Maxicare HMO Program

MAXICARE PLUS - MINDANAO with Davao Doctors Hospital
Plan
Maximum
Room & Board
Benefit Limit
Accommodation
(MBL)
Membership Fees
ACU Type
Annual
Semi-annual
Quarterly
Monthly***
PRINCIPALS
PLATINUM
PLATINUM
PLATINUM
PLATINUM
GOLD
GOLD
GOLD
SILVER
SILVER
BRONZE
Small Suite
Open Pvt
Open Pvt
Lrg Pvt
Reg Pvt
Reg Pvt
Reg Pvt
Semi-Pvt
Semi-Pvt
Ward
200,000
200,000
150,000
150,000
150,000
100,000
75,000
75,000
60,000
50,000
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
10,099
8,818
8,569
8,296
7,503
7,253
6,988
5,699
5,539
4,582
5,453
4,762
4,627
4,480
4,052
3,917
3,774
3,077
2,991
2,474
2,828
2,469
2,399
2,323
2,101
2,031
1,957
1,596
1,551
1,283
959
838
814
788
713
689
664
541
526
435
Small Suite
Open Pvt
Open Pvt
Lrg Pvt
Reg Pvt
Reg Pvt
Reg Pvt
Semi-Pvt
Semi-Pvt
Ward
200,000
200,000
150,000
150,000
150,000
100,000
75,000
75,000
60,000
50,000
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
14,048
11,990
11,740
11,403
10,274
10,024
9,759
7,749
7,590
6,226
7,586
6,475
6,340
6,158
5,548
5,413
5,270
4,184
4,099
3,362
3,933
3,357
3,287
3,193
2,877
2,807
2,733
2,170
2,125
1,743
1,335
1,139
1,115
1,083
976
952
927
736
721
591
DEPENDENTS
PLATINUM
PLATINUM
PLATINUM
PLATINUM
GOLD
GOLD
GOLD
SILVER
SILVER
BRONZE
*** Monthly Mode of payment is applicable only for Small accounts with First Aggregate Modal fee of at least Php 20,000.
SEPARATE FEE (Optional per account):
Standard Dental Package:
Basic Dental Package:
Life with AD&D (Php25,000):
Annual Check-up: Routine (Clinic)- Basic 5:

MINDANAO
Annual
292
172
72
Semi- Annual
158
93
39
Quarterly
Annual
1,066
Semi- Annual
576
Quarterly
82
48
20
Monthly***
28
16
7
298
Monthly***
101
PROVINCIAL MAXICARE PLUS HEALTHCARE PROGRAM
A.
HEALTHCARE BENEFITS
OUT-PATIENT CARE
1
Consultations during regular clinic hours, except prescribed

medicines
Pre and Post Natal consultations

Eye, ear, nose and throat (EENT) treatment prescribed by an
Accredited Physician/Specialist
Treatment for minor injuries such as lacerations, mild burns, sprains
and the like
Subject to MBL
Dressings, conventional casts (plaster of Paris) and sutures.

X-Ray, laboratory examinations, routine, diagnostic and therapeutic
procedures prescribed by an Accredited Physician/Specialist,
provided however that the cost of diagnostic and therapeutic
procedures covered shall be limited to a specific amount.
Minor surgery not requiring confinement prescribed by an Accredited
Physician / Specialist
Eye laser therapy only for retinal tear, retinal hole, retinal
detachment and glaucoma prescribed by an Accredited
Physician/Specialist. Eye correction such as Lasik, PRK and the like
are not covered.
Cauterization of skin lesions such as plantar warts, flat warts,
periungual warts, filiform warts and molluscum contagiosum, in any
part of the body, except genital warts and condyloma acuminata,
prescribed by an Accredited Physician/Specialist
Sclerotherapy for varicose veins (except medicines and for cosmetic
purposes) as prescribed by an Accredited Physician, to be availed
through accredited vascular surgeons.
Allergy Testing/ allergy screening and other related examinations
prescribed by an Accredited Physician
Subject to MBL
3
4
5
6
7
8
10
11
12
Speech therapy (for stroke patients only)

13
B.
MAXICARE
Tuberculin test
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
Subject to MBL
Up to Php 10,000 /eye /member /year
Up to Php 1,000 /member /year
Up to Php 5,000 /leg /member /year

Up to Php 2,500 /member /year
Covered as charged up to Php 10,000/ member/ year
(reimbursement basis)
Note: Consultations shall be part of the limit and treated
as sessions
Up to Php 600 /member /year
IN-PATIENT CARE
1
Room and Board Accommodation

