Benefits Orientation for

ICON CLINICAL RESEARCH SERVICES

PHILIPPINES INC.
Coverage Period of January 01, 2025 to December 31, 2025

@PHILCAREPH
PRESENTATION OUTLINE:
01  PhilCare’s Profile & Service Initiatives
02  PhilCare’s Technology Enabled Services
03 Healthcare Benefits and Availment Process
04 Standard Exclusion List

@PHILCAREPH
 Why
SMARTER
is BETTER?

@PHILCAREPH
PHILCARE SNAP
PhilCare’s Near Field Communication (NFC) membership cards are designed to make hospital
transactions faster, more efficient, and almost paperless.

JUAN DELA CRUZ

Male, Single

JUAN DELA CRUZ

PC14980 CERT
#:ABC1234
JUAN DELA CRUZ
HEYPHIL APP VERSION 2.0
• For Android users, go to Google Playstore (device’s OS should be 6.0 or Marshmallow)
• For iPhone users, go to the App Store
• Download HeyPhil 2.0 and
complete the app’s basic questions.

STEP BY STEP PROCESS:

1. Creating a New account
• Provide certificate number
• Make sure that the email address is active and correct.
2. Logging In
• Enter your email and password then click Login. You will then be sent to the Verification Code page.
• Fill the provided fields with the OTP code that you will receive in your registered mobile number, then click
Submit. If you have not received the OTP code, click Resend Code.
• For any concerns, email HeyphilDigimed@[Link] and HeyphilTechSupport@[Link] for
assistance & provide the ff.:
• Certificate No
• Full name
• Company
• Birthday
• Email and contact no
• Concerns (you may share the screenshot of the error)
PhilCare’s Digital Channels: Hey Phil is a cognitive voice assistant that provides the
The HeyPhil App best healthcare support to all PhilCare members using
the latest artificial intelligence technology.

Unlimited DigiMed Consultation

with the following Physicians:
-Family Medicine Specialists
-Internal Medicine
-General Physician

Services:
 Issuance of medical assessment and prescription
 Referrals for specialty consult (if applicable)
 Endorsement for lab tests/procedures (if
applicable)
 Interpretation of laboratory test results
 Consultations for pre-existing conditions not
requiring emergency attention
PhilCare’s Digital Channels: LOA GENERATION
Members can generate LOAs for Consultation or Laboratory Procedures
The HeyPhil App anywhere and anytime at their convenience using their smartphone.

FIND A DOCTOR
Search for 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
Search for an accredited hospital or clinic and check for their address and
contact details.

DIGICARD
By presenting the 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.

DEPENDENTS ACCESS & LOA REQUESTS

Members can view their dependent’s details such as their benefits and
historical availments & generate an LOA for them using their credentials.

DIGIMED: MEDICAL & MENTAL HEALTH CONSULTATION

SERVICES
Get instant consultation with an accredited on-line doctor in your office or
at your home without queuing in hospitals or clinics.
MEMBER GATEWAY

Benefit Highlights:
• Reimbursement submission
• Latest Newsfeeds, and downloadable forms.
• LOA Request for (Php1,500 and below) with
PhilCare EASy
HEYPHIL DIGIMED PLUS

Video Teleconsultations

•Issuance of medical
assessment and
prescription
•Referrals for specialty
consults and procedures
•Interpretation of
laboratory test results
 THE MEDICAL CITY ORTIGAS

Service Highlights

ASIAN HOSPITAL AND MEDICAL CENTER

MAKATI MEDICAL CENTER​

VAST CUSTOMER SERVICE CHANNELS
Mondays to Sundays, 7am to 7pm
24/7 Support:  Email support:
Call Center Number: SupportServices@[Link]
Callcenter@[Link]
(02)8462-1800
 FB messenger support:
Toll Free Number: /philcareph
1-800-1-888-3230

Smart Line:
(0998) 562 1800

Globe Line:
(0917) 592 1800
CX SERVICE EXCELLENCE

Dedicated Customer Care

Representative (CCR)
 Services Offered:
• Wellness Diagnostic Surveys

• Wellness Tracker and Wellness

Dashboard
MINDSCAPES • Consultations with Experts
Mental Wellness
 Access Mental Wellness From Home.

