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(NAR) VOL. 20 NO.2 / APRIL - JUNE 2009

[ 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

Generic Name
Brand
Preparation (dose/cap/syrup/injectible/tab with ml/mg/gm content)
Qty
Unit Price
Actual Charges
Benefit Claim
Hospital
Member
P100 Co-Amoxiclav

625 mg/tab
14/pack
500.00
500.00
500.00

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.

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