PhilHealth Z Benefits for Open Heart Surgery

The Philippine Health Insurance Corporation (PhilHealth) has recently issued Circular No. 2025-0004, which details the new Z Benefit Packages for open heart surgeries. This initiative aims to broaden the coverage for cardiovascular diseases, which are a leading cause of death in the Philippines.

Covered Procedures and Package Rates

The new Z-Benefit packages will cover the following procedures with their corresponding rates:

• Coronary Artery Bypass Graft (CABG) Surgery:

  • Standard Risk: PHP 660,000

  • Expanded Risk: PHP 960,000

• Closure of Ventricular Septal Defect (VSD):

  • With or without Associated Special Conditions: PHP 498,000

  • With Severe Pulmonary Stenosis: PHP 614,000

• Total Correction of Tetralogy of Fallot (TOF): PHP 614,000

• Post-Cardiac Surgery Services: This includes cardiac rehabilitation and ancillary services with varying package rates.

How to Avail the Z-Benefit Package

All Filipinos are eligible to avail of this benefit package, provided they meet the clinical criteria outlined in the Pre-authorization Checklist and Request Forms. The approved pre-authorization is valid for 180 calendar days from the date of approval. The 45-day annual benefit limit will not apply to this package.

No Balance Billing Policy

For patients admitted in basic or ward accommodation, contracted health facilities are not allowed to charge any copayment for essential health services and postoperative complications. However, copayments may be charged for services not included in the essential health services list, choice of physician, or amenities.

This new policy, effective March 1, 2025, is a significant step towards providing more accessible and affordable healthcare for Filipinos suffering from heart disease. For more detailed information, members are encouraged to visit the official PhilHealth website or contact their nearest PhilHealth office.

Reference: PC2025-0004