Use of operating room, Intensive Care Unit (ICU), isolation room (if
prescribed by attending Accredited Physician) and recovery room.
Subject to the Member's Room and Board limit
2
3
Professional fees in accordance with Maxicare Schedule of Rates.
Subject to MBL
Subject to MBL
a. Attending Physicians
b. Surgeons
c. Anesthesiologists
d. Cardio-pulmonary clearance before surgery and cardiac
monitoring during surgery.
4
Standard Nursing Services
Subject to MBL
Medicines for in-patient use

Blood products transfusions and intravenous fluids, including blood
screening and cross matching.
X-Ray, laboratory examinations, routine, diagnostic tests and
therapeutic procedures incidental to confinement
Subject to MBL
Dressings, conventional casts (plaster of Paris) and sutures
Subject to MBL
Anesthesia and its administration
Subject to MBL
10
Oxygen and its administration
Subject to MBL
11
Standard Admission kit

All other items directly related in the medical management of the
patient, as deemed medically necessary by the attending Accredited
Physician
Subject to MBL
6
7
12
C.
Subject to MBL
Subject to MBL
Subject to MBL
ROUTINE PROCEDURES (whether IP or OP)

1
Blood Chemistries
100% of Actual Cost subject to MBL
Chest X-Ray
Complete Blood Count (CBC)
D.
Fecalysis
Urinalysis
DIAGNOSTIC PROCEDURES
1
12-Lead Electrocardiogram (ECG)
24-Hour Electroencephalogram (EEG) Monitoring
24-hour Holter Monitoring
Adrenocortical Function
Anti-Nuclear Antibody, C-Reactive Protein, Lupus Cell Exam
Arterial Blood Gas
Arthroscospic Procedures, Orthopedic Arthroscopy
Audiograms and Tympanograms
Bone Densitometry Scan (Dexascan)
10
Bone Mineral Density Studies
11
Cardiac Stress Tests (Thalium and Dipyridamole Stress Tests)
12
Computed Tomography Scans
13
Diagnostic Radiographs:
14
a. Biliary tract: Cholecystogram and Cholangiogram
b. Chest, ribs, sternum and clavicle

c. Digestive: Plain film of the abdomen, Barium Enema, Upper GI
Series, Lower GI Series, Small Bowel series
d. Face (including sinuses), Head and Neck

e. Urinary: Kidney, Ureter, Bladder (KUB), Pyelograms and
Cystograms
f. X-ray of the extremities and pelvis
g. X-ray of the spine (cervical, thoracic, lumbo-sacral)
Diagnostic Ultrasounds:
a. 2D-Echo with Doppler
b. Abdomen
c. Duplex Scan
d. Digestive and Urinary Systems
e. Ultrasound of the Lungs
15
Electroencephalogram (EEG) Monitoring
16
Electromyelography and Nerve Conduction Studies
17
Endoscopic Procedures
18
Fluorescein Angiography
19
Impedance Plethysmography
20
Magnetic Resonance Angiography (MRA)
21
Magnetic Resonance Imaging (MRI)
22
Mammography and Sonomammogram
23
Myelogram
24
Nuclear Radioactive Isotope Scan
25
Pap's Smear
26
Perfusion Scan
27
Plasma Urinary Cortisol, Plasma Aldosterone
28
Polysomnograms (Sleep Recording)
29
Pulmonary Function Tests
30
Radioisotope Scans and Function Studies:

a. Cardiac
b. Gastrointestinal
c. Liver
d. Parathyroid Bone, Pulmonary (Perfusion/ Ventilation Lung Scans)
e. Renal
f. Thyroid Scans
g. Total Body Scans
31
Radionuclide Ventriculography
32
Surface Electromyography (SEMG)
E.
33
Thallium Scintigraphy
34
Treadmill Stress Test (TMST)
THERAPEUTIC PROCEDURES
1
Arthrocentesis
2
Dialysis
Intravenous Chemotherapy
4
Phlebotomy
5
Physical therapy / Occupational therapy excluding subspecialties
such as cardiac rehabilitation, pulmonary rehabilitation and the like.
6
Thoracentesis
7
Up to six (6) sessions subject to MBL for OP; Up to