Members with Mind Care benefits will be able to track

their mental health through:

• Wellness Diagnostic Surveys

(For general anxiety and depression)

• Wellness Tracker and Wellness Dashboard

(Track progress towards mental health and
emotional wellness)

• Covered up to Php 50,000 per member per year (It can

be covered outright if availed within network; via
reimbursement if outside network)

Mindcare Coverage
YOUR HMO PLAN
Your Healthcare Benefits

PRINCIPAL

Classification Room and Board Accommodation Maximum Benefit Limit (MBL)

Employee Regular Private 250,000.00

Overage Employee (66 to 70 Years Old) Regular Private 250,000.00

Overage Employee (71 to 75 Years Old) Regular Private 250,000.00

DEPENDENT

Classification Room and Board Accommodation Maximum Benefit Limit (MBL)

Dependent Regular Private 250,000.00

Overage Dependent (66 to 70 Years Old) Regular Private 250,000.00

Overage Dependent (71 to 75 Years Old) Regular Private 250,000.00

Your Healthcare Benefits

NOTE:
1. MBL Works on a per illness, per member, per year
• MBL applies separately to each specific illness, provided they are not related. For example, if you have two different illnesses
within a year, such as dengue and an appendectomy, each illness has its own separate benefit limit; Php 250,000.00 for dengue
and another Php 250,000.00 for appendectomy. However, related conditions, like complications from diabetes mellitus (e.g., stroke
or kidney failure), are charged under a single MBL.
2. With Access to Six (6) Major Hospitals:
 Asian Hospital and Medical Center
 St. Luke’s Medical Center - Quezon City,
 The Medical City,
 Cardinal Santos Medical Center,
 Makati Medical Center, and
 St. Luke’s Medical Center - Global City.
3. With access to Premium Hospital: Notre Dame de Chartres Hospital/ Philippine Orthopedic Institute/ Manila Adventist Medical Center
2025 BENEFITS ENHANCEMENTS:

Benefit Item 2024 Policy 2025 Renewal

Allergy testing / Allergy screening and other related Up to Php5,000 per member per year (From
Up to MBL
examinations Php2,500)
Up to Php2,500 per member per year (From
Tuberculin test Up to MBL
Php600)
Botox which is not cosmetic in nature nor for Up to Php20,000 per member per year (From Up to 50% of MBL (Shared limit with IP
beautification purpose Php5,000) and OP)
Up to Php60,000 shared limit for OP and IP per Up to 50% of MBL (Shared limit with IP
Continuous Positive Airway Pressure (CPAP) therapy
member per year subject to MBL and OP)
ENROLLMENT ELIGIBILITY
Employees: 18 years up to 75 years (Upon Hire)

Dependents:

Married Employees
Spouse = 18 years old up to 75 years old
Children = 0 days (full term) to 26 years old from eldest to youngest, provided single, unemployed, and fully dependent on the employee

Single Employees
Parents = 18 years old up to 75 years old; either of the parents may be enrolled first
Siblings = 0 days (full term) to 26 years old from eldest to youngest, provided single, unemployed, and fully dependent on the employee

Single Parents
Children = 0 days (full term) to 26 years old from eldest to youngest, provided single, unemployed, and fully dependent on the employee
Parents = 18 years old up to 75 years old; either of the parents may be enrolled first
 Documents Required in Skipping of Hierarchy
 To skip enrollment of deceased dependents
 To provide copy of Death Certificate

 To skip enrollment of dependents with other HMO/Insurance

 To provide copy of the HMO card/proof of coverage

 To skip enrollment of a spouse working abroad or outside the Philippines

 To provide proof (e.g. copy of Visa, certification of employment, etc.)

 To skip enrollment of a separated spouse (applicable for enrollment of children only)

 To provide copy of Legal Separation decree
 To provide copy of Barangay Certificate and HR Certification
 To provide copy of Solo Parent ID
YOUR SCHEDULE OF
HEALTH BENEFITS
HEALTH PLAN | PREVENTIVE CARE
 ANNUAL PHYSICAL EXAMINATION, may be availed in PhilCare Clinic,
PhilCare Affiliated Clinics
 Review of Medical History
 Physical Examination
 Chest X-Ray
 Urinalysis
 Fecalysis
 CBC
 ECG for members 35 years old and above
 Pap smear for females 35 years old and above
 Fasting Blood Sugar(FBS), for member at least 35 years old
 Total Cholesterol, for at least 35 years old
HEALTH PLAN | PREVENTIVE CARE
 PREVENTIVE CARE
 Health Education Counseling on diet or exercise
 Periodic Monitoring of Health Problems
 Family Planning Counseling

