Formal Economy Parents who are sixty (60) years old or above, not

otherwise an enrolled member, whose monthly income

 Government Employee
is below an amount to be determined by PhilHealth in
An employee of the government, who renders services accordance with the guiding principles set forth in the
in any of the government branches, military or police NHI Act of 2013; and,
force, political subdivisions, agencies or
Parents with permanent disability regardless of age as
instrumentalities, including government-owned
determined by PhilHealth, that renders them totally
and-controlled corporations, financial institutions with
dependent on the member for subsistence.
original charter, Constitutional Commissions, and is
occupying either an elective or appointive position, Qualified dependents shall be entitled to a separate
regardless of status of appointment. coverage of up to 45 days per calendar year. However,
the 45 days allowance shall be shared among them.
• Private Employee
Important:
i. Corporations, partnerships, or single proprietorships,
NGOs, cooperatives, non-profit organizations, social, Qualified dependents must be declared by the principal
civic, or professional or charitable institutions, member. Their names must be listed under the
organized and based in the Philippines including those principal member's Member Data Record (MDR) to
foreign owned; ensure hassle-free benefits availment.

ii. Foreign governments or international organizations Informal Economy

with quasi-state status based in the Philippines which
entered into an agreement with the Corporation to Migrant Workers
cover their Filipino employees in PhilHealth; - documented or undocumented Filipinos who are
iii. Foreign business organizations based abroad with engaged in a remunerated activity in another
agreement with the Corporation to cover their Filipino country of which they are not citizens
employees in PhilHealth.
Informal Sector
• All other workers rendering services, whether in
- includes among others, street hawkers, market
government or private offices, such as project-based
vendors, pedicab and tricycle drivers, small
contractors, and the like
construction workers, and home-based industries
• Owners of Micro Enterprises and services.

• Owners of Small, Medium and Large Enterprises Self-Earning Individuals

• Household Help - individuals who render services or sell goods as a

as defined in Republic Act 10361 or “Kasambahay
means of livelihood outside of an
Law” employer-employee relationship or as a career. These
include professional practitioners including but not
• Family Drivers limited to doctors, lawyers, engineers, artists,
Who are qualified as dependents? architects and the like, businessmen, entrepreneurs,
actors, actresses and other performers, news
The following also enjoy PhilHealth coverage without
correspondents, professional athletes, coaches,
additional premiums
trainers, and such other individuals.
Legitimate spouse who is not a member;
Filipinos With Dual Citizenship
Child or children - legitimate, legitimated,
- Filipinos who are also citizens of other countries.
acknowledged and illegitimate (as appearing in birth
certificate) adopted or stepchild or stepchildren below Naturalized Filipino Citizens
21 years of age, unmarried and unemployed.
- those who have become Filipino citizens through
Children who are twenty-one (21) years old or above naturalization as governed by Commonwealth Act
but suffering from congenital disability, either physical No. 473 or the Revised Naturalization Law.
or mental, or any disability acquired that renders them
totally dependent on the member for support, as Citizens of other countries working and/or residing
determined by the Corporation; in the Philippines

Foster child as defined in Republic Act 10165 otherwise

known as the Foster Care Act of 2012;
- foreign citizens with valid working permits and/or gets hospitalized in the Philippines, the same set of
Alien Certificate of Registrations (ACRs), working benefits shall be available for the dependents to avail
and/or residing in the Philippines themselves of. PhilHealth supports inpatient care
through the All Case Rate payment scheme for most
Overseas Filipino Workers
illnesses and surgical procedures.
Sea-based Filipino workers or seafarers – any
4. OFs may be entitled to Lifetime membership
person who is employed or engaged in any capacity
on board a seagoing ship navigating foreign seas Overseas Filipinos who have reached the age of
other than a government ship used for military or retirement and have paid at least 120 months’
non-commercial purposes. The definition shall contribution are automatic Lifetime members of
include fishermen, cruise ship personnel and those PhilHealth
serving foreign maritime mobile offshore and
5. Availment for both the OF and qualified
drilling units.(same definition of seafarer per '38
dependents is easy and readily accessible.
Rule II Part I of POEA Rules and Regulations
Governing Recruitment and Employment of Should hospitalization become necessary for both the
Seafarers'; (ss) Section 1, Rule II of Omnibus Rules OF and dependents, they need not worry about
and Regulations Implementing the Migrant Workers numerous documents to submit because most
and Overseas Filipinos Act of 1995, as amended by accredited healthcare institutions are now connected
Republic Act No. 10022) to the Health Care Institution Portal where eligibility
to avail of benefits can readily be checked.
II. Land-based overseas Filipino workers – an
Overseas Filipino Worker who is other than a 6. PhilHealth covers over 4,600 medical and surgical
sea-based OFW procedures including cancer cases and other dreaded
diseases
III. Filipinos with Dual Citizenship – Filipinos who
are also citizens of other countries. Most illnesses and other causes of hospitalization are
being paid for by PhilHealth. For instance, for
dialysis patients, PhilHealth has extended support
up to 90 days for hemodialysis sessions per year, and
360 days for peritoneal dialysis sessions per year.

