ARTISTS WELFARE PROJECT, INC.
HMO PROGRAM
| HEALTHCARE BENEFITS | COVERAGE/LIMIT | |
| OUT-PATIENT (OP) CARE | ||
| 1 | Consultations during regular clinic hours, except prescribed medicines | Covered |
| 2 | Pre and Post Natal consultations | 14 sessions |
| 3 | Eye, ear, nose and throat (EENT) treatment prescribed by an Accredited Physician/Specialist | Covered |
| 4 | Treatment for minor injuries such as lacerations, mild burns, sprains and the like | Covered |
| 5 | Dressings, conventional casts (plaster of Paris) and sutures | Covered |
| 6 | 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. | Covered |
| 7 | Minor surgery not requiring confinement prescribed by an Accredited Physician /Specialist | Covered |
| 8 | Eye laser therapy only for retinal hole, retinal detachment and glaucoma, excluding eye correction such as lasik, PRK and the like | Up to Php10,000 per eye |
| 9 | Cauterization of Warts (neck down except genital warts) | Up to Php1,000 |
| 10 | Sclerotherapy | Up to Php5,000 |
| 11 | Allergy Testing/ allergy screening and other related examinations | Up to Php2,500 |
| 12 | Speech Therapy | 12 sessions |
| 13 | Tuberculin Test (on reimbursement) | Up to Php600 |
| IN-PATIENT (IP) CARE | ||
| 1 | Room and Board Accommodation | Subject to the Member’s Room and Board limit |
| 2 | Use of operating room, Intensive Care Unit (ICU), isolation room (if prescribed by Attending Accredited Physician) and recovery room. | Covered |
| 3 | Professional fees in accordance with HMO rates | |
| a. Attending Physicians | Covered | |
| b. Surgeons | Covered | |
| c. Anesthesiologists | 50% of Surgeon’s Fee | |
| d. Cardio-pulmonary clearance before surgery and cardiac monitoring during surgery. | Covered | |
| 4 | Standard Nursing Services | Covered |
| 5 | Medicines for in-patient use | Covered |
| 6 | Blood products transfusions and intravenous fluids, including blood screening and cross matching. | Covered |
| 7 | X-Ray, laboratory examinations, routine, diagnostic and therapeutic procedures incidental to confinement | Covered |
| 8 | Dressings, conventional casts (plaster of Paris) and sutures | Covered |
| 9 | Anesthesia and its administration | Covered |
| 10 | Oxygen and its administration | Covered |
| 11 | Standard Admission kit | Covered |
| 12 | All other items directly related in the medical management of the patient, as deemed medically necessary by the Attending Accredited Physician | Covered |
| SPECIAL BENEFITS | ||
| 1 | 24 Holter Monitoring | Covered |
| 2 | 2D Echo with Doppler | Covered |
| 3 | Adrenocortical Function | Covered |
| 4 | Anti Nuclear Antibody, C-Reactive Protein, Lupus Cell Exams | Covered |
| 5 | Arterial Blood Gas | Covered |
| 6 | Audiograms and Tympanograms | Covered |
| 7 | Bone Densitometry Scan (Dexascan) | Covered |
| 8 | Bone Mineral Density Studies | Covered |
| 9 | Cardiac Stress Tests | Covered |
| 10 | Conventional Hemorrhoidectomy | Covered |
| 11 | Cyrosurgery (once a year) | Covered |
| 12 | CT Scan | Covered |
| 13 | Electromyelography and Nerve Conduction Studies | Covered |
| 14 | Endoscopic Procedures | Covered |
| 15 | Hysteroscopic Myoma Resection | Covered |
| 16 | Hysteroscopically Guided D&C | Covered |
| 17 | Impedance Plethysmography | Covered |
| 18 | Lung Function Studies | Covered |
| 19 | Magnetic Resonance Imaging | Covered |
| 20 | Mammography and Sonomammogram | Covered |
| 21 | Microscopic Examinations | Covered |
| 22 | Myelogram | Covered |
| 23 | Neuroscan (Professional fee will be subject for reimbursement) | Covered |
| 24 | Nuclear Radioactive Isotope Scan | Covered |
| 25 | Organ Donation/Transplant (except cost of organs) | Covered |
| 26 | Percutaneous Ultrasonic Adrenalectomy | Covered |
| 27 | Perfusion Scan | Covered |
| 28 | Plasma Urinary Cortisol/Plasma Aldosterone | Covered |
| 29 | Radionuclide Ventriculography | Covered |
| 30 | Radioscope Scans and Function Studies | Covered |
| 31 | Scalpel Hemorrhoidectomy | Covered |
| 32 | Treadmill Stress Test | Covered |
| 33 | Video Gastroscopy | Covered |
| 34 | Chemotherapy | 12 sessions |
| 35 | Dialysis | 12 sessions |
| 36 | Physical Therapy | 12 sessions |
| 37 | Radiotherapy | 12 sessions |
| 38 | Angiogram/Angioplasty/Coronary Artery Bypass Graft | Up to MBL |
| 39 | Arthroscopic Procedures | Up to MBL |
| 40 | Flourescein Angiography | Up to Php30,000 |
