PHIC PHILHEALTH CIRCULAR NO. 20, S. 2009, May 07, 2009
COVERAGE FOR P100 DRUGS AND MEDICINES FOR ELIGIBLE SPONSORED MEMBERS
RATIONALE
PhilHealth’s mandate is to ensure financial protection in times of
sickness especially for those who belong to the marginalized sector or
the poorest of the poor. It is likewise the policy of the Government to
ensure universal access to affordable and quality medicines.
Currently, the Corporation reimburses drug products and services
consistent with rational prescription. Further, in order to influence
the delivery of quality services, PhilHealth recommends the use of
Clinical Practice Guidelines in the management of treatment of ill
health.
In line with this commitment, to ensure access to cheaper quality
drugs and medicines for illnesses significantly affecting the health of
Filipinos, particularly the poor, the Corporation shall expand coverage
for drugs and medicines to include take home medications under the P100
Program (Treatment Packs worth Php 100.00) initiated by the Department
of Health (DOH).
LEGAL BASIS
In line with the Implementing Rules and Regulations (IRR) of Republic
Act (RA) 9502 otherwise known as the “Universally Accessible Cheaper
Medicines Act of 2008” and pursuant to PhilHealth Board Resolution 1214
s-2009, approving the PhilHealth coverage of the P100 drugs for eligible
sponsored members, PhilHealth shall cover drugs and medicines that are
listed as P100 drugs beyond the patient’s confinement period (as take
home medication).[1]
GENERAL RULES
A. This benefit shall initially cover all eligible sponsored members and their qualified dependents.
B. P100 Drugs shall be given/prescribed to sponsored members, as
applicable, during confinement and extra pack(s) needed beyond the
confinement period subject to the following limitations:
a. Full course treatment (maximum of two weeks) for infections covering antimicrobial drugs.
b. For chronic illnesses, P100 drugs shall be limited to cover two weeks maintenance dose after discharge.
c. For other acute illnesses, P100 drugs shall be limited to one extra pack as take home medications after discharge.
d. Should be within the prescribed in-patient benefit limits for drugs and medicines.
C. In case the required P100 drugs are unavailable in the
accredited hospital/facility where the member is admitted, the purchase
of such drugs from any P100 outlets/sources authorized by the Department
of Health (e.g. DOH and LGU supervised facilities, Botika ng Bayan
outlets, Botika ng Barangay) may be covered provided that corresponding
official receipts are attached to the claim application for direct
reimbursement to the patient/member subject to the in-patient benefit
ceiling on drugs and medicines and filing of claims within the
prescribed period of 60 days (after discharge);
D. Administration of P100 drugs and claims thereto should be
appropriate, necessary and consistent with the principles of rational
drug use, established Clinical Practice Guidelines (CPGs) and other
acceptable standards of medical practice and ethics. (please see
attached annex A[*] for list of P100 drugs);
E. In cases where P100 Treatment Pack(s) are not consumed during the
period of confinement, PhilHealth shall reimburse the same per pack
basis. Meaning, those left per treatment pack after confinement will
still be reimbursed subject to the benefit ceilings for drugs and
medicines.
Illustration:
Mr. Rey, a sponsored member was confined at East Avenue Medical
Center for diabetes mellitus. He was given P100 Treatment Pack
metformin 500 mg (90 tablets) to be taken three (3) times a
day. Mr. Rey was discharged after 5 (five) days thus he consumed only 15
tabs of treatment pack. PhilHealth shall reimburse the whole pack (90
tabs) subject to the in-patient benefit ceiling limits for drugs and medicines.
ELIGIBILITY
1. All sponsored members and their qualified dependents with date(s)
of confinement within the validity period of their membership as
indicated in the ID card/Member Data Record.
CLAIMS AVAILMENT
1. There will be no separate claim application for P100 drugs. Claims
for these shall be incorporated in the Claim Form 2 part III for the
in-patient services.
To illustrate:
Part III – DRUGS AND MEDICINES
2. For P100 drugs purchased from any P100 DOH authorized
outlets/sources outside the hospital/facility during confinement, claims
for such may be reimbursed accordingly provided, corresponding official
receipts are attached to the claim application.
EFFECTIVITY
This issuance shall take effect for benefit claims of sponsored members with admission date starting June 1, 2009.
Please be guided accordingly.
Adopted: 07 May 2009
(SGD.) DR. REY B. AQUINO
President and CEO
[1] This
Circular is the initial Implementing Circular of PBR 1214, s. 2009.
Subsequent Circulars shall be issued pursuant to the provisions of the
said PBR and the Implementing Rules and Regulations (IRR) of the
Universally Accessible Cheaper and Quality Medicine Act of 2008.
[*] Not Filed with ONAR.