Invitation to Bid for
Provision of DFPC Healthcare Services 2015
HRMD1502
Duty Free Philippines Corporation (DFPC), through its Corporate Budget 2015 intends to
apply the sum of Forty Two Million Pesos (PhP42,000,000.00) being the Approved Budget for
the Contract (ABC) to payments under the contract for Memorandum HRMD-ESD-BENEFITS
SECTION (15)-027 dated 07 May 2015. Bids received in excess of the ABC shall be
automatically rejected at bid opening.
DFPC now invites bids for Provision of Healthcare Services. Prospective bidders must have
at least five (5) years experience in providing corporate healthcare services. The
prospective bidder should be duly licensed to operate as HMO by the Bureau of Health Facilities
and Services of the Department of Health (DOH). The description of an eligible bidder is
contained in the Bidding Documents, particularly, in Section II. Instructions to Bidders.
DFPC will not accept brokers/agents to represent any HMO company.
Bidding will be conducted through open competitive bidding procedures using the nondiscretionary “pass/fail” criterion as specified in the Implementing Rules and Regulations (IRR) of
Republic Act (RA) 9184, otherwise known as the “Government Procurement Reform Act”.
Bidding is restricted to Filipino citizens/sole proprietorships, partnerships, or organizations with at
least sixty percent (60%) interest or outstanding capital stock belonging to citizens of the
Philippines, and to citizens or organizations of a country the laws or regulations of which grant
similar rights or privileges to Filipino citizens, pursuant to RA 5183 and subject to Commonwealth
Act 138.
Interested Bidders may now obtain further information from DFPC and inspect and/or purchase
the Bidding Documents at the address given below from 9:00AM – 5:00PM, Mondays thru
Fridays until 14 September 2015.
It may also be downloaded free of charge from the website of the Philippine Government
Electronic Procurement System (PhilGEPS) and the website of the Procuring Entity, provided that
Bidders shall pay the non-refundable fee of Twenty Five Thousand Pesos (PhP25,000.00) for
the Bidding Documents not later than the submission of their bids.
DFPC will hold a Pre-Bid Conference on 24 August 2015 at 2:00PM at the address given below,
which shall be open only to all interested parties who have purchased the Bidding Documents.
Bids must be delivered to the address below on or before 15 September 2015 at 10:00AM. All
Bids must be accompanied by a bid security in any of the acceptable forms and in the amount
stated in ITB Clause 18.
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
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Bid opening shall immediately follow at 10:15AM at the address given below. Bids will be
opened in the presence of the Bidders’ representatives who choose to attend at the address
below. Late bids shall not be accepted.
DFPC reserves the right to waive any formality on the eligibility requirements of this project.
Furthermore, DFPC reserves the right to reject any and all proposals, to annul the bidding
process, or declare a failure of bidding, or not award the contract in any of the situations stated
under Section 41 of the Revised IRR of RA 9184, and makes no assurance that a contract shall
be entered as a result of this invitation without thereby incurring liability to the affected bidder or
bidders.
BAC Secretariat
DUTY FREE PHILIPPINES CORPORATION
EHA Bldg, Fiesta Mall, Columbia Complex
Ninoy Aquino Ave., Parañaque City
(632) 552-4343; (632) 552-4337 / 16555 loc. 3039 / 3096
Telefax No. (632) 552-4345, 879-3664, 552 4399 loc 833 / 834
bacsecretariat@dfp.com.ph
(Sgd.) MA. LOURDES D. VELARDE
BAC Chairperson
III. Bid Data Sheet
ITB Clause
1.1
The PROCURING ENTITY is DUTY FREE PHILIPPINES CORPORATION
1.2
The lot and reference is:
Healthcare Services
Memorandum HRMD-ESD-BENEFITS SECTION (15)-027
2
The Funding Source:
The Government of the Philippines (GOP) through the 2015 Corporate
Budget of Duty Free Philippines Corporation in the amount of :
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Provision of DFPC Healthcare Services 2015
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ITB Clause
Forty Two Million Pesos (PhP42,000,000.00)
The name of the project is :
Provision of DFPC Healthcare Services 2015 (HRMD1502)
3.1
No further instructions.
5.1
No further instructions.
5.2
None of the circumstances mentioned in the ITB Clause exists in this Project.
Foreign bidders, except those falling under ITB Clause 5.2(b), may not
participate in this Project.
5.4
The Bidder must have completed, within the period specified in the Invitation
to Bid and ITB Clause 12.1(a)(iii), a single contract that is similar to this
Project, equivalent to at least fifty percent (50%) of the ABC equivalent to:
Twenty One Million Pesos (PhP21,000,000.00)
Similar contract shall refer to provision of corporate healthcare services.
7
No further instructions.
8.1
Subcontracting is not allowed.
8.2
Not applicable.
9.1
The Date and Venue of the Pre-Bid Conference is:
24 August 2015, 2:00PM
DUTY FREE PHILIPPINES CORPORATION
3rd Floor EHA Building, Fiestamall,
Columbia Complex, Ninoy Aquino Ave.
Parañaque City
10.1
The PROCURING ENTITY’s address is:
Duty Free Philippines Corporation Ground Floor, EHA Building,
Fiestamall, Columbia Complex, Ninoy Aquino Avenue, Parañaque City
MA. LOURDES D. VELARDE
BAC Chairperson
Thru: BAC Secretariat
Tel No : 552 4337 loc 3039, 552 4343
Fax No. 879 3664 / 552 4345 / 552 4399 loc. 834
bacsecretariat@dfp.com.ph
Employee Paid Dependents
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ITB Clause
12.1(a)
No further instructions.
12.1(a)(i)
2014 General Information Sheet stamped received by the SEC.
12.1(a)(iii)
The statement of all ongoing and completed government and private
contracts shall include all such contracts within five (5) years (2011-2015)
prior to the deadline for the submission and receipt of bids.
13.1
No additional requirements.
13.1(b)
Proposed Rates for Section IX Employee-Paid Dependents (Refer to Annex 1
of Section IX).
13.2
The ABC is
Forty Two Million Pesos (PhP42,000,000.00)
Any Bid with a financial proposal exceeding this amount shall not be
accepted.
15.4(a)(iii)
No incidental services are required.
15.4(b)
No incidental services are required.
16.1(b)
The Bid prices for Goods and services supplied from outside of the
Philippines shall be quoted in Philippine Pesos.
16.3
Not applicable.
17.1
Bids will be valid until 13 January 2016.
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ITB Clause
18.1
The bid security shall be in any of the following amount:
ACCEPTABLE FORMS
AMOUNT
1. Cash or cashier’s/manager’s
check issued by a Universal or
Commercial Bank
2. Bank draft/guarantee (signed
by the appointee) or irrevocable
letter of credit (original and
notarized)
issued
by
a
Universal or Commercial Bank:
Provided, however, that it shall
be confirmed or authenticated
by a Universal or Commercial
Bank, if issued by a foreign
bank
3. Surety bond callable upon
demand issued by a surety or
insurance
company
duly
certified by the Insurance
Commission as authorized to
issue such security.
4. Any
combination
foregoing.
of
the
5. Bid Securing Declaration
18.2
20.3
21
Two Percent (2%) of the ABC or
Eight Hundred Forty Thousand
Pesos (PhP840,000.00)
Five Percent (5%) of the ABC or
Two Million One Hundred
Thousand Pesos
(PhP2,100,000.00)
Proportionate to share of form
with respect to total amount of
security
No percentage required.
Refer to Bidding Form No. 2
The bid security shall be valid until 13 January 2016.
Each Bidder shall submit one (1) original and three (3) copies of its
Eligibility/Technical Component and Financial Component.
