the Philippines Maxicare shall reimburse 100% of the hospital bills and professional fees,

based on Maxicare standard rates up to MBL/availment/member/year

Areas without affiliated hospitals within the Philippines Maxicare shall reimburse 100% of the hospital bills and professional fees,

based on Maxicare standard rates up to MBL

Emergency Care Coverage (FOR NON-AFFILIATED)

CLAIMS & REIMBURSEMENT PROCEDURE

All claims must be submitted to the Wells Fargo HR Team within 30 days from

date of discharge from the hospital. The following are the required documents

for reimbursement:

Claim Reimbursement Form for MRC (with filled out SMS number and email);

Original receipts of all hospital bills & professional fee of the Doctor;

Original charge slips (with itemized breakdown of charges);

Clinical abstract, admitting history and medical certificate;

Histopath/Surgical Report (if surgical operation was done);

Police Report in case of accident and medico legal cases:

Processing of Claims will be 7-15 days from receipt of complete documents.

Approved reimbursement shall be paid via check and shall be delivered and

endorsed to the Wells Fargo HR Team

COVERAGE LIST Pre-existing dreaded and non dreaded conditions

Up to MBL

Work related cases based on conditions set by ECC (Employee Compensation Commission)- for principals only

Motor or Vehicular Accident (subject to exclusions and limitations)

Provoked / Non Provoked Assault

Consultation for Chronic Dermatoses

Coverage for Scoliosis (whether pre-existing, acquired, congenital & developmental)

Congenital Conditions except physical therapy sessions and

developmental disorders (shared limit for OP and IP) Principals: Up to MBL;

Dependents: Up to P20,000

Prosthetic device Up to P40,000

Slipped Disc and Spondylosis UP to MBL

Sleep Study related to Organic Illness (if diagnosis is covered) Up to MBL

Group Life Accident Death and Dismemberment Up to P10,000

COVERAGE LIMIT

COVERAGE LIST

Caesarean P25,000.00

Normal P20,000.00

Miscarriage P15,000.00

Home Delivery P7,500.00

COVERAGE LIMIT

Maternity Benefit MATERNITY BENEFIT MATERNITY BENEFIT

• For female employees (married or single) and spouse of male employees only

• LOA facilitated if availed at accredited hospitals; reimbursement basis if availed at non-accredited hospitals

Coverage: Limit

*All laboratory procedures directly related to maternity shall not be covered

Oral Prophylaxis – twice a year

Simple tooth extractions

Temporary fillings – covered as needed

Permanent fillings – 2 teeth

Emergency dental treatment

Comprehensive restorative & prosthodontic treatment planning

Desensitization of hypersensitive teeth – 2 teeth

Simple adjustment of dentures

Re-cementation of loose crowns – inlays or onlays

Dental Nutrition and dietary Counseling

Palliative treatment for simple mouth sores & blisters

Open incision and drainage

Pre-natal check of teeth and gums

TMJ consultation

Gum treatment for cases like inflammation & bleeding

Member sets an appointment

by calling (02) 582-1900

DENTAL HUB NETWORK

with access to Accredited

Dental Facilities nationwide

Members can also call directly to any accredited dental

clinic.

Injuries arising from war or any combat-related

activities while in military service

Self inflicted injuries

Injuries from misconduct or gross negligence

Medical emergencies from beautification procedures

Chronic Dermatoses (Psoriasis, Skin Asthma)except

consultations

Government funded healthcare benefits

Personal medical requirements

Involvement in hazardous sports

Non insurable conditions

Additional charges

Additional charges resulting from room

upgrading, or additional personal comfort items

not included in the room & board

accommodation ( T.V., telephone, etc.)

Corrective appliances, artificial aids, prosthetic

appliances

Take home medicines

Services obtained from Non-accredited

Physicians and hospitals or other provider of care,

except under emergency care.

Purchase or lease of durable medical equipment,

oxygen dispensing equipment, and oxygen

except during covered in-patient care.

Custodial, domiciliary and convalescent care.

Long-term rehabilitation and Psychiatric care.

Dental and maternity cases

Circumcision, sex transformation, diagnosis and treatment of

fertility or infertility, artificial insemination, sterilization or

reversal of such.

All expenses incurred in the process of organ donation and

transplantation, unless the Member thereof is the recipient of

such donation or transplantation.

All physical deformities prior to enrolment

Experimental medical procedures, acupuncture

Hepatitis screening and all diagnostic examinations for

Members who have pre-existing Hepatitis B.

You are cared

for by the

leader.

Thank You!