PhilHealth benefits for OFs

Advantages of being a
Overseas Filipino members may avail themselves of
PhilHealth member
PhilHealth benefits even if they are confined in
1. Overseas Filipinos may avail themselves of hospitals abroad. At the same time, their qualified
PhilHealth benefits for hospital confinements and dependents in the Philippines may avail themselves
out-patient surgeries in the Philippines. of the benefits even if the principal is working
overseas.
Confinements of Overseas Filipinos and their
dependents in any accredited health care institution These benefits include:
in the Philippines are being paid for by PhilHealth
Inpatient Benefits
through the All Case Rate payment scheme.
Outpatient Benefits
2. Confinements of OFs overseas may be reimbursed
Z Benefits
Overseas Filipinos confined abroad are entitled to
PhilHealth benefits through claim MDG-Related Benefits
[Link] are given 180 days upon
discharge to submit their claim documents to any of
the PhilHealth offices in the Philippines. Conditions for benefit availment

3. Qualified dependents of members are entitled to Overseas Filipino members must meet the following
the same set of benefits as the principal members conditions to be able to avail of benefits:

This means reduced stress for OFs from worrying 1. The availment period falls within the validity
about family members’ health care needs while period of the Overseas Filipino member’s coverage
abroad. Should any of the OF’s qualified dependents
2. The 45-day annual benefit limit for hospital room 1. Day Surgeries (Ambulatory Or Outpatient
and board allowance has not yet been consumed Surgeries) Are Services That Include Elective
(Non-Emergency) Surgical Procedures Ranging
3. The health care institution and health care
From Minor To Major Operations, Where Patients
professional are accredited (applicable only for
Are Safely Sent Home Within The Same Day For
confinements in the Philippines)
Post-Operative Care
Filing a claim for overseas confinements

If an Overseas Filipino member is confined abroad,

the following documents must be sent either via
overseas courier or electronic mail to the PhilHealth • Payments for these procedures are made to the
Regional Office or Local Health Insurance Office accredited facility through All Case Rates
nearest the OF’s Philippine address within 180
• The case rate amount shall be deducted by the HCI
calendar days from the date of discharge:
from the member’s total bill, which shall include
1. Medical abstract or medical record written in professional fees of attending physicians, prior to
English or copy of Medical Certificate indicating the discharge
final diagnosis, confinement period and medical
• The case rate amount is inclusive of hospital
services rendered;
charges and professional fees of attending physician
2. Copy of the operative record written in English, if
• Availment condition: Member must have six (6)
an operation was performed
months contributions preceding the three months
3. Statement of account qualifying contributions within the 12-month period
prior to the first day of confinement
4. Official Receipt issued by the hospital and doctor
• Documents needed: copy of Member Data Record
Properly filled out PhilHealth Claim Form 1
and duly accomplished PhilHealth Claim Form 1
If an Overseas Filipino member or his qualified
• Where available: Accredited Ambulatory Surgical
dependent is confined in the Philippines, a properly
Clinics (ASCs)
filled out PhilHealth Claim Form 1 must be
submitted to the Billing Section of the accredited 2. Radiotherapy
hospital before being discharged.
• The case rate for radiotherapy using cobalt is
 Inpatient Benefits P2,000 per session and P3,000 per session for linear
accelerator
 These benefits are paid to the accredited Health
Care Institution (HCI) through All Case Rates • Includes radiation treatment delivery using cobalt
and linear accelator
 The case rate amount shall be deducted by the
HCI from the member’s total bill, which shall • Claims for multiple sessions may be filed using
include professional fees of attending physicians, one (1) claim form for both inpatient and outpatient
prior to discharge radiation therapy

 The case rate amount is inclusive of hospital • May be availed of even as second case rate (full
charges and professional fees of attending case rate amount)
physician
• 45 days benefit limit: One session is equivalent to
 Availment condition: Member must have six (6) one day deduction from the 45 allowable days per
months contributions preceding the three year
months qualifying contributions within the
• If procedure is done during confinement, only the
12-month period prior to the first day of
total number of confinement days shall be deducted
confinement
• Exempted from Single Period of Confinement (SPC)
 Documents needed: copy of Member Data
rule (admissions and re-admissions due to same
Record or PhilHealth Benefit Eligibility Form
illness or procedure within 90-calendar day period)
(PBEF) and duly accomplished PhilHealth Claim
Form 1 • Availment condition: Member must have six (6)
months contributions preceding the three months
 Outpatient benefits
qualifying contributions within the 12-month period • 45 days benefit limit: One session for each
prior to the first day of confinement procedure is equivalent to one day deduction from
the 45 allowable days per year Exempted from the
• Where available: Accredited HCIs including
SPC rule
Primary Care Facilities that are accredited for the
said service • Where to avail: All Accredited HCIs

