A.

SCHEDULE OF ANNUAL PREMIUM FOR PERIOD January 1, 2018 TO December 31, 2018
Page 2 of 2
Other Extended Family Members
Qualified Dependents (QD) Extended Family Members (EFM) (OEFM)
PLAN Annual
Principal
(Room & Benefit Philhealth Non-Philhealth 2
Member
Board) Limit Philhealth Non-Philhealth 2 ABL Phil- health Non-Philhealth 2
PEC (60K limit) PEC (60K limit)
600 1 P150T 10,620 9,780 16,724 3 11,146 19,506 3 P100T 15,732 18,482 16,388 19,138
1 3 13,97 3
800 P200T 13,310 11,980 20,958 24,450 P150T 19,608 22,358 20,426 23,176
2
19,57
1000 P250T 18,588 16,728 29,276 3 34,156 3 P200T 24,068 26,818 25,070 27,820
4
21,40
1100 P300T 20,386 18,348 P250T 26,476 29,226 27,578 30,328
4
22,26
1200 P300T 21,208 19,088 P250T 27,798 30,548 28,956 31,706
8
23,91
1300 P400T 22,764 20,488 P300T 29,564 32,314 30,796 33,546
0
25,12
1400 P400T 23,926 21,534 P300T 31,044 33,794 32,338 35,088
2
26,22
1500 P400T 24,970 22,474 P300T 32,592 35,342 33,950 36,700
0
1
Without access (inpatient & outpatient services) to Makati Medical Center (MMC), St. Luke's Medical Center (SLMC) Quezon City, Asian Hospital, Cardinal
Santos Medical Center and The Medical City (TMC)
2
The HMO will cover the equivalent of PhilHealth share in case of hospitalization of the enrollee.
3
Premium for parents of single employees with age 71 or over but less than 76 y/o as of January 1, 2018, and previously enrolled in CY 2017 HMO Advisory Group/LBPEA
coverage.
B. OPTIONAL DENTAL BENEFITS (For Principal and QD/s only) Additional Premium per Member
Enrollment is conditional; availability is subject to required minimum of 1000 actual enrollees for CY 2017.
The dental benefits may be availed of in the network of accredited dental clinics under an open door availment system; setting of appointment P 975.00
required; package includes amalgam and lightcure permanent filling up to two (2) teeth.
C. TERMS AND CONDITIONS
1. The MINIMUM plan for Principal members (Rank and File employees) is PLAN 800
2. Qualified Dependent (QD), Extended Family Member (EFM) and Other Extended Family Member (OEFM)
2.1 Qualified Dependent (QD) in the case of Married Employees
- Spouse less than 71 years old as of date of effectivity of coverage
-Children, age of at least 15 days old to less than 29 years as of date of effectivity of coverage; single/unmarried; whether, legitimate, illegitimate; or legally adopted, newly born children
should be enrolled not later than 30 days after birth.
2.2 Qualified Dependent (QD) in the case of Single/Unmarried Employees
- Parents less than 71 years old as of date of effectivity of coverage;
-Parents age 71 or over but less than 76 years old as of effectivity of coverage and previously enrolled under the MEDICard Coverage Contracted by the HMO Advisory Group or the
LBPEA for 2017, please note special package.
- Children, age of at least 15 days old to less than 29 years as of date of effectivity of coverage; single and not gainfully employed; newly born children should be enrolled not later than 30
days after birth.
2.3 Extended Family Members (EFM), included in the group of Principals, QDs/EFMs (No New EFM/OEFM can be enrolled)
- Single/unmarried children, 29 years old and above but less than 46 years old as of as of January 1, 2018 (whether legitimate, or illegitimate)
- Married children, less than 46 years old as of January 1, 2017 (whether legitimate, or illegitimate)
-
Parents of married employees, less than 71 years old as of effectivity of coverage, and previously enrolled under the HMO Coverage contracted by the HMO Advisory Group/LBPEA for
2017.