| 41 | Magnetic Resonance Angiography | Up to Php30,000 |
| 42 | Transurethral Microwave Therapy of Prostate | Up to Php30,000 (once a year) |
| 43 | Percutaneous Ultrasonic Nephrolithotomy | Up to Php30,000 (once a year) |
| 44 | Stapled Hemorrhoidectomy | Up to Php10,000 |
| 45 | New or sophisticated procedures | Up to Php5,000 |
| 46 | Polysomnograms (Sleep Recording) | Up to Php5,000 |
| 47 | Laparoscopic Cholecystectomy/Adrenalectomy | Up to MBL |
| 48 | Lithotripsy | Up to Php30,000 |
| 49 | Thallium Scintigraphy | Covered |
| 50 | Other modalities of treatment and/or diagnosis requiring sophisticated equipment for which there are no conventional counterparts | Maximum limit of Php5,000 |
| EMERGENCY CARE | ||
| 1 | In Accredited Hospitals | |
| a. Doctor’s services | Covered | |
| b. Emergency Room Fees | Covered | |
| c. Medicines used for immediate relief during treatment | Covered | |
| d. Oxygen, Intravenous fluids and blood products | Covered | |
| e. Dressings, conventional casts (plaster of Paris) and sutures | Covered |
| f. X-Rays, laboratory and diagnostic examinations, and other medical services related to the emergency treatment of the patient | Covered | |
| 2 | Room Upgrade in case of room unavailability | Covered for the first 24 Hours |
| 3 | In Non-Accredited Hospitals (within the Philippines) | 100% up to MBL based on relative unit value rates |
| 4 | Outside the Philippines | 80% up to Php30,000 based on relative unit value rates |
| 5 | Areas without Accredited Hospitals | 100% up to MBL based on relative unit value rates |
| 6 | Ambulance Service (hospital to hospital) | Up to Php2,500 (reimbursement basis) |
| 7 | Anti Tetanus, Rabies and Venom | Covered within the first 24 hours |
| PRE-EXISTING CONDITIONS | ||
| 1 | Principals | Covered up to P15,000 /yearAll pre existing lumped together |
| 2 | PEC conditions of Mr. Fernando Josef | Covered up to P15,000/illness/year |
| CONDITIONS WITH SPECIFIC LIMITATIONS | ||
| 1 | Work Related Conditions | Covered |
| 2 | Cataract Extraction (except cost of lens) | Php20,000/member |
| 3 | Motor Vehicular Accident (subject to Police Report Evaluation & Standard Exclusion | Covered |
| 4 | Unprovoked Assault | Covered |
| 5 | Scoliosis, Spinal Stenosis, Slipped disc & Spondylosis | Up to Php20,000 |
| 6 | Congenital Conditions except physical therapy sessions and developmental disorders | |
| DENTAL BENEFITS | ||
| 1 | Dental consultation including orthodontic & aesthetic services | Covered |
| 2 | Simple oral prophylaxis | 1 |
| 3 | Any number of non-surgical tooth extraction | Covered |
| 4 | Recementation of jacket, crowns, inlays and onlays | NA |
| 5 | Emergency desensitization of hypersensitive teeth | NA |
| 6 | Gum treatment excluding the cost of prescribed medicines | NA |
| 7 | Minor adjustments of dentures | NA |
| 8 | Care for oral lession, wounds & burns | Covered |
| 9 | Temporary Fillings | 1 |
| 10 | Relief of acute dental pain | Covered |
| 11 | 2 teeth light cure filling | NA |
| ANNUAL CHECK-UP | ||
| To be conducted at a designated Affiliated Clinic (except Healthway Medical Clinic) | ||
| 1 | Taking of Medical History | Covered |
| 2 | Physical Examination | Covered |
| 3 | Chest X-ray | Covered |
| 4 | Urinalysis | Covered |
| 5 | Stool examination | Covered |
| 6 | Complete Blood Count (CBC) | Covered |
| 7 | Electrocardiogram | For members 35 years old & above |
| 8 | Pap smear | For female members 35 years old & above |
| EXECUTIVE CHECK-UP (ECU) | ||
| 1 | ECU IP | Not Covered |
| 2 | ECU OP | Not Covered |
| OTHER PROVISIONS | ||
| 1 | Maternity Benefit | Not Covered |
| 2 | Point of Service | Not Covered |
| 3 | Refund Formula for Cancelled Members | (Number of days covered) / Number of days in the billing period x Premium |
| 4 | Medico Legal Case (Reimbursement; Subject to Police Report) | Not Covered |
| 5 | Cost of artificial limbs, joint prosthesis and heart valve prosthesis | Not Covered |
| 6 | Experience Discount | Not Applicable |
| 7 | Filing of Reimbursement Claims | 30 calendar days |
| 8 | Bill-back Arrangement | 12% service fee |
| 9 | PhilHealth Fee | Php3,300 per individual |
| GROUP LIFE INSURANCE WITH ACCIDENTAL DEATH, DISMEMBERMENT & DISABLEMENT (ADD&D) BENEFITS – for ALL MEMBERS | ||
| 1 | Natural Death (amount of insurance) | Php10,000 |
| 2 | Accidental Death and Disablement (amount of insurance) | Php10,000 |