3. Hemodialysis 5. Primary Care Benefit (PCB)

• The Case Rate for hemodialysis is P2,600 per Coverage

session
• Indigent
• Covers both inpatient and outpatient procedures
• Sponsored Members
including emergency dialysis procedures for acute
renal failure • Overseas Workers Program (Land-based)

• Claims for multiple sessions may be filed using • Organized Groups/iGroups

one (1) claim form for both inpatient and outpatient
Where to avail
hemodialysis
• Accredited rural health units,
• May be availed of even as second case rate (full
case rate amount) • Accredited health center

• 90 days benefit limit: One session is equivalent to • Accredited government hospitals

one day deduction from the 90 allowable days per
Disease Conditions:
year
• Asthma
• If procedure is done during confinement, only the
total number of confinement days shall be deducted • Acute Gastroenteritis (AGE) with no or mild
dehydration
• The procedure is exempted from Single Period of
Confinement rule (admissions and re-admissions • Upper Respiratory Tract Infection (URTI)
due to same illness or procedure within 90-calendar
• Pneumonia (minimal and low risk)
day period)
• Urinary Tract Infection (UTI)
• Availment condition: Member must have six (6)
months contributions preceding the three months Benefit Inclusions:
qualifying contributions within the 12-month period
• Preventive Services
prior to the first day of confinement
1. Consultation
• Where available: All Accredited HCIs – this benefit
is no longer restricted to hospitals and free standing 2. Visual inspection with acetic acid
dialysis centers provided that the service is within
3. Regular BP measurements
their capability as provided for in the DOH license
4. Breastfeeding program education
4. Outpatient Blood Transfusion
5. Periodic clinical breast examinations
• The case rate for outpatient blood transfusion is
P3,640 (one or more units) 6. Counseling for lifestyle modification

• Includes Drugs & Medicine, X-ray, Lab & Others, 7. Counseling for smoking cessation
Operating Room
8. Body measurements
• Covers outpatient blood transfusion only
9. Digital rectal examination
• One day of transfusion of any blood or blood
• Diagnostic Examinations (as recommended by the
product, regardless of the number of bags, is
doctor)
equivalent to one session
1. Complete blood count
• May be availed of as second case rate (full case rate
amount) 2. Urinalysis

3. Fecalysis
4. Sputum microscopy • Acute Gastroenteritis (AGE) with no or mild
dehydration
5. Fasting blood sugar
• Upper Respiratory Tract Infection (URTI)
6. Lipid Profile
• Pneumonia (minimal and low risk)
7. Chest x-ray
• Urinary Tract Infection (UTI)
• Drugs and Medicines
• Hypertension
1. Inhaled Corticosteroids (Fluticasone)
• Diabetes Mellitus Type II
2. Short acting beta 2 agonists/Inhalation solution or
metered dose inhaler (Salbutamol) Benefit Inclusions:

3. Oral or systemic corticosteroids (Prednisone) • Health screening and assessment/consultation

4. Oral Rehydration Salts (ORS) • Essential Services (based on the life stage as
indicated in the AO 2017-0012: Guidelines on the
5. Amoxicillin
Adoption of Baseline Primary Health Care
6. Macrolide (Erythromycin) Guarantees for All Filipinos )

7. Beta Lactams with beta lactamase inhibitors Lifestage group Essential Services
(Cephalexin)
0-12 months CBC
8. 2nd generation cephalosporins (Cefuroxime)
>1-4 years CBC= Fecalysis =Urinalysis
9. Oral fluoroquinolones (Ofloxacin)
5-9 years old CBC=Fecalysis =Urinalysis
10. Co-trimoxazole
10-19 years old Paps smear (as applicable)
How to avail:
Urinalysis
1. Assignment thru Local Health Insurance Offices
Fecalysis
(only for Indigent and Sponsored Members)
CBC
2. Visit the PCB provider where you are
assigned/enlisted Chest X-ray

Expanded Primary Care Benefit (EPCB) 20-60 years old (female) Paps smear( as applicable)

Coverage Chest X-ray

• Formal Economy (Employed) Lipid Profile

• Lifetime Members FBS (for follow up)

• Senior Citizen Oral Glucose Tolerance Test (for initial)

Where to avail: Sputum microscopy (as applicable e.g. Suspected TB)