The Address for Submission of Bids is:
DUTY FREE PHILIPPINES CORPORATION
3rd Floor EHA Building, Fiestamall,
Columbia Complex, Ninoy Aquino Ave., Parañaque City
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Provision of DFPC Healthcare Services 2015
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ITB Clause
The deadline for Submission of Bids is on
15 September 2015 at 10:00AM.
24.1
The place of Bid Opening is
Duty Free Philippines Corporation, 3rd Floor EHA Building, Fiestamall,
Columbia Complex, Ninoy Aquino Avenue, Parañaque City
The date and time of Bid opening is on:
15 September 2015 at 10:15AM.
24.2
No further instructions.
27.1
No further instructions.
28.3
The goods are grouped in single lot and the lot shall not be divided into sublots for the purpose of bidding, evaluation, contract award.
28.3(b)
Bid modification is not allowed.
28.4
No further instructions.
29.2(a)
1. 2014 Income Tax Return (form 1701/1702)
2. Business Tax Return (forms 2550M and 2550Q) for the last six (6)
months (February to July 2015) prior to opening of Bids filed thru
Electronic Filing and Payment System (EFPS).
Only tax returns filed and taxes paid through the BIR Electronic Filing
and Payment System (EFPS) shall be accepted.
29.2(c)
1. Company profile with names and designation of the company’s
officers/partners (original).
2. Location map and photo of the office (original).
32.4(g)
No further instructions.
Special Conditions of the Contract
GCC Clause
1.1(g)
The PROCURING ENTITY is Duty Free Philippines Corporation.
1.1(i)
The Supplier is _______________________
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Provision of DFPC Healthcare Services 2015
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GCC Clause
1.1(j)
The Funding Source is:
The Government of the Philippines (GOP) through the Corporate
Budget of Duty Free Philippines Corporation 2015 in the amount of :
FORTY TWO MILLION PESOS ONLY (PhP42,000,000.00)
1.1(k)
The Project Site is :
DUTY FREE PHILIPPINES CORPORATION, Ground Floor, EHA
Building, Fiestamall, Columbia Complex, Ninoy Aquino Avenue,
Parañaque City
5.1
The PROCURING ENTITY’s address for Notices is:
DUTY FREE PHILIPPINES CORPORATION, EHA Building, Fiestamall,
Columbia Complex, Ninoy Aquino Ave., Parañaque City
Lorenzo C. Formoso
Chief Operating Officer
Tel. Nos. (632) 879-3559
Fax No. (632) 552 4301
Victor Ramon G. Marfori
HRMD Manager-OIC
Tel. Nos. (632) 552 4346
marforirg@dfp.com.ph
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
___________________________________________________
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
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GCC Clause
6.2
Services To Be Rendered and Documents
Delivery of Services shall be made by the SUPPLIER in accordance with
the terms specified in the Schedule of Requirements.
I. Membership
1. For purposes of determining eligibility of members, the following
provisions shall govern: The age to be considered for purposes of
enrolment is the age in years, regardless of the months or days,
except in the case of newly born children.
2. The enrolment of the Immediate Dependent Members shall follow
the hierarchy:
2.1 Married Principal Members - spouse first, followed by the
eldest child, second child and so on.
2.2 Single Principal Members - parents first, followed by the
eldest sibling, second to the eldest sibling, and so on.
2.3 Single-Parent Principal Members - eldest child first, followed
by second child and so on, then last, parents.
3. Hierarchy shall be waived for members covered by our previous
SUPPLIERs for the last three (3) years. For this purpose, proof of
membership shall be submitted. Hierarchy shall not apply under the
following circumstances:
3.1 Spouse working or living abroad or covered by another
SUPPLIER or separated (legally or de facto);
3.2 Children studying or living abroad or covered by another
SUPPLIER
4. Members who reach the age of ineligibility within the contract year
shall remain covered until the contract expires, provided the full
contract premium for the said members have been paid.
5. Principal members who changed their civil status during the
contract period may opt to enroll their former immediate
dependents, if any, as specified in Section IX - Employee-Paid
Dependents under Item I.1.1 for the remaining period of the
contract.
6. Enrolment shall be for a period of thirty (30) days following the
commencement of the contract. Should a member be classified as
Senior Citizen (SC) under R.A. 9994 and/or persons with disability
(PWD) under R.A. 7277, he/ she shall submit a photocopy of
his/her OSCA/PWD ID.
7. Members who will be enrolled during the contract period shall be
entitled to full coverage. Enrolment of additional members after the
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Provision of DFPC Healthcare Services 2015
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GCC Clause
enrolment period shall only be allowed for the following:
7.1 Newly regularized employees as Principal Members and
their immediate dependents.
7.2 Newly born children of the enrolled Principal Member.
Member to submit thru DFPC a copy of birth certificate.
7.3 Spouse of newly-wed Principal Member. Member to submit
copy of marriage certificate.
Effectivity of any request for additions in membership shall
commence upon receipt of the letter endorsement report of the
Procuring Entity.
8. Severance of the principal member’s employment with the
PROCURING ENTITY shall automatically terminate his/her
coverage including that of his/her dependents.
Any deletion in membership before the expiry date of the contract,
shall entitle the PROCURING ENTITY to a refund of the unused
premium, provided that the SUPPLIER shall be informed before the
member’s resignation date or end of his contract. Refund shall be
done two months after receipt of ID and the written request for
refund.
Computation of the PRO-RATE REFUND FOR UNUSED
MEMBERSHIP FEES shall be according to the following formula:
REFUND OF UNUSED MEMBERSHIP FEES = (Total Quarterly
Premium Paid x Number of day unused) / 90 days
II. PHILHEALTH BENEFITS
1. The healthcare program shall be net of Philhealth benefits. Should
the member be unable to claim said Philhealth benefits, the amount
corresponding to the same shall be for the account of the member.
2. For non-Philhealth members, an additional annual fee/quarterly fee
upon enrollment is required.
III. OTHER BENEFITS PROVIDED BY LAW
1.
BENEFITS UNDER SENIOR CITIZENS’ ACT. The SUPPLIER
shall ensure that all Senior Citizens are granted the corresponding
discounts on all medical benefits. For this purpose, the SUPPLIER
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Provision of DFPC Healthcare Services 2015
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GCC Clause
shall notify the hospitals, clinics and doctors of the members’
classification based on submitted master list and documents.
2.
BENEFITS UNDER THE MAGNA CARTA FOR DISABLED
PERSONS. The SUPPLIER shall ensure that all Persons with
Disability are granted the corresponding discounts on all medical
benefits. For this purpose, the SUPPLIER shall notify the hospitals,
clinics and doctors of the members’ classification based on
submitted master list and documents.
Procuring Entity shall submit proof of such classification to the
SUPPLIER during enrollment.
IV. CLAIMS FOR REIMBURSEMENTS
Subject to the provision on Maternity Assistance, SUPPLIER agrees to
reimburse hospital bills inclusive of professional fees, based on their
relative values. Emergency Care however, is one hundred percent
100% reimbursable. Availment of healthcare services which cannot be
provided by the SUPPLIER’s medical specialist/s, service units,
accredited hospitals or medical centers, shall be reimbursed one
hundred percent (100%), but not to exceed the amount of maximum
benefit limit.
Claims for Reimbursement shall be filed within thirty (30) days from
issuance of the official receipt/invoice. No claims for reimbursement
shall be processed unless all requisite documents are submitted. In the
event that a required document is unavailable due to causes beyond
the control of the claimant, the SUPPLIER shall be notified as such.
The Member shall immediately submit to the SUPPLIER the said
document as soon as it becomes available.
Payment of claims shall be made within fifteen (15) days from receipt of
complete requirements. Any request for reconsideration shall be
submitted within thirty (30) days from receipt of the notice of
disapproval or partial reimbursement, which in turn shall be ruled upon
the SUPPLIER within a maximum period of thirty (30) days.
V. PRE-EXISTING CONDITIONS AND DREADED ILLNESSES
All pre-existing conditions including dreaded illnesses are covered by
the SUPPLIER up to the maximum benefit limit, per illness, per member
per year subject to item 1.4 of Schedule of Requirements under
Medical Services.