MBL for IP
Up to MBL
Up to MBL
MBL for IP
Shared limit of up to twelve (12) sessions/member/year
subject to MBL for OP; Up to MBL for IP.
Note: Therapy of one (1) body area shall be considered
as one (1) session.
MBL for IP
Therapeutic Radiology:
a. Brachytherapy
Up to MBL
b. Cobalt
Up to MBL
c. Linear Accelerator Therapy
Up to MBL
d. Radioactive Cesium
Up to MBL
Up to MBL
e. Radioactive Iodine
F.
Continuous Positive Airway Pressure (CPAP)
Up to Php60,000 shared limit for OP and IP
Oral Chemotherapy
Up to Php60,000 shared limit for OP and IP
ANNUAL CHECK-UP
1
Executive Check-up (IP)*
Separate Fee or Fee-for-Service Arrangement
Executive Check-up (OP)*
Semi-Executive Check-up (OP)*
Routine (clinic) which includes:
Separate Fee
ECG and Pap's Smear shall be for members 35 years old & above.
This shall be conducted at a designated Maxicare Accredited Clinic once a year.
*
F.
G.
ECU can be availed at TMC and MMC only if account chooses separate fee arrangement.
PREVENTIVE CARE
1
Passive and active vaccines for treatment of tetanus and animal

bites
Periodic monitoring of health problems
Covered
Health-education and counselling on diets or exercise
Covered
Health habits and Family Planning counseling
Wellness programs
Covered up to Php18,000 / member / year
Covered
Separate Fee
ADDITIONAL PROCEDURES AND MODALITIES (shared limit for OP and IP; Professional Fees, Hospital Bills and other incidental
expenses relative to the procedure shall form part of the limit)
1
Angiography (gastrointestinal, brain, retinal and peripheral vascular)
2
Coronary Angiogram and/or Angioplasty/Coronary Artery Bypass
Graft
3
Cryosurgery
4
Gamma Knife Surgery
5
Hysterescopic Myoma Resection
Hysteroscopically-guided D&C
Laparoscopy
Lithotripsy
Percutaneous Ultrasonic Nephrolithotomy
10
Stereotactic Brain Biopsy
11
Conventional Hemorrhoidectomy
12
Scalpel Hemorrhoidectomy
13
Stapled Hemorrhoidectomy
Covered up to Php 5,000 /member /year
14
Mammotome
15
4D Ultrasound except for maternity-related cases
16
Esophageal Manometry
17
Intensified Modulated Radiotheraphy
18
Botox which is not cosmetic in nature nor for beautification purpose
19
Positron Emission Tomography
20
CT Pulmonary Angiography
21
Photodynamic Therapy
Other medically necessary modalities not mentioned above and
those for which there are no comparable, conventional or traditional
counterparts
22
23
H.
Transurethral Microwave Therapy of Prostate
In Accredited Hospitals
a. Doctors services
Subject to MBL
b. Emergency Room Fees
Subject to MBL
c. Medicines used for immediate relief during treatment
Subject to MBL
d. Oxygen, Intravenous fluids and blood products.
Subject to MBL
e. Dressings, conventional casts (plaster of Paris) and sutures.

f. X-Rays, laboratory and diagnostic examinations, and other medical
services related to the emergency treatment of the patient.
Subject to MBL
g. Room Upgrade in case of room unavailability

2
In Non-Accredited Hospitals
3
Outside the Philippines
4
5
6
J.
Areas without Accredited Hospital

Ambulance Service (Accredited Hospital/Clinic to Accredited
Hospital/Clinic)
Ambulance Service (Non-accredited Hospital/Clinic to Accredited
Hospital/Clinic)
Subject to MBL
up to 24 hours
Reimbursable up to 80% of hospital bills & professional
fees based on Maxicare rates incurred during the first
24 hrs. of treatment up to Php 30,000 /availment
/member /year
Reimbursable up to 100% of actual cost up to Php30,
000 /availment /member /year
100% based on Maxicare rates up to MBL
Up to MBL
Reimbusable up to Php 2,500 per conduction
Note: The ambulance service provided herein shall be available regardless of the location within the Philippines
Covered for the first 24 hrs. from the time of bite
subject to MBL
Initial Treatment of Animal Bites
PRE-EXISTING CONDITIONS
1
Dreaded Conditions
Covered
Non-Dreaded Conditions
Covered
DENTAL CARE (Optional - Separate Fee)

1
K.
EMERGENCY CARE
1
I.
Covered up to Php 5,000/ procedure /member /year
Covered
Annual Dental examination and consultation