• Accredited EPCB Health Care Institution to ECG (for 30 y/o and up)
include the following:
> 60 years old Pap smear (for female)
- OPD of Level 1, 2 and 3 government and private
Chest X-ray
hospital
Lipid Profile
- Ambulatory Surgical Clinic
FBS (for follow up)
- Infirmaries
Oral Glucose Tolerance Test (for initial)
- Private medical outpatient clinics
Sputum microscopy (as applicable e.g. Suspected TB)
Disease Conditions:
ECG
• Asthma
• Drugs and Medicines
1. Amoxicillin essential services and drugs. (e.g. CBC for suspected
dengue case, chest X-ray for suspected TB, antibiotics
2. Co-Amoxiclav (Amoxicillin + Potassium
for infected wounds, impetigo and other skin
Clavulanate)
infections)
3. Cotrimoxazole (Sulfamethoxazole +
Z Benefits
Trimethoprim)
Benefit Package and
4. Erythromycin
Amount of Benefit
5. Fluticasone + Salmeterol
Acute Lymphocytic / Lymphoblastic Leukemia
6. Ofloxacin
(standard risk) P500,000- a. Signed Member
7. Oral Rehydration Salts Empowerment (ME) Form; b. Age 1 to less than 10
years old; c. White blood cell count ‹50,000/µL; d.
8. Prednisone
No CNS leukemia at diagnosis; e. There should be
9. Salbutamol (as Sulfate) + Ipratropium Bromide no testicular involvement of male patient at
diagnosis; and f. WHO Classification: B or T
10. Salbutamol
lymphoblastic leukemia immunophenotype
11. Paracetamol (mature B-cell ALL or Burkitt leukemia are
excluded).
12. Simvastatin
Breast Cancer(stage 0 to IIIA) P100,000- Clinical and
13. Gliclazide
TNM staging:
14. Metformin Hydrochloride
- Stage 0 TisN0M0
15. Enalapril
- Stage IA T1N0M0
16. Metoprolol
- Stage IB T0,T1N1M0
17. Amlodipine
- Stage IIB T2N1M0 or T3N0M0
18. Hydrochlorothiazide + Losartan
- Stage IIIA T0, T1, T2N2M0 or T3N1N2M0
Note/s:
Prostate Cancer (low to intermediate risk)
1. FREE (only for the member or 1 of his/her
P100,000-a. Signed ME Form; b. Male patients age
dependent)
up to 70 years old; c. Clinical stage (T1a-T2c), PSA
• Initial Health screening and assessment level 10 to 20 ng/ml,

• Initial Essential Services Tumor Grade (Gleason’s score of 2-7)

2. FIXED CO-PAYMENT* (applicable for member - Low risk: T1-T2a and Gleason score 2-6, and
and dependents)
PSA ‹10 ng/ml
• Initial and follow-up medicines
- Intermediate risk: T2b to T2c, Gleason score of 7,
• Follow-up consultation
and PSA 10-20 ng/ml d. Localized prostate cancer;
• Follow-up laboratory included in the list and e. No uncontrolled co-morbid conditions

3. REGULAR FEE End-stage renal disease eligible for requiring

kidney transplantation (low risk)
• Initial health screening, assessment and essential
services for beneficiaries not availing of the free P600,000 a. Signed ME Form;

• Other laboratory services and prescribed

medicines not included in the list
b. Age ›10 and ‹70 years;
* 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 c. Single organ transplant;
laboratories and medicines included in the list of
d. Patient on chronic dialysis because of end stage j. Eligible patient for kidney transplant must have a
renal disease or patient for pre-emptive kidney certification from the social service of the hospital
transplantation with the following: that they can maintain anti-rejection medicines for
the next three (3) years.
i. The potential recipient should have an
irreversible renal disease that has been progressive Coronary Artery Bypass Graft Surgery (standard
over the previous 6 – 12 months risk)

ii. The recipient’s measured (nuclear scan) P550,000 a. Signed ME Form

glomerular filtration rate, 24-hour urine creatinine
b. Age 19-70 years
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
c. Stable Coronary Artery Disease requiring
non-diabetic renal disease
ELECTIVE ISOLATED Coronary Artery Bypass
Graft Surgery (CABG) with indication based on
coronary anatomy, symptom severity, LV function,
e. Low immunologic risk defined as:
and/or viability tests; non-invasive testing
i. Past Panel Reactive Antibody (PRA) less than or completed and discussed with patient
equal to 20%

ii. Primary kidney transplant (no previous solid

d. Current Medical Status
organ transplant)
i. Not in severe decompensated heart failure (NYFC
iii. No donor specific antibody (DSA) in the
IV)
potential recipient
ii. Not with severe angina (CCS Class III)
iv. At least 1 HLA-DR match
iii. No other cardiac/vascular procedures
/interventions planned to be done with CABG
f. Potential recipient has no previous history of during the admission
cancer (except basal cell skin cancer), should be
HIV negative, Hepatitis B surface antigen negative,
and Hepatitis C antibody negative e. Past History:

i. No previous cardiac surgery such as CABG, valve

surgery, etc.
g. Transplant candidate who is CMV-negative
cannot receive an organ from a CMV-positive ii. No previous transcutancous cardiac intervention
donor. such as coronary angioplasty or stenting

f. ONLINE EUROSCORE II and/or STS scoring

predictive of low mortality risk (‹5%) NCR
h. Absence of current severe illness (Congestive
heart failure Class 3-4, liver cirrhosis (findings of Asian Hospital, Inc.
small liver with coarse granular/heterogenous echo
pattern with signs of portal hypertension), chronic
lung disease requiring oxygen, etc) Chinese General Hospital and Medical Center

i. Absence of the following: hemi-paralysis because Surgery for Tetralogy of Fallot in Children
of stroke, leg amputation because of peripheral
P320,000 a. Signed ME Form
vascular disease or diabetes, mental retardation
such that informed consent cannot be made, and b. Age: 1 to 10 years + 364 days
substance abuse for at least 6 months prior to start
c. 2D-echocardiogram:
of transplant work-up.
i. Pulmonary artery size