2.4 Other Extended Family Members (OEFM) to be treated separately from the group of Principals, QDs, and EFMs. (No New EFM/OEFM can be enrolled)
- Relatives by Consanguinity, less than 66 years old as of effectivity of coverage, and enrolled under the 2017 HMO Advisory Group/LBPEA HMO coverage: Children (other than
those qualified as QDs or EFMs); Grandparents; Grandchildren; Brothers & Sisters; Aunts & Uncles; and Nieces & Nephews.
- Relatives by Affinity, less than 66 years old as of effectivity of coverage, and enrolled under the 2017 HMO Advisory Group/LBPEA HMO coverage: Parents-in-law; Children-in-law;
and Brothers/Sisters-in-law.
3. The Principal Member and his QD/EFM/OEFM may select different Plans under MEDICARD. However, a QD/EFM/OEFM cannot be enrolled in a Plan that is higher than that of the Principal
Member.
4. UPGRADING OF PLANS SHALL BE ALLOWED TO EMPLOYEES/PRINCIPAL MEMBERS ONLY with NO DREADED DISEASE/S.
5. The Principal Member must enroll his newborn QD/s (must be at least 15 days old to qualify as member/s) within thirty (30) days after birth; otherwise, membership will be allowed only in the
next semester. A newly married employee must enroll his spouse within (30) days after date of marriage for immediate coverage; otherwise membership will be allowed only in the next
semester.
6. Pre-Existing Conditions (PEC)
6.1 PECare waived for the principal members; his/her QD/s and EFM/s (enrolled in CY 2017 as QD or EFM). However, the Coverage of PEC for OEFMs shall be up to P60, 000.00 per
member per year but not to exceed ABL, regardless of the members plan.
6.2 An illness or condition is considered to have been in existence prior to the effective date of coverage if:
a. Any professional advice or treatment was obtained for such illness or condition;
b. Such illness or condition was in any way evident to the member; and
c. The onset and pathogenesis of such illness or condition has started whether or not the Member is aware of such illness or condition.
6.3 The following are automatically considered as pre-existing conditions if treatment is sought within the first twelve (12) months of coverage.
Abnormalities of nasal septum and turbinates Hemorrhoids, anal fistulae
Arthritis Hernia
Bronchial Asthma Hypertension
Buergers Disease Prostate Disorder
Calculi, Urinary tract Sinus conditions requiring surgery
Cataracts, Glaucoma Tuberculosis
Diabetes Mellitus Tumors of the skin, muscular tissue, breast, bone or
E.N.T Tumors and other tumors (benign or malignant) malignancies of blood or bone marrow
Endometriosis, uterine myoma, and ovarian cyst Urethral Stenosis/Urinary Tract Strictures
Gall Bladder stones Varicose Veins
Goiter
7. The following are considered Dreaded Diseases
Cerebrovascular Accidents (stroke) Poliomyelitis and complications/sequelae
Cardiovascular disease Encephalitis and complications/sequelae
Neurological disease/neuro-surgical conditions Malignancies/cancer
Blood Dyscrasia (ex. Leukemia, hemophilia) Chronic urological/nephrological disease
Cirrhosis of the liver Collagen diseases
Chronic pulmonary obstructive diseases, except bronchial asthma Meningitis and complications/sequelae
Organ transplant, where member is the recipient, except for sex-change purposes (for principal members and qualified dependents)
Diabetes mellitus and complications
Immunological disorders such as AIDS (except when acquired through sexual activity)
 Any other illness or conditions aside from the above enumeration which will necessitate the use of the Intensive Care Unit (ICU)
D . DEADLINE FOR ENROLLMENT/PAYMENT OF PREMIUM IS ON DECEMBER 01, 2017.
DISTRIBUTION: Please submit the accomplished application form in THREE (3) COPIES (each attached with a copy of deposit slip as proof of payment) to be distributed as follows; ORIGINAL
(including duplicate copy of deposit slip) - HMO; DUPLICATE HMO SELECTION COMMITTEE and TRIPLICATE Employees receiving copy.