Emergency Out-patient Dental Treatment - to be availed at
accredited dental clinics only
Oral prophylaxis
Simple tooth extractions
Restorative and Prosthodontic treatment planning
Temporary Fillings
Desensitization of hypersensitive teeth
Simple adjustment of dentures
Covered
Recementation of loose crowns
Covered
10
Dental Nutrition and Dietary Counseling
Covered
11
Dental Health Education
12
Permanent Fillings (Not applicable for Basic Dental package)
13
Pre-natal check of teeth and gums
Covered
14
Temporo Mandibular Joint Consultation
Covered
15
Gum treatment for cases like inflammation or bleeding
Covered
Covered
Covered - Once a year
Covered
Covered
Unlimited, As needed
Up to 2 teeth
Covered
2 Teeth per year
GROUP LIFE INSURANCE WITH ACCIDENTAL DEATH AND DISABLEMENT (AD&D) BENEFITS (Optional - Separate Fee)
1
Insurance Provider
Death (amount of insurance)
Sun Life of Canada (Philippines), Inc.

up to Php 25,000 /member
Schedule of Losses for AD&D Coverage

a. life
100% of amount of insurance
b. entire sight of both eyes
c. both hands or both feet
d. one hand and one foot
e. either hand or foot and sight of one eye
f. Arm at or above elbow
g. Leg at or above knee
h. One hand at or above wrist
i. One foot at or above the ankle
j. Hearing of both ears
k. Sight of one eye
l. Four fingers and thumb of one hand
Eligible Members
18 to 65 years of age (who are all regular, full time and
actively at work)
legal spouse whose insurance age is 18 to 65 years old
Dependents of Married employees
children whose insurance age is 15 days but not over
21 years old, unemployed and fully dependent on the
principal
parents
whose
insurance
age is 18 to 65 years old
Dependents of Single Employees
siblings who are 15 days but not more than 21 years
old, unemployed and fully dependent on the principal
children who are 15 days but not more than 21 years
old, or parents whose insurance age is 18 to 65 years
old
Dependents of Single Parent Employees
siblings who are 15 days but not more than 21 years
old. (Children and siblings must be unemployed and
fully dependent on the principal)
Payment of any insurance benefit shall not be made for any loss resulting from or caused directly or indirectly, wholly or
partially by:
a. bodily or mental infirmity or disease of any kind, or infection other than infection occuring simultaneously with and in
consequence of an accidental cut or wound; or
Employees
b. suicide or attempted suicide while sane or insane, or self-inflicted injuries; or

c. committing or trying to commit any crime, felony or other illegal act; or
d. murder or provoked assault; or
e. poison, carbon monoxide or drug overdose; or
f. war (declared or undeclared), insurrection, civil commotion or hostile action of armed forces, riots, rebellion; or
g. entering, operating or servicing ascending or descending from or with any aerial or submarice device or conveyance except
while the Member is riding as a passenger in an aircraft operated by a commercial passenger airline or a scheduled air
service over on established route.
L.
CONDITIONS WITH SPECIFIC LIMITATIONS

1
Work Related Conditions based on conditions covered by ECC
2
3
Motor Vehicular Accidents

Provoked and Unprovoked Assault, including domestic violence,
whether initiated by the Member or by a known or unknown third
party
Scoliosis, including necessary procedures, except physical therapy
sessions, whether congenital, pre-existing, developmental or
acquired
Congenital Conditions except physical therapy sessions and
developmental disorders
Congenital Hernia
Chronic Dermatoses
Scabies
Exclusion #25
Hepatitis B
Up to MBL (Principals only)

Covered subject to MBL and Exclusions and
Limitations Provisions
Up to MBL
up to Php 20,000 /member /year (shared limit for OP
and IP)
up to Php 20,000 /member /year (shared limit for OP
and IP)
Covered up to MBL
Consultations only
Consultations and treatments
Covered up to MBL
Covered up to MBL (if acquired)
EXCLUSIONS AND LIMITATIONS PROVISIONS