- McGoon’s index (Aorta/Pa ratio) ≥ 1.5

- Z score Pulmonary Valve Annulus : Acceptable if e. Functional Class I-II
z score / BSA : ≥ 3 or better
f. No co-morbid factors, such as any of the ff:
- Z score peripheral PA’s : Acceptable if ≥ 2 or
i. Preoperative seizures
better
ii. Brain abscess
ii. Absence of major aortopulmonary collateral
arteries (MAPCAs) iii. Stroke events

iv. Bleeding disorders

d. If cardiac catheterization / hemodynamic study v. Infective endocarditis

available: PA size: adequate by Z score standards /
BSA
g. No chromosomal abnormalities and other
associated congenital defects NCR
e. No previous cardiac surgery (Blalock Taussig
Philippine Heart Center
Shunt)
Chemoradiation with Cobalt and Brachytherapy
(low dose) or Primary surgery for Stage IA1, IA2 –
f. Functional Class I-II IIA1

P120,000

g. No co-morbid factors, such as any of the ff: Chemoradiation with Linear Accelerator and
Brachytherapy (high dose)
i. Preoperative seizures
P175,000 a. Signed ME Form;
ii. Brain abscess

iii. Stroke events

b. No previous chemotherapy
iv. Bleeding disorders

v. Infective endocarditis
c. No previous radiotherapy
vi. Other congenital anomalies

Surgery for Ventricular Septal Defect in Children

d. No uncontrolled co-morbid conditions
P250,000 a. Signed ME Form

b. Age: 1 to 5 years + 364 days

e. Treatment plan from gynecologic oncologist
c. 2D-echocardiography
Z-MORPH (Mobility,
i. Isolated VSD perimembranous, subaortic or
subpulmonic Orthosis, Rehabilitation, Prosthesis Help)

ii. No combined shunts such as atrial septal defect - first right and/or left below the knee
or patent ductus arteriosus or atrioventricular
P15,000
septal defect
- both limbs
iii. No other associated CHD’s : such as coarctation
of the aorta, or moderate to severe aortic P30,000 a. Signed ME Form;
insufficiency, or moderate to severe pulmonic
b. No associated disabilities or co-morbidities, such
stenosis
as contractures, deformities, mental or behavioral
iv. Pulmonary artery pressure: ‹50 mmHg or at least incapacity, quadriparesis, cardiopulmonary
2/3 systolic blood pressure disease;

v. QP QS: > 1.5:1 c. Community ambulation with or without cane,

crutches or walker;
d. No previous cardiac surgery (PA Banding)
d. At least three (3) months post-amputation, if 4. displaced hip fracture
acquired; and
ii. with avascular necrosis of the femoral head
e. At least 15 years and 364 days of age, if (FICAT Stage III and IV); OR
congenital. NCR
iii. hip dysplasia (CROWE I-IV); OR
Selected Orthopedic Implants
iv. severe osteoarthritis; OR
1. Implants for Hip Arthroplasty
v. severe inflammatory joint disease (rheumatoid,
- Implants Hip Prosthesis, cemented* gout, psoriatic, ankylosing spondylitis)

P103,400 c. Pre-injury status: ambulatory patients

- Total Hip Prosthesis, cementless**

P169,400 d. With no more than two co-morbid illnesses

based on: Physical status classification based on
- Partial Hip Prosthesis, bipolar
ASA (low to moderate risk)
P73,180

*cemented: 66 years old and above

ASA I – normal healthy patient
** cementless: 65 years and 364 days old and below
ASA II – Patient with mild systematic disease; no
2. Implants for Hip Fixation functional limitation

- Multiple screw fixation (MSF)*** 6.5mm

cannulated cancellous screws with washer
a. Signed ME Form
P61,500

***59 years and 364 days old and below (both

b. Any hip fracture not covered under the total hip
displaced and undisplaced fracture); 60 years old
package for femoral neck fracture
and above (undisplaced fracture
i. with no avascular necrosis of the femoral head;
3. Implants for Pertrochanteric Fracture
OR
- Compression Hip Screw Set (CHS)
ii. acute fracture of the hip; OR
P69,000
iii. hip fracture with no pre-existing cox-arthritis;
- Proximal Femoral Locked Plate (PFLP) OR

P71,000 iv. displaced hip fracture

4. Implants for Femoral Shaft Fracture

- Intramedullary Nail with Interlocking Screws c. Pre-injury status: ambulatory patients