 Three (3) Wellness session per contract year

 Vaccine for Tetanus, animal bites and scratches covered up to

Php 50,000.00 per member per year. Covering the following:
(a) the initial treatment and vaccines (provided administered within 24 hours
from the time of incidence); and
(b) (b) necessary subsequent doses.
HEALTH PLAN | ENHANCED BENEFITS AND
HEALTHCARE RIDERS
 Out Patient Medicine covered up to Php 5,000.00 per member per year covered via reimbursement as long as prescribe by
accredited doctor. Except for vitamins.

Drugs such as but not limited to the following are not covered:
 Vitamins including food supplements
 Medicines for treating infertility, virility and potency
 Medicines prescribed by a dermatologist for the purpose of beautification
 Medicines prescribed for psychological/psychiatric cases
 Medicines that come in the form of soap, lotion, mouthwash, toothpaste and shampoo
 Except as prescribed, any drug which may be purchased without a prescription
HEALTH PLAN | OUTPATIENT CARE
 Consultations with affiliated physicians (except cost of prescribed medicines)
 Treatment of minor injuries such as lacerations, mild burns and minor surgery not requiring confinement.
 Pre & post natal consultations (except laboratory & diagnostic procedures related to pregnancy)
 Dressings, conventional casts (plaster of Paris) and suture covered up to MBL
 X Ray, laboratory examinations, routine, diagnostic and therapeutic procedures prescribed by an affiliated physician, Provided
however that the cost of diagnostic and therapeutic procedures covered shall be limited to a specific amount
 Blood products transfusions and intravenous fluids, including blood screening and cross matching covered up to MBL
 (Eye, ear, nose, throat (EENT) treatments
 Electrocauterization of skin lesions such as plantar warts, flat warts, peringual warts, filiform warts and molluscum contagiosum, in
any part of the body, except genital wartsand condyloma cuminata, prescribed by Affiliated Physician covered up to 5,000.00
 Eye laser therapy is covered up to MBL for retinal tear, retinal hole, retinal detachment and glaucoma prescribed by an affiliated
Physician/Specialist , excluding eye correction such as Lasik, PRK and the like
 Speech Therapy secondary to stroke patients covered subject to MBL excluding developmental delay (reimbursement basis if HMO
has no accredited specialist).
Note: Consultations shall be part of the limit and treated as sessions.
 Physical Therapy - Covered subject to MBL, excluding subspecialties such as cardiac rehabilitation, pulmonary rehabilitation and
the like;
Note: “Therapy of one body area shall be considered as one session ”
 Sclerotherapy for varicose veins covered subject to MBL (except medicines and for cosmetic purposes) as prescribed by an
Affiliated Physician, to be availed through affiliated vascular surgeons only
 Scoliosis covered subject to MBL (whether pre-existing, congenital or acquired) including necessary procedures, except physical
therapy sessions
AVAILMENT PROCESS | OUTPATIENT
LETTER OF AUTHORIZATION (LOA)
LETTER OF AUTHORIZATION
Letter of authorization duly issued by PhilCare to, and signed by,
the Member which shall serve as the authority of the latter to
avail of the medical services.

You have to submit the 2 copies of the LOA to the doctor. He will
forward one copy to PhilCare for his professional fee to be
processed and paid. And the other copy of the LOA is for his
reference.

Kindly affix member's signature and take note that the validity
of LOA is for three (3) days starting on the date it was issued.

