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Standard Benefits
BENEFITS FOR SPECIAL DIAGNOSTIC PROCEDURES:
The member shall be entitled to any of the following procedures upon the request of a Fortune CARE affiliated Physician and approval by the Utilization Management Committee, except in emergency cases as herein defined:
Immunologic and Special Laboratory Examinations:
- Hepatitis profile, e.g. HbeAG, HBS AG, Anti HBC (IgM) and Anti-HAV (IgM)
- ANA profile, e.g. Anti-Nuclear-Antibody, Anti native-DNA, Anti-Sm, Anti-SSA, Beta-HCG, ANA
- Thyroid Profile, e.g. T3 T4, TSH, FTA-ABS.
- TORCH profile, e.g. Anti-Toxoplasma Gondii (IgM), Anti-Rubella, Anti-Cystomegalo-Virus (Total IgG).
- SLE test, FAT, Widal Test, ASO Titer, Serum IgG, Alpha-Feto protein, ESR
- Urine/ blood culture and sensitivity test.
- 24-hour protein determination
- Troponin
- Glycosylated Hemoglobin
- Prostate Specific Antigen (PSA)
Special and Computer-Based Diagnostic and Therapeutic Procedures:
1. Mammography P 5,000.00/disease/year
2. All types of Ultrasound No limit
3. Stress Testing (all types) P 10,000.00/year
4. All types of Cat Scan P 5,000.00/disease/year
5. Nuclear Imaging (including Parathyroid Scan) P 5,000.00/disease/year
6. Total Body Scan P 5,000.00/disease/year
7. Bone Scan P 5,000.00/disease/year
8. Renal Scan P 5,000.00/disease/year
9. Pulmonary Scan P 5,000.00/disease/year
10. Thallium Scan/ Thyroid Scan P 5,000.00/disease/year
11. Echocardiography (all types) P 5,000.00/disease/year
12. Fluorescein Angiography or P 2,500.00/eye/year
Angiography of Eye Total
13. Warts, Except Genital and P 2,500.00/year
Sexually Transmitted Warts
14. Breast Scintigraphy P 5,000.00/breast/year
15. Magnetic Resonance Imaging (MRI) P 5,000.00/disease
The member shall be entitled to any of the following procedures upon the request of a Fortune CARE affiliated Physician and approval by the Utilization Management Committee, except in emergency cases as herein defined:
Immunologic and Special Laboratory Examinations:
- Hepatitis profile, e.g. HbeAG, HBS AG, Anti HBC (IgM) and Anti-HAV (IgM)
- ANA profile, e.g. Anti-Nuclear-Antibody, Anti native-DNA, Anti-Sm, Anti-SSA, Beta-HCG, ANA
- Thyroid Profile, e.g. T3 T4, TSH, FTA-ABS.
- TORCH profile, e.g. Anti-Toxoplasma Gondii (IgM), Anti-Rubella, Anti-Cystomegalo-Virus (Total IgG).
- SLE test, FAT, Widal Test, ASO Titer, Serum IgG, Alpha-Feto protein, ESR
- Urine/ blood culture and sensitivity test.
- 24-hour protein determination
- Troponin
- Glycosylated Hemoglobin
- Prostate Specific Antigen (PSA)
Special and Computer-Based Diagnostic and Therapeutic Procedures:
1. Mammography P 5,000.00/disease/year
2. All types of Ultrasound No limit
3. Stress Testing (all types) P 10,000.00/year
4. All types of Cat Scan P 5,000.00/disease/year
5. Nuclear Imaging (including Parathyroid Scan) P 5,000.00/disease/year
6. Total Body Scan P 5,000.00/disease/year
7. Bone Scan P 5,000.00/disease/year
8. Renal Scan P 5,000.00/disease/year
9. Pulmonary Scan P 5,000.00/disease/year
10. Thallium Scan/ Thyroid Scan P 5,000.00/disease/year
11. Echocardiography (all types) P 5,000.00/disease/year
12. Fluorescein Angiography or P 2,500.00/eye/year
Angiography of Eye Total
13. Warts, Except Genital and P 2,500.00/year
Sexually Transmitted Warts
14. Breast Scintigraphy P 5,000.00/breast/year
15. Magnetic Resonance Imaging (MRI) P 5,000.00/disease