P48,740

- Locked Compression Plate (LCP) – Broad / d. With no more than two co-morbid illnesses
Metaphyseal / Distal Femoral LC based on: Physical status classification based on
ASA (low to moderate risk)
P50,740

a. Signed ME Form
ASA I – normal healthy patient
b. Clinical Features
ASA II – Patient with mild systematic disease; no
i. hip fracture
functional limitation
1. with avascular necrosis of the femoral head; OR

2. neglected fracture of the hip; OR

a. Signed ME Form
3. hip fracture with pre-existing cox-arthritis; OR
b. CHS: stable fracture of the intertrochanteric area Clinical Criteria
(AO Classification Type A1 fracture)
i. Must be at least 10 years of age;
c PFLP: unstable/comminuted pertrochanteric
fracture (AO Classification Type A2 and A3
fracture) ii. Diagnosed to have end-stage renal disease
requiring renal replacement therapy;
d. Pre-injury status: ambulatory patients

e. With no more than two co-morbid illnesses

based on: Physical status classification based on iii. No previous history of cancer other than a
ASA (low to moderate risk) successfully and completely treated cutaneous
squamous cell or basal cell carcinoma or carcinoma
in-situ of the cervix , within the past 5 years;
ASA I- normal healthy patient

ASA II – Patient with mild systemic disease; no

iv. HIV-negative;
functional limitation

v. No mental incapacity such that informed consent

a. Signed ME Form
cannot be made or that would interfere with the
patient’s ability to comply with the PD
prescription;
b. Femoral shaft fracture

i. without malignant/metastatic pathologic fracture:

AND vi. For pediatric patients, aged 10 to 18 years and
364 days, informed consent from the parents or
ii. with any complete fracture of the femur
when appropriate, from the guardian, must be
Pre-injury status: ambulatory patients secured;

c. Physical status classification based on ASA (low vii. Absence of current severe illness, including
to moderate risk) congestive heart failure Class IV, liver cirrhosis
(findings of small liver with coarse
granular/heterogeneous echo pattern with signs of
ASA I – normal healthy patient portal hypertension) and chronic lung disease
requiring oxygen;
ASA II – Patient with mild systemic disease: no
functional limitation

“PD First” - for End-Stage Renal Disease Requiring viii. Absence of hemiparalysis and leg amputation
Peritoneal Dialysis because of peripheral vascular disease;

P270,000 per year a. Signed ME Form (to be

submitted annually together with the
ix. No history of substance abuse for at least 3
pre-authorization)
months prior to start of chronic dialysis treatment;
b. Patients must have a permanent Tenckhoff
peritoneal dialysis catheter properly placed in the
abdominal cavity; x. Absence of any disease of the abdominal wall,
such as injury or surgery, burns, hernia, extensive
c. Patients must have completed PD initiation in an
dermatitis involving the abdomen;
accredited healthcare institution so that the patient
is no longer uremic, with stable vital signs and
adequately trained (patient himself/herself or a
xi. Absence of any inflammatory bowel diseases (ex.
caregiver) to perform PD at home using manual
Crohn’s disease, ulcerative colitis or diverticulitis)
exchanges;
xii. Absence of any intra-abdominal tumors or Tarlac Provincial Hospital
intestinal obstruction;

Region IVA
xiii. Absence of active serositis;
K-Matters Dasmariñas

xiv. Absence of known or suspected allergy to PD

Nephrocare
solutions NCR

Antipolo City Hospital System - Cabading

New Hope Peritoneal Dialysis Clinic

GP Genesis Dialysis Clinic & Diagnostic Center

Region V

Bicol Peritoneal Dialysis Center, Inc.

Kidney Foundation of the Philippines

Albay Peritoneal Dialysis Center, Inc.

Kidney Solutions, Inc.

Region VI
K-Matters Taguig
Corazon Locsin Montelibano Memorial Regional
Hospital
Makati Medical Center

St. Paul's Hospital of Iloilo, Inc.

National Kidney Transplant Institute

Region VII
Rizal Provincial Hospital System – Binangonan
Cebu Provincial Hospital – Carcar

UP - Philippine General Hospital

Region VIII

Eastern Visayas Regional Medical Center

Valenzuela Citycare Medical Center

Region IX
Region I
Zamboanga City Medical Center
Ilocos Training and Regional Medical Center

Zamboanga Dialysis Clinic

Mariano Marcos Memorial Hospital and Medical
Center
CARAGA

Manuel J. Santos Hospital

CAR

Cordillera Kidney Specialist, Inc.