 We highly suggest calling the provider first for you to inquire the
availability of the doctor and to secure your prefer schedule since
some of the providers are by appointment and doctor's schedule
may change without prior notice.
HEALTH PLAN | INPATIENT CARE
 No admission deposit in any of the affiliated hospitals
 Room Upgrade – If the entitled room is not available, member may occupy (1) one category higher up to 48 hours
(except suite room) without incremental charges.
Note: After 48 hours, whether the room becomes available or not, incremental charges will be billed to member.
 Room and board accommodation (According to Plan)
 Use of operating, ICU and recovery rooms
 Professional fees of Attending physician, Surgeons, Anesthesiologists,
 Dressings, conventional casts (plaster of Paris) and suture Up to MBL
 X Ray, laboratory examinations, routine, diagnostic and therapeutic procedures prescribed by an affiliated physician,
Provided however that the cost of diagnostic and therapeutic procedures covered shall be limited to a specific amount
 Cardio-pulmonary clearance before surgery and cardiac monitoring during surgery
 Admission Kit
 Drugs & medicines for in-patient use
 Human blood products (e.g platelets/packed RBC) and its processing except gamma globulin and cost of donor
 All other items directly related in the medical management of the patient as deemed medically necessary by the
attending affiliated physician
• Anesthesia and its administration
• Oxygen and its administration
• Routine procedures
• Diagnostic procedures
• Therapeutic procedures
• Special Modalities of treatment* (*Some are subject to pre-set limits)
AVAILMENT PROCESS| INPATIENT
HEALTH PLAN | EMERGENCY CARE
Emergency Condition:
 Sudden and unexpected
 Sever Discomfort or Pain

 Examples of Emergency: Coma , Stroke, Convulsions, Heart Attack,

Massive bleeding, Acute Appendicitis, Fractures, Multiple injuries
secondary to accidents, Diarrhea with severe dehydration, Syncope

 Emergency room fees and doctors' services

 All medicines used for immediate relief and during treatment
 Dressings, cast and sutures
 Oxygen, I.V. fluids, whole blood, and human blood products
 All charges related to the emergency management
• X-ray, laboratory, and diagnostic exams
• Room Upgrade except Suite in case of room unavailability within 48hrs
AVAILMENT PROCESS| EMERGENCY
HEALTH PLAN | EMERGENCY CARE
Emergency Care (Non-affiliated)
Availment in Non-Accredited Hospital
100% of hospital bills & professional fees based on PhilCare rates covered subject
to MBL (Reimbursement Basis)
Availment Outside the Philippines
100% of hospital bills & professional fees based on PhilCare rates covered subject
to MBL (Reimbursement Basis) (in PHP currency)
Areas without affiliated hospitals within the Philippines
100% of hospital bills & professional fees based on PhilCare rates covered subject
to MBL

Ambulance Service
Covered up to MBL (affiliated to affiliated)
• Ambulance Service (Affiliated Hospital/Clinic to Affiliated Hospital/Clinic) Covered
Subject to MBL.
• Otherwise, via Reimbursement up to Php 5,000.00 per conduction
AVAILMENT PROCESS| EMERGENCY
PLAN RIDER | MATERNITY ASSISTANCE COVERAGE

Maternity assistance for all female employees subject to the limits:

Caesarean Section - up to Php 5,000.00

Normal Delivery- up to Php 5,000.00

Other Limit – up to Php 5,000.00

NOTE:

• In case the availment of maternity benefits is through a non-affiliated hospital or non-affiliated physician, the maximum
reimbursement amount representing hospital bills and doctor’s professional fee shall be on the above coverage.

• Maternity limits shall be applicable for hospital care during pregnancy and delivery only. Maternity work-ups are not covered.