VI. ROOM AND BOARD
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GCC Clause
Room and Board, as described in Section VII -Technical Specifications,
under Item II, will be based on the room classifications of the hospitals
regardless of their rates.
Member is given an option to downgrade his/her accommodation with
the specified room classification as the highest.
In case of non-availability of room plan during confinement, member
may occupy the next higher room classification without being liable to
incremental charges and excess in room and board until appropriate
room becomes available, provided that the member secures a
certification from the admitting section that there is no room available
within the member’s plan. Failure to transfer upon availability of a room
corresponding to the member’s plan shall make the member liable for
said incremental charges and excess in room and board rate from the
day the room becomes available up to the member’s date of discharge.
VII. LIMITATION IN SUPPLIER’S SERVICES
The SUPPLIER shall not be held responsible for the following:
1. Delay or failure to render services due to major disasters,
brownouts or epidemics affecting facilities or personnel.
2. Unusual circumstances such as complete or partial destruction of
facilities, war, riots, disability of a significant number of SUPPLIER’s
personnel or similar events which result in delay to provide
services.
3. A Member’s refusal to receive the recommended treatment for
personal reasons, for which SUPPLIER’s Accredited Physicians
believe no professionally acceptable alternative treatment exists.
VIII.
PAYMENT SCHEDULE
The SUPPLIER shall submit the Statement of Account at the end of
each quarter.
Quarterly payment shall be due not later than sixty (60) days from the
submission of an invoice and statement of account.
IX. OTHER PROVISIONS
1. Open-door-policy where Members can avail of Healthcare Services
(as described in Section VI Schedule of Requirements) from any of
the SUPPLIER’s accredited hospitals/clinics nationwide.
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Provision of DFPC Healthcare Services 2015
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GCC Clause
2. For medical services requiring confinement in a medical facility,
hospital, or clinic, no deposit shall be required.
3. If a member is referred by the SUPPLIER-accredited Physician to a
non-accredited Specialist, the latter’s full professional fee for the
administration of the required medical services shall be for the
account of the SUPPLIER.
4. The SUPPLIER shall provide an itemized monthly (calendar month)
utilization report for principals and dependents (separate reports for
company paid and employee paid) via e-mail to the Procuring
Entity showing among others ID Number, Member’s Name, Age,
Availments: Check-in date, Check-out date, Diagnosis, Type of
Availment, Name and Classification of Provider,
Member’s
Expenses for Room and Board, medicines & medical supplies,
professional fees/doctors’ fees, Member’s Deductions which include
Philhealth, Senior Citizens, Persons with Disability and other
discounts, and total amount billed, see Annex A on MONTHLY
REPORT. The monthly utilization report of the preceding month
shall be submitted within fifteen (15) days of the following month.
Should there be unreported availments, adjustments can be made
immediately in the succeeding month.
The SUPPLIER shall provide a quarterly (three month period)
summary utilization report of principal members and dependents
(separate reports for company paid and employee paid), both in
hard and soft copies to the Procuring Entity based on the format
provided by Procuring Entity. The QUARTERLY SUMMARY
UTILIZATION REPORT shall contain the summary of availments
for the given quarter and shall include the following info: Name of
member, date of availment, diagnosis, total amount paid by
supplier, total utilization per member/illness, MBL, running MBL.
Refer to Annex B. The quarterly utilization report shall be submitted
within thirty (30) days from end of the third month.
5. The enrolment of a member under this contract shall, at all times,
be honored regardless of the number of coverage the member may
have with the same SUPPLIER-HMO or with other HMOs.
X. ADDITIONAL MEMBERSHIP UNDER SECTION IX - EMPLOYEEPAID DEPENDENTS
The Principal Member may opt to enroll additional dependents as
defined under Section IX - Employee-Paid Dependents. A separate
agreement, with the same terms and conditions EXCEPT
MATERNITY as this agreement, shall be entered into by the
SUPPLIER and PROCURING ENTITY to cover these additional
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Provision of DFPC Healthcare Services 2015
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GCC Clause
dependents.
XI. EFFECTIVITY AND DURATION OF THIS AGREEMENT
The effectivity of this contract shall be upon issuance of the Notice to
Proceed.
The duration of this contract shall be for one (1) year.
10.4
Not applicable.
13.4(c)
No further instructions.
16.1
None.
17.3
Not applicable.
17.4
Not applicable.
21.1
No additional provision.
VI. Schedule of Requirements
I.
SCOPE OF SERVICES
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SUPPLIER shall arrange for the following Healthcare services using its Medical Service Units,
Accredited Hospitals or Medical Centers, to all members and employee-dependents enrolled by
the Procuring Entity for a period of one (1) year. The services shall include:
1. MEDICAL SERVICES
As prescribed by the SUPPLIER’s Accredited Physician/Specialist/Coordinator, all medical
services for the diagnosis, treatment and procedures for all types of illnesses, diseases and
accidents related injuries shall be covered up to the Maximum Benefit Limit (MBL), per
illness, per member unless specified under dreaded illnesses, limitations and/or exclusions
under 1.4, 1.5 and 1.6 of this title. Under no circumstances shall the member be required to
pay in advance any cost due and for the account of the SUPPLIER.
1.1
INCLUSIONS:
The medical services shall include, but not necessarily limited to the following:
1.1.1
1.1.2
1.1.3
1.1.4
1.1.5
1.1.6
1.1.7
1.2
Access to hospital facilities including necessary supplies ordinarily provided by
hospitals and clinics.
Administration of Drugs and Medications including supplemental vitamins and
minerals when prescribed during confinement.
Administration of first passive and active dose of anti-rabies, anti-venom and
anti-tetanus.
Processing/Screening and infusion of human blood products.
Professional Medical Services.
Laboratory/Radiology/Diagnostic Procedures including skin tests.
Modern/Complex diagnostic/Rehabilitation and Therapeutic modalities,
examinations/treatment and interventional surgical procedures.
PROCEDURE FOR AVAILMENT:
To avail of the medical services, the members shall, except in emergency cases,
secure the issuance of a Letter of Authorization (LOA) from the following:
1.2.1
1.2.2
1.2.3
1.2.4
1.3
Supplier’s Clinics.
Accredited Clinics.
Accredited Hospitals.
Accredited Coordinators.
MODES OF AVAILMENT:
The medical services can be availed of under any of the modes as follows:
1.3.1
OUT-PATIENT- Availment of all medical services as described above, except
prescribed home-medication, not requiring confinement in a medical facility,
clinic or hospital.
1.3.2
IN-PATIENT- Availment of all medical services which requires confinement in
a medical facility, clinic or hospital.
1.3.3
EMERGENCY CARE- Availment of all medical services in any hospital or
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clinic by a member who is in imminent danger of losing one’s life or any part of
the body or is in severe pain that requires medical attention or relief without
delay subject to the following conditions:
1.3.3.1
Emergency Care in Accredited Hospitals/Clinics.
1.3.3.2
Emergency Care in Non-Accredited Hospitals/Clinics- The
SUPPLIER agrees to reimburse one hundred percent (100%) of
the total hospital bills inclusive of professional fees. Emergency
care may include the confinement of the member until such time
that the member has been issued a clearance for transfer to an
accredited hospital/clinic by the attending physician of the nonaccredited hospital/clinic.
The SUPPLIER shall pay the said amount when it is verified that
the SUPPLIER’s facilities were not used because in doing so it
would entail a delay resulting in death, serious disability or
significant jeopardy to the member’s condition, or the choice of
hospital was beyond the control of the member or the member’s
family.
Follow-up
care/consultations
in
non-accredited
hospitals/clinics shall not be covered.
1.3.3.3
Emergency Care in a Foreign Country- In the event that a
principal member is in need of emergency care in a foreign
territory, the SUPPLIER shall reimburse in Philippine currency
100% of the total hospital bills and professional fees for a
maximum of USD 1,000 or its equivalent, provided the MBL for
such illness has not yet been exceeded.