Region XI

Davao Doctors Hospital

Region III
 a. Biopsy proven rectum cancer stages I to III
(clinically T1-4, N0-2, M0)
Southern Philippines Medical Center

Colon and Rectum Cancer

b. No previous pelvic radiation
Colon Cancer

Stage I-II (low risk) – P150,000

c. Pre-operative physical risk protection
Stage II (high risk) – III – P300,00
ASA I – normal health patient OR

ASA II – patient with mild systemic disease

Rectum Cancer

Stage I (clinical and pathologic) – P150,000

d. ECOG Performance Status
Pre-operative clinical stage I
e. Mandatory and other services ( procedures,
but with post-operative pathologic
diagnostics, medicines & others)
stage II-III
See Tables 6, 7, 8 of Circular No. 028-2015 NCR
- using linear accelerator as mode of radiotherapy) -
The Medical City – Ortigas
P400,000

- using cobalt as mode of radiotherapy - P320,000

UP-Philippine General Hospital

Clinical Stage II-III

CAR
- using linear accelerator as mode of radiotherapy) -
P400,000 Baguio General Hospital and Medical Center

- using cobalt as mode of radiotherapy -P320,000 1.

Signed Member Empowerment (ME) Form
Region IIIA
For Colon Cancer
Angeles University Foundation Medical Center
a. Clinical and TNM Staging from stage I to III
(Clinically T1-T4, N0-2, M0)
Region IVB

St. Frances Cabrini Medical Center

b. Pre-operative physical risk classification

ASA I – normal health patient OR

Region VII
ASA II – patient with mild systemic disease
Perpetual Succour Hospital of Cebu, Inc.

c. ECOG Performance Status

Region XI

Southern Philippines Medical Center

d. Mandatory and other services (procedures,
diagnostics, medicines & others)

PREMATURE and SMALL NEWBORN

e. See Table 1 of Circular No. 028-2015 Prevention of Preterm Delivery

For Rectum Cancer [Link] of preterm delivery with severe

pre-eclampsia/eclampsia - 3,000.00
[Link] of preterm delivery, with preterm 2. Essential interventions with mechanical
pre-labor rupture of membrane (pPROM) - 1,500.00 ventilation and Kangaroo Care for 32 weeks to < 37
weeks - 71,000.00 The following benefits shall
be available for premature newborns who are
3. Prevention of preterm delivery without visually small or very small, 24 weeks to < 37 weeks
pre-eclampsia/eclampsia or rupture of membranes by fetal aging or 500g to ≤ 2,499g fetal weight
but with labor or vaginal bleeding or multifetal
Children with Developmental Disabilities
pregnancy - 600.00

Assessment and discharge assessment ranges from

4. With coordinated referral and transfer from a
P3,626.00 – P5,276.00
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,
Rehabilitation Therapy Sessions P5,000.00 per set*
at risk of preterm delivery. The packages for the
prevention of preterm delivery are availed
exclusive of each other, with or without the
*Eligible children with developmental disability
coordinated referral and transfer [Link]
can only avail of a maximum of nine sets of
VII
therapies. Each set of therapies has a maximum of
Gov. Celestino Gallares Memorial Hospital 10 sessions

Preterm and Small Newborns

(24 to < 32 weeks) a. Chronological age must be zero to 17 years and

364 days old; and

1. Essential interventions for 24 to < 32 weeks -

35,000.00 b. A child presents with functional problems
secondary to delays, regressions, or deviations in
any of the following developmental domains:
2. Essential intervention with minor ventilator cognitive-adaptive, sensorimotor, communication,
support and Kangaroo Care for 24 weeks to < 32 social, emotional, or behavioral
weeks - 85,000.00
Children with Mobility Impairment

3. Essential interventions with major ventilatory

Requiring assistive devices ranges from P13,110.00
support and Kangaroo Care for 24 weeks to < 32
– P163,540.00
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
Requiring seating device, basic and intermediate
preterm delivery. The packages for the prevention
wheelchair ranges from P12,730.00 – P29,450.00
of preterm delivery are availed exclusive of each
other, with or without the coordinated referral and
transfer package. Region VII
Yearly services and replacement of devices ranges
Gov. Celestino Gallares Memorial Hospital from P1,590.00 – P13,690.00

Preterm and Small Newborns a. General Criteria

(32 to < 37 weeks) i. Age must be 0 to 17 years and 364 days old;

1. Essential interventions for 32weeks to < 37 weeks

- 24,000.00
ii. Absence of conditions that will compromise Children With Visual Disabilities
safety and functionality with the use of prosthesis,
orthosis,
Package code and rates for initial assessment and
intervention
iii. On physical examination: no fresh or
non-healing wound on body part of interest
Initial assessment and intervention (i.e.
rehabilitation and training) for Category 1 Visual
iv. At least three months-post-surgery, if acquired impairment - 25,920.00
amputation

Initial assessment and intervention (i.e. electronic

b. With mobility impairment, presenting with any assistive device, rehabilitation and training) for
of the following: Categories 2, 3, and 4 Visual impairment - 31,920.00

i. Disorders resulting to mobility impairment: Initial assessment and intervention (i.e. electronic
assistive device, rehabilitation and training) for
a.) Musculoskeletal conditions characterized with
Category 5 Visual impairment - 9,070.00
any of the following: limb loss (amputation), limb
deficiency, limb deformity and spine deformity
(Cobb’s angle ≥ 20 degrees and Risser ˂ 4)
Optical Aid 1: Low Power Distance, Categories 1, 2,
classified into:
3 and 4 visual impairment eyeglasses + low power
optical device - 7,350.00

i.) Gross motor function classification system

(GMFCS) 1 and 2 for prosthesis and orthoses
Optical Aid 2: High power Distance, Categories 1, 2,
3 and 4 visual impairment progressive eyeglasses +
high optical device - 13,820.00
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
Optical Aid 3: Colored Filter, Categories 1, 2, 3 and
years & 364 days),
4 visual impairment - 2,940.00

iii.) Talipes equinovarus (clubfoot)