Notwithstanding any provisions to the contrary, the following shall not be covered except otherwise specified in Maxicare Benefits
1 Services obtained for non-emergency conditions from Physicians and Hospitals in any of the following circumstances
a. non-Accredited Physicians in non-Accredited Hospitals
b. non-Accredited Physicians in Accredited Hospitals
c. Accredited Physicians in non-Accredited Hospitals or other non accredited healthcare facility.
2 Additional hospital charges and physician's professional fees resulting from:
a. room-upgrading beyond Member's allowable time during emergency care
b. extension of hospital stay despite release of discharge order from Member's attending physician
c. fees of the assistant surgeons / resident doctors who assisteed the Attending Physician in the process of rendering the above
mentioned services shall not be chargeable to the Member and/or Maxicare except for hospitals that do not have resident physicians to
assist during surgeries subject to the prior approval of Maxicare
d. use or extra bed, TV, electric fan, DVD/VCD, and other similar items unless such appliances and items are necessarily and ordinarily
medical services brought about by obtaining a room accommodation higher than the Member's Room and Board Accommodation limit
e. extra food
f. toilet articles like face towel, soap, toothbrush and the like
g. difference in room and board, the incremental rate differences for professional fees, diagnostic and laboratory examinations, and
other ancillary medical services brought about by obtaining a room accommodation higher than the Member's Room and Board
Accommodation limit;
h. services of a private or a special nurse;
i. all other items not medically necessary in the medical management of the patient.
3 Custodial, domiciliary, convalescent and intermediate care.
4 Long-term rehabilitation and psychiatric and/or psychological illnesses and conditions including neurotic and psychotic behavior
disorders; anxiety disorders
5 Treatment for injury and its complications resulting from self-inflicted injuries including infections as a result of tattoos, piercing of the
ear or in any body part, whether self-inflicted or done by a third party or attempted suicide or self-destruction, whether sane or insane.
6 Developmental disorders including functional disorders of the mind, such as but not limited to Attention-Deficit Disorder (ADD)
/Attention-Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorders, Bipolar Disorders, Central Auditory Processing Disorder
(CAPD), Cerebral Palsy, Down Syndrome, Neural Tube Defects, and Mental Retardation.
7 Treatment of any injury received when there is negligence, unauthorized use of prohibited drugs or regulated drugs, alcoholic liquor
intake, direct or indirect participation in the commission of a crime whether consummated or not, violation of a law or ordinance or
unnecessary exposure to imminent danger, knowingly or unknowingly or hazard to health, by the Member. Maxicare may rely on the
Police or Doctor's report to evaluate such claim.
8 Aesthetic, cosmetic and reconstructive surgery or any consultation or treatment for any beautification purposes except if necessary to
treat a functional defect due to accidental injury within the initial confinement.
9 Oral surgery following accidental injury to teeth for purposes of beautification. Dental examinations, extractions, fillings, other dental
treatment and their complications except to the extent that are medically necessary for repair or alleviation of damage to the Member
caused solely by an accident. Medical care resulting from any dental related conditions.
10 Maternity care and all other conditions (except pre and post natal consultations) related to and/or resulting from pregnancy and/or
delivery which affect the conditions of the Member and the unborn child.
11 Circumcision (except for treatment of urological conditions), sex transformation, diagnosis, treatment and procedures related to fertility
or infertility, artificial insemination, sterilization or reversal of such and their complications.
12 Experimental medical procedures and its complications.
13 Acupuncture, chirotherapy and other forms of therapies and its complications.
14 All expenses incurred in the process of organ donation and transplantation if the Member is the donor of such donation or
transplantation, and its complications.
15 Routine physical examinations required for obtaining or continuing employment, requirement in school, insurance/travel or government
licensing, health permit and other similar purposes.
16 Purchase or lease of durable medical equipment, oxygen dispensing equipment, and oxygen except during covered in-patient care.
17 Corrective appliances, prosthetics and orthotics such as but not limited to eye glasses and contact lenses, hearing aids, pacemaker,
artificial limbs, valves, knee-tibial insert for total knee arthroplasty, vascular grafts, titanium thread, myringotomy tube, intravascular
catheters, vascular stents, bone screws/plates, pins, wires, balloons, orthopedic internal fixator/fixation systems, orthopedic external
fixator/fixation systems, intraocular lens, braces, crutches.
18 Take-home medicine and out-patient medicine except:
a. chemotherapy medicine
b. medicine administered during an emergency treatment
19 Congenital, genetic and hereditary diseases and their complications (except for hernias) affecting functions of individuals.
20 All physical deformities prior to enrollment.
21 Treatment of injuries/illnesses caused directly or indirectly by engaging in any professional sport or hazardous activity such as but not
limited to scuba diving, surfing, water skiing, mountain climbing, rock climbing, mountaineering, parachuting, airsoft, drag racing,
paintballing, wakeboarding and bungee jumping, except for activities under company-sponsored sports activities.
22 Injuries resulting from direct participation in riots, strikes, and other civil disturbances.
23 Treatment of injuries or illnesses resulting from war or any combat-related activities while in military service.
24 Sexually transmitted diseases, genital warts, AIDS and AIDS related diseases.
25 Valvular heart disease (congenital and/or acquired) including Cardiomyopathies, Chronic Glomerulonephritis, previous craniotomy
sequelae/hearing impairment/ Neurologic disease and Spinal Stenosis (if pre-existing)/Poliomyelitis/Slipped disc (if pre-existing) and
Guillain-Barre Syndrome, Diabetes and its complications (if pre-existing), Complicated Hypertension (e.g. those with history of stroke,
myocardial ischemia or infarction and poor kidney function), and all malignant tumors (if pre-existing).
26 Treatment for chronic dermatoses.
27 Infectious diseases (i.e. Avian Flu, Meningococcemia, etc.) that are declared epidemic or pandemic by the Department of Health, World
Health Organization or any recognized health authority.
28 Pre-existing Hepatitis B and screening and vaccines for all types of Hepatitis.
29 Animal bite/scratch/lick or snake bite including its complications.
30 Benefits covered by Philhealth and all other government funded healthcare entitlements as provided for by law.
31 Laser procedures/treatments.
32 Speech therapy for developmental and congenital diseases.
33 Weight reduction programs, surgical operation or procedure for treatment of obesity, including gastric stapling or balloon procedures
and liposuction.
34 Routine, diagnostic, therapeutic and other procedures of the same or similar nature not otherwise specified in this Agreement.
35 Cost of vaccines for immunization including its administration.
36 Cost of medico-legal cases.
37 All screening tests.
38 Treatment of work-related injuries of high-risk occupations such as but not limited to construction workers, miners, loggers and drillers.
39 Cost of the medical services and professional fees in excess of the MBL/ABL.