1.4
DREADED ILLNESSES- Principal members diagnosed with cancer, cardiovascular
diseases and chronic kidney diseases shall be entitled to an additional 20% of
Maximum Benefit Limit per aforementioned illness.
1.5
LIMITATIONS- All medical services shall be subject to the Maximum Benefit Limit
(MBL) provided in the Technical Specifications, except for the following:
1.5.1 Medically prescribed sleep study and sclerotherapy are each covered up to
Twenty Thousand Pesos (PhP20,000.00).
1.5.2 Medically prescribed cauterization of warts are covered up to Fifteen
Thousand Pesos (PhP15,000.00) inclusive of facial warts which is covered up
to Three Thousand Pesos (PhP3,000.00).
1.5.3 Implants, artificial aids, prosthetic devices and corrective appliances including
lens for post cataract extractions (implants for brevity) are each covered up to
Forty Thousand Pesos (PhP40,000.00), provided the illness suffered where
such implants was/were used has not exceeded the MBL. Eyeglasses,
contact lenses, hearing aids, dentures and dental braces are not covered.
1.5.4 Availment of Executive Check Up shall be allowed to any Supplier’s accredited
hospitals and clinics except for the five (5) major hospitals namely: Asian
Hospital, Alabang, Muntinlupa City, Makati Medical Center, Makati City,
Cardinal Santos Medical Center, San Juan City, St. Luke’s Medical Center,
Quezon City and the Medical City, Pasig City.
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1.6
EXCLUSIONS- Medical services availed under any of the circumstances/conditions
as follows:
1.6.1
Use by a member from a non-accredited physician/hospital or other provider of
care except as described in the emergency care in non-accredited hospital or
referred to by an accredited Specialist /Coordinator.
1.6.2
Plastic and reconstructive surgery for cosmetic purposes and for physical
congenital deformities and abnormalities.
1.6.3
Dermatological care for aesthetic purposes such as chemical treatment for
skin tags, xanthelesma, keloids, scars, etc. or any exposed areas of the body.
Surgery for purposes of beautification.
1.6.4
Corrective eye surgery for error of refraction including laser surgery for
correction of myopia and hypermyopia.
1.6.5
Experimental medical procedures
reflexology and chiropractics.
1.6.6
Services to diagnose and/or reverse infertility or fertility and virility
potency (erectile dysfunction).
1.6.7
Medical expenses incurred by donor of organ transplantation.
1.6.8
Diagnostics for hypersensitivity and desensitization treatment EXCEPT for
Allergen test.
1.6.9
Purchase or lease of durable medical equipments, oxygen dispensing
equipment and oxygen except during hospital confinement under the Hospital
Confinement Benefit.
like
accupuncture,
accupressure,
1.6.10 Psychiatric and psychological illnesses including neurotic and psychotic
behavior disorders.
1.6.11 Treatment for any chemical dependencies or deliberate overdose reaction for
the use of drugs.
1.6.12 Hormonal therapy.
1.6.13 Developmental disorders and eating disorders.
1.6.14 Any disease acquired through active sexual lifestyle with multiple partners
such as AIDS (except if secondary to accidental needle injection or blood
transfusion, which is covered up to maximum benefit limit per member),
Hepatitis B (except through other forms of transmission which shall be covered
up to a maximum benefit limit per member), condyloma, gonorrhea, syphilis,
herpes etc. and their attendant complications.
1.6.15 Physical examinations required for obtaining or continuing employment,
insurance or government licensing.
1.6.16 Injuries or illnesses resulting from participation in war-like or combat
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Provision of DFPC Healthcare Services 2015
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operations, riots, insurrection, rebellion, strikes and other civil disturbances.
1.6.17 Treatment of self inflicted injuries or injuries attributable to the member’s own
misconduct, gross negligence, use of alcohol and/or drugs, vicious or immoral
habits, commission of a crime, violation of a law or ordinance, unnecessary
exposure to imminent danger or hazard to health or engagement to extreme
sports.
1.6.18 Custodial, domiciliary care, convalescent and intermediate care.
1.6.19 Temporal mandibular joint disease surgery (TMJ) done by dental practitioner.
1.6.20 Circumcision except for correction of phymosis.
1.6.21 Prescribed take home medicines on an out-patient basis.
1.6.22 Treatment of injuries sustained in an accident if the member or his guardian
fails or refuses to execute the deed of Subrogation (if applicable). The
SUPPLIER shall be subrogated to the right of the member up to the extent of
actual cost incurred by the SUPPLIER in connection with medical services
rendered to such member.
1.6.23 Professional fees in Medico – legal cases.
1.6.24 Laboratory examinations for screening of sexually related illnesses.
1.6.25 All other items not directly related to the medical management of the confined
member such as services of a private nurse or doctor, use of extra bed or
other appliances, and extra food for companion.
2.
MATERNITY ASSISTANCE
2.1
Maternity Assistance shall include the following services:
2.1.1
2.1.2
2.1.3
2.1.4
2.1.5
2.1.6
2.1.7
2.1.8
2.2
Room and Board.
Use of the labor, delivery/operating and recovery rooms.
ICU confinement.
Medical Profession services.
Administration of drugs and medications including human blood products.
All laboratory examinations (including VDRL) except for pregnancy test and
ultrasound to determine gender. Laboratory examination costs are deductible
from the limit set in Item 2.2.
Pediatric Care is covered while mother is still confined in the hospital, also
deductible from the limit as provided below except for illness/complications
suffered by the newly-born. If child is pre-enrolled, medical services required
for such illnesses/complications shall be subject to child’s Maximum Benefit
Limit (MBL).
Prenatal consultations and one (1) postnatal consultation per member (not
deductible from the maternity benefit limit).
Maternity Assistance may be availed of by female principal members or legal spouses
of married male principal members, and subject to the following limits:
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
Page 17 of 44
Type of Delivery
Caesarian Section
30,000.00
Miscarriage
20,000.00
Complications of pregnancy
15,000.00
Threatened Abortion
10,000.00
2.3
Complication of pregnancy shall refer to conditions but not limited to Abruptio
Placenta, Placenta Previa, Post Partum Atony, H-Mole, Hyperemesis Gravidarum,
Ecclampsia, Ectopic Pregnancy.
2.4
Expenses incurred relative to the availment of the maternity assistance under the
following conditions shall be subject to reimbursement based on the HMO Relative
Value and to the maternity assistance limit:
2.4.2
2.4.3
Confinement in a Non-Accredited Hospital and attended to by a NonAccredited Doctor.
Confinement in a Non Accredited Hospital and attended to by an Accredited
Doctor.
Confinement in an Accredited Hospital and attended to by a Non Accredited
Doctor.
DENTAL SERVICES
3.1
The following dental care services may be availed by the members from any of the
SUPPLIER’s all accredited dental clinics but not limited to dental association:
3.1.1
3.1.2
3.1.3
3.1.4
3.1.5
3.1.6
3.1.7
3.1.8
3.1.9
3.1.10
3.1.11
3.1.12
3.2
4.
PhP 40,000.00
Normal Spontaneous Delivery
2.4.1
3.
Maternity Assistance Limit
per member
Consultations and oral examinations.
Twice a year prophylaxis.
Unlimited temporary fillings.
Permanent light cure filling is covered up to five (5) surfaces per member.
Simple tooth extractions only, complicated cases not covered.
Annual scaling and polishing.
Orthodontic and aesthetic consultation and oral examination.
Gum treatment except alveolectomy and gingivectomy.
Adjustment of dentures.
Recementation of loose jackets, crowns, in-lays and on-lays.
Treatment of mouth lesions wounds and burns.
Emergency desensitization of hypersensitive teeth.
Retainer dentist to be stationed at Procuring Entity’s Head Office Clinic three times
(3x) a week at four hours per visit.