White cane, Category 5 visual impairment - 1,000.00

b.) Neuromuscular conditions characterized with

Description for add-on* devices
any of the following: weakness or paralysis,
imbalance, incoordination, sensory deficits
classified into:
*These add-on assistive devices are availed of on
top of the benefits for initial assessment and
intervention for the Z Benefits for visual
i.) GMFCS 1 and 2 for prosthesis and orthosis, OR
disabilities.

ii.) GMFCS-3, 4, and 5 for seating device,

Description for yearly diagnostics, after the first
wheelchair and orthosis
year of enrolment

ii. Presence of cardiopulmonary, behavioral or

Yearly Diagnostics for Categories 1, 2, 3 and 4 -
cognitive conditions that impairs a child’s mobility
3,220.00
 Description for assessment and hearing aid
provision of children 0 to less than 3 years old at
Yearly follow up consultation for Category 5 -
the time of approval of pre-authorization
780.00

Assessment and hearing aid provision, with

Description for other benefits
moderate hearing loss

Electronic Aid Replacement done every 5 years -

Assessment: Otoacoustic Emission Screening and
6,000.00
Auditory Brainstem Response (ABR)

Ocular Prosthesis, per eye - 20,250.00

Habilitation: Hearing Aid fitting, hearing aid
device, batteries good for 5 years, ear mold, hearing
aid verification
** 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
Ear mold refitting every six months for five years
Item VII.1. c of PhilHealth Circular 2018-0010

a. General Criteria
53,460.00
1. Chronological age must be equal to 0 to 17 years
and 364 days old;

Assessment and hearing aid provision, with severe

to profound hearing loss
2. AND any of the following:

Assessment: Otoacoustic Emission Screening and

i. The child must have undergone a visual
Auditory Brainstem Response (ABR)
disabilities assessment from an ophthalmologist
where the child was categorized into Category 1, 2,
3, 4, or 5 visual disability and determined to need
Habilitation: Hearing Aid fitting, hearing aid
assistive devices with prescribed appropriate
device, batteries good for 5 years, ear mold, hearing
rehabilitation plan
aid verification

ii. Children needing an ocular prosthesis should

67,100.00
fulfill the following criteria:

a. The child has enucleated eye

Description for assessment and habilitation of
b. Other clinical indications determined by
children 3 to less than 6 years old at the time of
ophthalmologists
pre-authorization

3. Must be eligible at the time of pre-authorization

Assessment and hearing aid provision, with
moderate hearing loss

PhilHealth is in the process of contracting health

care institutions for the provision of the Z Benefits
Assessment: Age Appropriate Behavioral
for children with visual impairment.
Audiometry
Children With Hearing Impairment
Habilitation: Hearing Aid fitting, hearing aid Description for speech therapy assessment and
device, batteries good for 5 years, ear mold, hearing sessions
aid verification

Speech therapy assessment and sessions for

Ear mold refitting once a year for five year moderate hearing loss

45,400.00 Include speech evaluation, speech therapy sessions

and counselling

Assessment and hearing aid provision, with severe

to profound hearing loss 22,100.00

Assessment: Age Appropriate Behavioral Speech therapy assessment and sessions for severe
Audiometry to profound hearing loss

Habilitation: Hearing Aid fitting, hearing aid Include speech evaluation, speech therapy sessions
device, batteries good for 5 years, ear mold, hearing and counselling
aid verification

63,420.00
Ear mold refitting once a year for five years

Description for hearing aid replacement (The rates

54,100.00 mentioned cover the hearing aid, its prescription,
fitting, and fitting evaluation for one ear only)

Description for assessment and habilitation of

children 6 to less than 18 years old at the time of Replacement of hearing aid for moderate hearing
approval of pre-authorization loss, 5 to less than 18 years old

Assessment and habilitation, with moderate Includes hearing aid fitting, hearing aid, batteries
hearing loss good for five years , ear mold and hearing aid
fitting verification

Assessment: Diagnostic Pure Tone Audiometry

43,670.00

Habilitation: Hearing Aid fitting, hearing aid

device, batteries good for 5 years, ear mold, hearing Replacement of hearing aid for severe to profound
aid verification 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.
Ear mold refitting once a year for three years This require a new application for
pre-authorization. Includes hearing aid fitting,
hearing aid batteries good for five years, ear mold
43,880.00 and hearing aid fitting verification 48,670.00