• Eligibility - All Female Employees

• Waiting Period - None

• Filing Period (Days) - 60 days

PLAN RIDER | DENTAL
Annual Dental examination and consultation
Emergency Out-patient Dental Treatment - to be availed at affiliated dental clinics only
Oral prophylaxis - (Covered (2) Twice per year)
Simple tooth extractions
Restorative and prosthodontic treatment planning
Temporary Fillings – (unlimited as needed)
Permanent Light cure fillings – covered up to (4) counts
Desensitization of hypersensitive teeth
Simple adjustment of dentures
Re-cementation of loose crowns, inlays and onlays
Dental Nutrition and Dietary Counseling
Dental Health Education
Pre-natal check of teeth and gums
Temporo Mandibular Joint Consultation
Gum treatment for cases like inflammation or bleeding
5
4 **These dental services shall be provided only at Philcare accredited dental clinics.
1 3
2
REMINDER: SET APPOINTMENT PRIOR AVAILMENT.
Dental Affiliated Provider: Health Partners (HPDAI)
Contact Details: (0998)859-5122 (SMART) / (+63947)896-4132 (SMART) / (+63917)538-5111 (GLOBE)
1 tooth = 5 surfaces
Group
PLANLife and
RIDER AD&D
| GROUP LIFE AND AD&D FOR PRINCIPALS AND
DEPENDENTS
Death Php 50,000.00
AD&D Coverage Php 50,000.00
a. life 100% of amount of insurance
b. entire sight of both eyes 100% of amount of insurance
c. both hands or both feet 100% of amount of insurance
d. one hand and one foot 100% of amount of insurance
e. either hand or foot and sight of one eye 100% of amount of insurance
f. Arm at or above elbow 70% of amount of insurance
g. Leg at or above knee 60% of amount of insurance
h. One hand at or above wrist 50% of amount of insurance
i. One foot at or above the ankle 50% of amount of insurance
j. Hearing of both ears 50% of amount of insurance
k. Sight of one eye 50% of amount of insurance
l. Four fingers and thumb of one hand 50% of amount of insurance
Eligible Members Employees less 65 years of age (Non-Overage)
Claims Reimbursement and Process
PROCESS | CLAIM REIMBURSEMENT
For Emergency availments at Non affiliated provider, member’s shall submit below documents
to PhilCare’s Head Office within 60 calendar days from date of discharge from the hospital:
 Duly accomplished Claim Reimbursement Form
 Original Official Receipt/s of all Hospital Bills
 Original Receipt/s of the Professional fee/s of the doctor
 Statement of Account from where member was confined or treated
 Original Individual Charge Slips or itemized breakdown of charges to
support the Statement of Account
 For Inpatient Claims, Admitting History Report (to be obtained from
the Medical Records Section of the hospital where patient was
confined) 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.
Advance sending of soft copies: claims_aonsps@[Link] & [Link]@[Link]
Subject format for New: REIMB FOR PROCESS / PATIENT’S NAME / CERT NO / COMPANY NAME (1 of X if there are
multiple emails)
Subject for Compliance: COMPLIANCE / PATIENT’S NAME / BATCH NO
Subject for inquiries/follow-ups: INQUIRY OR FOLLOW UP / PATIENT’S NAME / BATCH NUMBER (if already available /
COMPANY NAME)
 REIMBURSEMENT

Dedicated Claims Officer

@PHILCAREPH
Standard Exclusion List
STANDARD EXCLUSION LIST
 Care by Non-Affiliated Physician in either Affiliated or Non-Affiliated Hospitals, or Care by Affiliated
Physician in Non-Affiliated Hospital except ER cases
 Additional hospital charges and Professional Fees resulting from Room Upgrade (except stated in
ER cases), additional personal comfort items (e.g. telephone and television) and such other items of
the same nature
 Take-home medicine, immunizing agents and out-patient medicines, with the exception of
intravenous chemotherapy medicine and those administered during an emergency treatment
 All hospital charges and Professional Fees incurred after the day and time the discharge from the
hospital has been duly authorized
 Allergens used for hypersensitivity testing regardless if administered as an out-patient or in-patient
procedure (in excess of coverable benefit)
 Procurement or use of corrective appliances, prosthesis, artificial aids and durable equipment (e.g.
stents, pins, screws, plates, wires, hearing aids; (f) intraocular lens, eyeglasses, contact lenses,
braces, crutches, pace maker, etc.
STANDARD EXCLUSION LIST
 Non-health related conditions  Self-inflicted/induced
Illnesses due to drug Injuries or illnesses due to
addiction, alcoholism, etc. military service or suffered under
conditions of war

Gross negligence
Circumcision, sterilization, sex
reversal/transformation, artificial
except for pre and post natal
consultations insemination, infertility

Attempted Suicide Hazardous sports Experimental Procedures

Weight reduction programs, surgical

Beautification purposes (except operation or procedure for treatment
reconstructive surgery) of obesity
STANDARD EXCLUSION LIST
 Physical examinations and other related services required for obtaining or continuing employment,
insurance or government licensing, or not related to the health maintenance of the client, Executive
check-ups
 Dental examination, extractions, fillings and general dental attention and conditions and all
complications arising there from, except to the extent that are necessary for repair or alleviation of
damage to the covered person caused solely by accidental injuries and those dental benefits as
specified in the Agreement
 All forms of behavioral disorders whether congenital or acquired; developmental or psychiatric
disorder; psychosomatic illness
 Laser Treatment (except as stipulated in the agreement)
 “Medico-Legal Fees” These are professional fees of a medico-legal consultant to whom a patient is
referred primarily for the issuance of a medical certificate for legal purposes
 Diseases declared by the Department of Health as "epidemic”
Questions?
 Thank you!

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