ANNUAL PHYSICAL EXAMINATION (APE)
4.1
Annual Physical Examination (APE) shall be provided to the principal members (Rank
& File and Supervisors) only by the SUPPLIER’s designated Medical Service Units
which shall include the following:
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Provision of DFPC Healthcare Services 2015
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4.1.1
4.1.2
4.1.3
4.1.4
4.1.5
4.1.6
4.1.7
4.1.8
4.1.9
4.1.10
4.2
5.
Taking of medical history.
Physical Examination.
Complete Blood Count.
Urinalysis (urine examination).
Fecalysis (stool examination).
Chest X-ray.
Electrocardiogram (for members age 35 and above, or if indicated).
Pap’s Smear (for women age 35 and above, or if indicated).
Eye refraction.
Management of Health Problems.
Upon payment of the 2nd quarter premium, APE shall be conducted at the
SUPPLIER’s Head Office Clinic or at the PROCURING ENTITY’s premises through
the SUPPLIER Mobile Medical Team, to be scheduled for a minimum of fifty (50)
principal members.
ANNUAL EXECUTIVE CHECK-UP (ECU)
5.1
Executive Check-up (ECU) to be provided to forty five (45) principal members,
Manager category at the clinics/hospitals except in the five (5) major hospitals,
namely, ASIAN Hospital and Medical Center, St. Luke’s Medical Center-Quezon City
The Medical City General Hospital, Cardinal Santos and Makati Medical Center. It
shall include the following procedures:
5.1.1
5.1.2
5.1.3
Comprehensive Physical Examination.
Complete Blood Count.
Blood Chemistry (FBS, BUN, BUA, Creatinine, Cholesterol, Sodium,
Potassium, Total Protein, Albumin, Calcium, Alkaline, Phosphatase, Total
Bilirubin, SGOT, SGPT, HDL/LDL, Triglycerides, PSA).
5.1.4 Urinalysis.
5.1.5 Fecalysis, w/ Occult Blood.
5.1.6 Chest X-ray.
5.1.7 Electrocardiogram.
5.1.8 Spirometry.
5.1.9 Pap’s Smear and Mammography for female.
5.1.10 Whole abdomen ultrasound, to include pelvis for female & prostate for male.
5.1.11 Treadmill Stress Test.
6.
5.2
SUPPLIER shall arrange the ECU with accredited clinics/hospitals except for the five
(5) major hospitals as provided above (1.5.4) for the following locations: Manila,
Quezon City, Paranaque, Mandaluyong, Pasig, Makati, Alabang and provincial areas.
Procuring Entity may schedule the ECU immediately upon payment of the 2nd quarter
premium.
5.3
Should there be more than forty five (45) principal members who will avail of the ECU,
SUPPLIER shall assist PROCURING ENTITY in the scheduling of the ECU at the
prescribed clinics upon request, however, actual expenses shall be charged directly to
the Procuring Entity.
OTHER SERVICES
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
Page 19 of 44
6.1
Provide Preventive Health Care services to all members:
6.1.1
Counseling on health habits, diet and Family Planning.
6.1.2
Wellness Program (6 times a year).
6.2
Ambulance services shall be covered on a reimbursement basis up to Five Thousand
Pesos (PhP5,000.00) per conduction from location to hospital including transfer of
patient to another hospital as per medical advice.
6.3
Secure GROUP LIFE INSURANCE for all members with benefits as follows
Schedule of Insurance Benefits
Principal Members
Death
Immediate
Dependents
PhP 50,000.00
PhP 50,000.00
Loss of both hands
20,000.00
20,000.00
Loss of both feet
20,000.00
20,000.00
Loss of sight (both eyes)
20,000.00
20,000.00
Loss of one hand & one foot
20,000.00
20,000.00
Loss of one hand & sight of one eye
20,000.00
20,000.00
Loss of one foot & sight of one eye
20,000.00
20,000.00
Loss of one hand or one foot
10,000.00
10,000.00
Loss of sight of one eye
10,000.00
10,000.00
The claim must be filed within sixty (60) days from the occurrence of death or
dismemberment.
For this purpose, the member should designate his/her beneficiary in the enrollment
form (to be provided by the Supplier) at the commencement of the contract. Should
his/her beneficiary be a minor, a trustee should be named in the same enrolment form.
Payment of claims shall be made within fifteen (15) days from receipt of complete
requirements.
Payment made by SUPPLIER under this section shall not be considered as availed
medical services, thus, not form part of the utilization.
The member will not be entitled to the insurance benefit if the cause of death is
among those listed in the exclusions under item 1.6.
II. MANPOWER
1.
The SUPPLIER agrees to provide the following personnel to be stationed at
PROCURING ENTITY’s Head Office Clinic in Parañaque City:
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Provision of DFPC Healthcare Services 2015
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Position
Qty
Schedule
Dentist
1
Four (4) hours a day, three times (3x) a week.
Nurse
1
Eight (8) hours a day, five times (5x) a week.
Doctor
1
Eight (8) hours a day, five times (5x) a week.
1.1
The assigned/stationed doctor shall provide his/her own medical equipment and
be authorized by the SUPPLIER to issue the necessary Letter of Authority (LOA)
for members’ availment of out-patient medical services under the following
circumstances:
1.1.1 Referral to accredited specialist.
1.1.2 Request for laboratory/diagnostic procedures required by a duly
accredited specialist. Copy of the request shall be attached to the
LOA.
1.1.3 Request for laboratory/diagnostic procedures as recommended in
the results of the annual medical check-up of the member.
1.1.4 Request for laboratory/diagnostic procedures required for his/her
assessment of the member-patient.
1.2
The assigned/stationed nurse shall also be authorized to issue LOA but shall be
limited to referrals to specialist/s and requests for laboratory/diagnostic
procedures, examination by an accredited physician.
1.3
The assigned/stationed dentist shall provide his/her own dental equipment and
materials.
2. The SUPPLIER shall designate an Account Officer who shall be responsible for answering
queries, problems etc., concerning HMO matters. Attend to reimbursement of employees’
hospital bills and other charges but not necessarily stationed at DFP Medical Clinic.
III. ACCREDITED MEDICAL INSTITUTIONS AND PHYSICIANS
1.
The SUPPLIER shall maintain its accreditation with Metro Manila Hospitals, including
but not necessarily limited to the following hospitals/clinics as enumerated below:
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
ASIAN Hospital and Medical Center
Capitol Medical Center
Cardinal Santos
Delos Santos Medical Center
Dr. Victor R. Potenciano Medical Center - Edsa, Mandaluyong
Makati Medical Center
Manila Doctor’s Hospital – U.N. Avenue, Manila
The Medical City General Hospital
Metropolitan Hospital – Masangkay, Manila
MPI – Medical Center Muntinlupa – Putatan, Muntinlupa
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Provision of DFPC Healthcare Services 2015
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1.11
1.12
1.13
1.14
1.15
1.16
1.17
1.18
1.19
Olivarez General Hospital, Inc., - Paranaque City
Our Lady of Lourdes Hospital – Sta. Mesa, Manila
Perpetual Help Medical Center-Las Pinas City
St. Luke’s Medical Center – Quezon City
Sto. Tomas University Hospital
San Juan de Dios Hospital & Medical Center – Roxas Blvd, Pasay City
National Kidney institute – East Ave., Quezon City
Philippine Heart Center – East Ave., Quezon City
Philippine General Hospital – Pedro Gil, Manila
Note: St. Luke’s Global not included
2.