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MAXICARE PLUS - MINDANAO with Davao Doctors Hospital

Annual Check-up: Routine (Clinic)- Basic 5:

PROVINCIAL MAXICARE PLUS HEALTHCARE PROGRAM

Consultations during regular clinic hours, except prescribed

Pre and Post Natal consultations

Dressings, conventional casts (plaster of Paris) and sutures.

Speech therapy (for stroke patients only)

Up to Php 10,000 /eye /member /year

Up to Php 1,000 /member /year

Up to Php 5,000 /leg /member /year

Room and Board Accommodation

Subject to the Member's Room and Board limit

Professional fees in accordance with Maxicare Schedule of Rates.

Standard Nursing Services

Medicines for in-patient use

Dressings, conventional casts (plaster of Paris) and sutures

Anesthesia and its administration

Oxygen and its administration

Standard Admission kit

ROUTINE PROCEDURES (whether IP or OP)

100% of Actual Cost subject to MBL

100% of Actual Cost subject to MBL

Complete Blood Count (CBC)

100% of Actual Cost subject to MBL

100% of Actual Cost subject to MBL

100% of Actual Cost subject to MBL

12-Lead Electrocardiogram (ECG)

100% of Actual Cost subject to MBL

24-Hour Electroencephalogram (EEG) Monitoring

100% of Actual Cost subject to MBL

24-hour Holter Monitoring

100% of Actual Cost subject to MBL

100% of Actual Cost subject to MBL

Anti-Nuclear Antibody, C-Reactive Protein, Lupus Cell Exam

100% of Actual Cost subject to MBL

Arterial Blood Gas

100% of Actual Cost subject to MBL

Arthroscospic Procedures, Orthopedic Arthroscopy

100% of Actual Cost subject to MBL

Audiograms and Tympanograms

100% of Actual Cost subject to MBL

Bone Densitometry Scan (Dexascan)

100% of Actual Cost subject to MBL

Bone Mineral Density Studies

100% of Actual Cost subject to MBL

Cardiac Stress Tests (Thalium and Dipyridamole Stress Tests)

100% of Actual Cost subject to MBL

Computed Tomography Scans

100% of Actual Cost subject to MBL

a. Biliary tract: Cholecystogram and Cholangiogram

100% of Actual Cost subject to MBL

b. Chest, ribs, sternum and clavicle

100% of Actual Cost subject to MBL

d. Face (including sinuses), Head and Neck

100% of Actual Cost subject to MBL

f. X-ray of the extremities and pelvis

100% of Actual Cost subject to MBL

g. X-ray of the spine (cervical, thoracic, lumbo-sacral)

100% of Actual Cost subject to MBL

100% of Actual Cost subject to MBL

100% of Actual Cost subject to MBL

100% of Actual Cost subject to MBL

100% of Actual Cost subject to MBL