The SUPPLIER shall maintain its accreditation with at least one (1) hospital per
Provincial Store Location; except for Cebu Store where the SUPPLIER shall
maintain its accreditation with at least two (2) hospitals from the list below:
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
2.13
2.14
2.15
2.16
2.17
2.18
2.19
2.20
2.21
2.22
2.23
Angeles University Foundation Hospital & Medical Center – Angeles City,
Pampanga
Mother Theresa of Calcutta Medical Center – San Fernando, Pampanga
V.L. Makabali Mem. Hospital – San Fernando, Pampanga
Cebu Doctor’s Hospital – Osmeña Blvd., Cebu City
Chong Hua Hospital – Fuente Osmeña Ave., Cebu City
Perpetual Succour Hospital – Gorordo Ave., Cebu City
Davao Doctor’s Hospital – Davao City
San Pedro Hospital – Davao City
Ricardo Limso Med. Cntr. – V. Ilustre St., Davao City
De La Salle Medical Center – Dasmariñas, Cavite
Our Lady of the Pillar or Imus Medical Center – Imus, Cavite
Divine Grace Med. Cntr. – Gen. Trias, Cavite
Perpetual Help Medical Center – Binan, Laguna
Los Baños Doctors Hospital – Los Baños, Laguna
MMG-PPC Cooperative Hospital – Burgos cor. Madrid Sts. Puerto Princesa
City
Palawan Adventist Hospital – San Pedro, Puerto Princesa City
RTN Foundation Inc. – Bataraza, Palawan
AGO General Hospital – Rizal St., Legazpi City, Albay
Aquinas University Hospital – Legazpi City, Albay
Albay Doctors Hospital - Peñaranda St., Legazpi City
Aklan Cooperative Mission Hospital – Roxas Ave. Ext., Andagao, Kalibo,
Aklan
Aklan Med. Cntr. – Estancia, Kalibo, Aklan
Iloilo Doctor’s Hospital – West Ave., Molo, Iloilo City
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Provision of DFPC Healthcare Services 2015
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2.24
2.25
2.26
2.27
2.28
2.29
2.30
2.31
2.32
2.33
2.34
2.35
2.36
2.37
2.38
2.39
2.40
3.
Iloilo Mission Hospital – Mission Road, Jaro, Iloilo City
St. Paul’s Hospital Iloilo, Inc. – Gen. Luna St., Iloilo City
The Medical City – Brgy. Tap-Oc, Molo, Iloilo City
Ranada Gen. Hosp Brgy. 9 Balintawak St., Laoag City
Baquiran Hospital – Samonte St., Laoag City
Cagayan de Oro Medical Center, CDO City
Polymedic Hosp. Don Apolinario Velez St., CDO City
Madonan and Child Hospital – J. Serina St., Carmen, CDO City
St. Paul Hospital Hosp Inc., Bocaue, Bulacan
Our Lady of Mercy General Hosp. Inc. – Pulilan, Bulacan
Manila East Medical Center, Taytay, Rizal
Antipolo Doctors Hospital – Antipolo
Bio-Clinica Labortory - Silay, Bacolod City
Therapea Medica Laboratorico – Burgos St. Bacolod City
Bacolod Adventist Medical Center – Tacuiling, Bacolod City
Bacolod Our Lady of Mercy Specialty Hospital – Mandalagan, Bacolod City
The Doctors Hospital – Benigno Aquino Drive, Bgy Villamonte, Bacolod City
For the whole duration of the Contract, the SUPPLIER must maintain accreditation of at
least twelve (12) different types of specialists for in-patient and out-patient per hospital
located in Metro Manila, Cebu and Davao as enumerated under items 1 and 2. The types
of specialists may include, but not necessarily limited to the following:
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
3.11
3.12
3.13
3.14
3.15

Cardiologist/Intensivist
Endocrinologist/Diabetologist
ENT
Gastro Enterologist
OB Gynecologist
Anesthesiologist
Surgeon
Pediatrician
Oncologist
Ophthalmologist
Pulmonologist
Hematologist
Nephrologist
Orthopedic – Rehab Medicine
Urologist
National Kidney Institute and Philippine Heart Center need not comply with
the “twelve (12)-specialist requirement”.
_____________________________
Signature over printed name
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
_____________________________
Position
Page 23 of 44
Duly authorized to sign this compliance to the Schedule of Requirements for and on behalf of
________________________.
VII. TECHNICAL SPECIFICATIONS
Bidders must state here either “Comply” or “Not Comply” against each of the individual parameters of each
Specification stating the corresponding performance parameter of the equipment offered. Statements of
“Comply” or “Not Comply” must be supported by evidence in a Bidders Bid and cross-referenced to that
evidence. Evidence shall be in the form of manufacturer’s un-amended sales literature, unconditional
statements of specification and compliance issued by the manufacturer, samples, independent test data etc.,
as appropriate. A statement that is not supported by evidence or is subsequently found to be contradicted by
the evidence presented will render the Bid under evaluation liable for rejection. A statement either in the
Bidders statement of compliance or the supporting evidence that is found to be false either during Bid
evaluation, post-qualification or the execution of the Contract may be regarded as fraudulent and render the
Bidder or supplier liable for prosecution subject to the provisions of ITB Clause 3.1 (a.2) and/or GCC Clause
2.1 (a.2).
STATEMENT OF
COMPLIANCE
Minimum Specification
I.
MATRIX OF MEMBERS
MEMBER
CLASSIFICATION
A. COO
Age Bracket : 00-25
26-39
40-59
60-65
Subtotal
B. Manager
Age Bracket : 00-25
26-39
40-59
60-65
Subtotal
C. Supervisor
Age Bracket : 00-25
26-39
40-59
60-65
Subtotal
D. Rank & File
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
MEMBER
PRINCIPAL
DEPENDENTS
MALE 0 FEMAL
E
0
1
1
0
1
1
1
1
859
MALE
FEMALE
1
1
2
18
5
25
0
32
7
39
27
1
15
3
46
28
5
13
4
50
4
23
83
2
112
1
25
105
7
138
114
14
48
14
190
112
15
71
10
208
Page 24 of 44
STATEMENT OF
COMPLIANCE
Minimum Specification
Age Bracket : 00-25
26-39
40-59
60-65
Subtotal
4
57
279
11
351
7
55
140
6
208
288
29
80
25
422
228
40
226
19
513
TOTAL ENROLLEES
489
385
658
772
GRAND TOTAL
874
1430
Note: Figures stated above are subject to change.
1.
MEMBERSHIP:
1.1
II.
PRINCIPAL MEMBER
Permanent or regular employees of the Procuring Entity, 18
to 65 years old with the following classifications:
Chief Operating Officer
Managers
Supervisors
Rank and File
1.2 IMMEDIATE DEPENDENT OF MARRIED PRINCIPAL
MEMBER
1.2.2
The legal spouse up to 65 years old.
1.2.3
Newly born children up to 25 years old, unemployed
and unmarried.
1.3 IMMEDIATE DEPENDENT OF SINGLE PRINCIPAL
MEMBERS
1.3.1
Parents up to 65 years old.
1.3.2
Siblings (Full) 15 days to 25 years old, unemployed
and unmarried.
1.4 IMMEDIATE DEPENDENT OF SINGLE PARENT
PRINCIPAL MEMBERS
1.4.1
Newly born children up to 25 years old,
unemployed and unmarried.
1.4.2
Parents up to 65 years old.
ROOM AND BOARD AND MAXIMUM BENEFIT LIMIT
MEMBER
CLASSIFICATION
ROOM AND
BOARD
MAXIMUM BENEFIT LIMIT
PER YEAR
PRINCIPAL
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
DEPENDENTS
Page 25 of 44
STATEMENT OF
COMPLIANCE
Minimum Specification
LARGE PRIVATE
COO
MANAGERS
SUPERVISORS
RANK AND FILE
Note:
1,000,000.00
160,000.00
220,000.00
190,000.00
170,000.00
160,000.00
130,000.00
110,000.00
LARGE PRIVATE
REGULAR PRIVATE
REGULAR PRIVATE
See SCC 6.2 Clause V. Room and Board
Member is given an option to downgrade his/her room
accommodation with the abovementioned classification as the
highest.
Additional Documentary Requirements to be submitted on the date of Opening of Bids:
1. Valid and current certificate of clearance to operate as HMO from the Bureau of Health
Facilities and Services of the Department of Health (DOH) or Certificate of Authority
issued by the Insurance Commission (IC).
2. Latest and updated list of accredited hospitals and clinics in Metro Manila Hospitals,
including but not necessarily limited to the following hospitals/clinics as enumerated below
(hard copy and soft copy)
Metro Manila Hospitals
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
2.11
2.12
2.13
2.14
2.15
2.16
2.17
2.18
2.19
2.20
ASIAN Hospital and Medical Center
Capitol Medical Center
Cardinal Santos
Chinese General Hospital
Delos Santos Medical Center
Dr. Victor R. Potenciano Medical Center - Edsa, Mandaluyong
Makati Medical Center
Manila Doctor’s Hospital – U.N. Avenue, Manila
The Medical City General Hospital
Metropolitan Hospital – Masangkay, Manila
MPI – Medical Center Muntinlupa – Putatan, Muntinlupa
Olivarez General Hospital, Inc., - Paranaque City
Our Lady of Lourdes Hospital – Sta. Mesa, Manila
Perpetual Help Medical Center-Las Pinas City
St. Luke’s Medical Center – Quezon City
Sto. Tomas University Hospital
San Juan de Dios Hospital & Medical Center – Roxas Blvd, Pasay City
National Kidney institute – East Ave., Quezon City
Philippine Heart Center – East Ave., Quezon City
Philippine General Hospital, Pedro Gil, Manila
 Note: St Luke’s Global City, Taguig City, is not included in the list of accredited hospital
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
Page 26 of 44
Provincial Hospitals (at least one (1) hospital per Provincial Store Location; except for
Cebu Store where the SUPPLIER shall maintain accreditation with
at least two (2) hospitals.
2.1
Angeles University Foundation Hospital & Medical Center – Angeles City,
Pampanga
2.2
Mother Theresa of Calcutta Medical Center – San Fernando, Pampanga
2.3
V.L. Makabali Mem. Hospital – San Fernando, Pampanga
2.4
Cebu Doctor’s Hospital – Osmeña Blvd., Cebu City
2.5
Chong Hua Hospital – Fuente Osmeña Ave., Cebu City
2.6
Perpetual Succour Hospital – Gorordo Ave., Cebu City
2.7
Davao Doctor’s Hospital – Davao City
2.8
San Pedro Hospital – Davao City
2.9
Ricardo Limso Med. Cntr. – V. Ilustre St., Davao City
2.10 De La Salle Medical Center – Dasmariñas, Cavite
2.11 Our Lady of the Pillar or Imus Medical Center – Imus, Cavite
2.12 Divine Grace Med. Cntr. – Gen. Trias, Cavite
2.13 Perpetual Help Medical Center – Binan, Laguna
2.14 Los Baños Doctors Hospital – Los Baños, Laguna
2.15 MMG-PPC Cooperative Hospital – Burgos cor. Madrid Sts. Puerto Princesa City
2.16 Palawan Adventist Hospital – San Pedro, Puerto Princesa City
2.17 RTN Foundation Inc. – Bataraza, Palawan
2.18 AGO General Hospital – Rizal St., Legazpi City, Albay
2.19 Aquinas University Hospital – Legazpi City, Albay
2.20 Albay Doctors Hospital - Peñaranda St., Legazpi City
2.21 Aklan Cooperative Mission Hospital – Roxas Ave. Ext., Andagao, Kalibo, Aklan
2.22 Aklan Med. Cntr. – Estancia, Kalibo, Aklan
2.23 Iloilo Doctor’s Hospital – West Ave., Molo, Iloilo City
2.24 Iloilo Mission Hospital – Mission Road, Jaro, Iloilo City
2.25 St. Paul’s Hospital Iloilo, Inc. – Gen. Luna St., Iloilo City
2.26 The Medical City – Brgy. Tap-Oc, Molo, Iloilo City
2.27 Ranada Gen. Hosp Brgy. 9 Balintawak St., Laoag City
2.28 Baquiran Hospital – Samonte St., Laoag City
2.29 Cagayan de Oro Medical Center, CDO City
2.30 Polymedic Hosp. Don Apolinario Velez St., CDO City
2.31 Madonan and Child Hospital – J. Serina St., Carmen, CDO City
2.32 St. Paul Hospital Hosp Inc., Bocaue, Bulacan
2.33 Our Lady of Mercy General Hosp. Inc. – Pulilan, Bulacan
2.34 Manila East Medical Center, Taytay, Rizal
2.35 Antipolo Doctors Hospital – Antipolo
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Provision of DFPC Healthcare Services 2015
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2.36
2.37
2.38
2.39
2.40
Bio-Clinica Labortory - Silay, Bacolod City
Therapea Medica Laboratorico – Burgos St. Bacolod City
Bacolod Adventist Medical Center – Tacuiling, Bacolod City
Bacolod Our Lady of Mercy Specialty Hospital – Mandalagan, Bacolod City
The Doctors Hospital – Benigno Aquino Drive, Bgy Villamonte, Bacolod City
3. Certificate of Good Standing from at least ten (10) of the following Metro Manila
hospitals and one (1) per provincial location hospitals (Cavite, Laguna, Rizal,
Pampanga, Legazpi City, Cebu City, Davao City, Laoag, Kalibo, Cagayan de Oro, Iloilo,
Bacolod City and Puerto Princesa):
4. Latest and updated list of accredited specialists for in-patient and out-patient of at least
twelve (12) different types of specialists per hospital located in Metro Manila, Cebu and
Davao as enumerated under item 2. The types of specialists may include, but not necessarily
limited to the following:
a. Cardiologist/Intensivist
b. Endocrinologist/Diabetologist
c. ENT
d. Gastro Enterologist
e. OB Gynecologist
f. Anesthesiologist
g. Surgeon
h. Pediatrician
i. Oncologist
j. Ophthalmologist
k. Pulmonologist
l. Hematologist
m. Nephrologist
n. Orthopedic – Rehab Medicine
o. Urologist
 National Kidney Institute and Philippine Heart Center need not comply with the
“twelve (12)-specialist requirement”.
5. Latest and updated list (hard and soft copy) of at least one hundred thirty (130)
accredited dentists in Metro Manila and at least two hundred (200) in the following areas
in Cebu City, Davao City, Legazpi City, Kalibo, Iloilo, Laoag, Cagayan de Oro, Puerto
Princesa, Bacolod City and Pampanga.
________________________________
Signature over printed name
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
_____________________________
Position
Page 28 of 44
Duly authorized to sign this compliance to the Technical Specifications for and on behalf of
________________________.
Bidding Form No. 1
FINANCIAL DOCUMENTS FOR ELIGIBILITY CHECK
Year 20___
1
Total Assets
2
Current Assets
3
Total Liabilities
4
Current Liabilities
5
Net Worth (1-3)
6
Net Working Capital (2-4)
The Net Financial Contracting Capacity (NFCC) based on the above data is computed as
follows:
NFCC = K (current asset – current liabilities) minus value of all outstanding works under
ongoing contracts including awarded contracts yet to be started
NFCC = P ____________________________________
K = 10 (for a contract of one year or less)
K = 15 (for a contract of more than one year up to two years)
K = 20 (for a contract more than two years)
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
Page 29 of 44
Submitted by:
_____________________________________________
Name of Bidder
_____________________________________________
Signature of Authorized Representative over Printed Name
Date: __________________________
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
Page 30 of 44
Bidding Form No. 2
Page 1 of 2
REPUBLIC OF THE PHILIPPINES )
CITY OF _______________________ ) S.S.
x-------------------------------------------------------x
BID-SECURING DECLARATION
Invitation to Bid/Request for Expression of Interest No.1: [Insert reference number]
To:
Duty Free Philippines Corporation
Fiestamall, Columbia Complex,
Ninoy Aquino Avenue, Parañaque City
I/We, the undersigned, declare that:
1. I/We understand that, according to your conditions, bids must be supported by a Bid
Security, which may be in the form of a Bid-Securing Declaration.
2. I/We accept that: (a) I/we will be automatically disqualified from bidding for any contract
with any procuring entity for a period of two (2) years upon receipt of your Blacklisting
Order; and, (b) I/we will pay the applicable fine provided under Section 6 of the
Guidelines on the Use of Bid Securing Declaration3, if I/we have committed any of the
following actions:
(i) Withdrawn my/our Bid during the period of bid validity required in the Bidding
Documents; or
(ii) Fail or refuse to accept the award and enter into contract or perform any and
all acts necessary to the execution of the Contract, in accordance with the
Bidding Documents after having been notified of your acceptance of our Bid
during the period of bid validity.
3. I/We understand that this Bid-Securing Declaration shall cease to be valid on the
following circumstances:
(a) Upon expiration of the bid validity period, or any extension thereof pursuant to
your request;
(b) I am/we are declared ineligible or post-disqualified upon receipt of your notice to
such effect, and (i) I/we failed to timely file a request for reconsideration or (ii)
I/we filed a waiver to avail of said right;
(c) I am/we are declared as the bidder with the Lowest Calculated and Responsive
Bid/Highest Rated and Responsive Bid4, and I/we have furnished the
performance security and signed the Contract.
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
Page 31 of 44
Bidding Form No. 2
Page 1 of 2
IN WITNESS WHEREOF, I/We have hereunto set my/our hand/s this ____ day
of [month] [year] at [place of execution].
[Insert NAME OF BIDDER’S
AUTHORIZED REPRESENTATIVE]
[Insert signatory’s legal capacity]
Affiant
SUBSCRIBED AND SWORN to before me this __ day of [month] [year] at [place
of execution], Philippines. Affiant/s is/are personally known to me and was/were identified
by me through competent evidence of identity as defined in the 2004 Rules on Notarial
Practice (A.M. No. 02-8-13-SC). Affiant/s exhibited to me his/her [insert type of government
identification card used], with his/her photograph and signature appearing thereon, with no.
______ and his/her Identification Card No. _______ issued on ______ at ______.
Witness my hand and seal this ___ day of [month] [year].
NAME OF NOTARY PUBLIC
Serial No. of Commission ___________
Notary Public for ______ until _______
Roll of Attorneys No. _____
PTR No. __, [date issued], [place issued]
IBP No. __, [date issued], [place issued]
Doc. No. ___
Page No. ___
Book No. ___
Series of ____.
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
Page 32 of 44
Bidding Form No. 3
Page 1 of 2
Omnibus Sworn Statement
REPUBLIC OF THE PHILIPPINES )
CITY/MUNICIPALITY OF ______
) S.S.
AFFID AVIT
I, [Name of Affiant], of legal age, [Civil Status], [Nationality], and residing at [Address of
Affiant], after having been duly sworn in accordance with law, do hereby depose and state that:
1. Select one, delete the other:
If a sole proprietorship: I am the sole proprietor of [Name of Bidder] with office address
at [address of Bidder];
If a partnership, corporation, cooperative, or joint venture: I am the duly authorized and
designated representative of [Name of Bidder] with office address at [address of Bidder];
2. Select one, delete the other:
If a sole proprietorship: As the owner and sole proprietor of [Name of Bidder], I have full
power and authority to do, execute and perform any and all acts necessary to represent
it in the bidding for [Name of the Project] of Duty Free Philippines Corporation;
If a partnership, corporation, cooperative, or joint venture: I am granted full power and
authority to do, execute and perform any and all acts necessary and/or to represent the
[Name of Bidder] in the bidding as shown in the attached [state title of attached
document showing proof of authorization (e.g., duly notarized Secretary’s Certificate
issued by the corporation or the members of the joint venture)];
3. [Name of Bidder]is not “blacklisted” or barred from bidding by the Government of the
Philippines or any of its agencies, offices, corporations, or Local Government Units,
foreign government/foreign or international financing institution whose blacklisting rules
have been recognized by the Government Procurement Policy Board;
4. Each of the documents submitted in satisfaction of the bidding requirements is an
authentic copy of the original, complete, and all statements and information provided
therein are true and correct;
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
Page 33 of 44
5. [Name of Bidder]I is authorizing the Head of the Procuring Entity or its duly authorized
representative(s) to verify all the documents submitted;
6. Select one, delete the rest:
If a sole proprietorship: I am not related to the Head of the Procuring Entity, members of
the Bids and Awards Committee (BAC), the Technical Working Group, and the BAC
Secretariat, the head of the Project Management Office or the end-user unit, and the
project consultants by consanguinity or affinity up to the third civil degree;
If a partnership or cooperative: None of the officers and members of [Name of Bidder] is
related to the Head of the Procuring Entity, members of the Bids and Awards Committee
(BAC), the Technical Working Group, and the BAC Secretariat, the head of the Project
Management Office or the end-user unit, and the project consultants by consanguinity or
affinity up to the third civil degree;
Bidding Form No. 3
Page 2 of 2
If a corporation or joint venture: None of the officers, directors, and controlling
stockholders of [Name of Bidder] is related to the Head of the Procuring Entity, members
of the Bids and Awards Committee (BAC), the Technical Working Group, and the BAC
Secretariat, the head of the Project Management Office or the end-user unit, and the
project consultants by consanguinity or affinity up to the third civil degree;
7. [Name of Bidder] complies with existing labor laws and standards; and
8. [Name of Bidder] is aware of and has undertaken the following responsibilities as a
Bidder:
a) Carefully examine all of the Bidding Documents;
b) Acknowledge all conditions, local or otherwise, affecting the implementation of the
Contract;
c) Made an estimate of the facilities available and needed for the contract to be bid, if
any;
d) Inquire or secure Supplemental/Bid Bulletin(s) issued for the [Name of the Project];
and
e) Responsible for any erroneous interpretation or conclusion out of the data
furnished by the PROCURING ENTITY.
9. [Name of Bidder] did not give or pay directly or indirectly, any commission, amount, fee, or
any form of consideration, pecuniary or otherwise, to any person or official, personnel or
representative of the government in relation to any procurement project or activity.
IN WITNESS WHEREOF, I have hereunto set my hand this __ day of ___, 20__ at
____________, Philippines.
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
Page 34 of 44
_____________________________________
Bidder’s Representative/Authorized Signatory
SUBSCRIBED AND SWORN to before me this _____ day of _______________ 20___,
in ________________, by herein affiant, who has satisfactorily proven to me his/her identity thru
his/her ______________________________ Identification Card No. ____________________,
that he/she is the same person who signed the foregoing instrument before me and
acknowledged that he/she executed the same.
_______________________
(Notary Public)
Doc. No. _______
Page No. _______
Book No. _______
Series of _______
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
Page 35 of 44
Bidding Form No. 4
BID FORM
Date:
To:
Ma. Lourdes D. Velarde
Duty Free Philippines Corporation
Fiestamall, Columbia Complex,
Ninoy Aquino Avenue, Parañaque City
Gentlemen and/or Ladies:
Having examined the Bidding Documents including Bid Bulletin Numbers [insert
numbers], the receipt of which is hereby duly acknowledged, we, the undersigned, offer to
perform Provision of DFPC Healthcare Services 2015 in conformity with the said Bidding
Documents for the sum of [total bid amount in words and figures] or such other sums as may
be ascertained in accordance with the Schedule of Prices attached herewith and made part of
this Bid.
We undertake, if our Bid is accepted, to deliver the goods in accordance with the delivery
schedule specified in the Schedule of Requirements.
If our Bid is accepted, we undertake to provide a performance security in the form,
amounts, and within the times specified in the Bidding Documents.
We agree to abide by this Bid for the Bid Validity Period specified in BDS provision for ITB
Clause 18.2 and it shall remain binding upon us and may be accepted at any time before the
expiration of that period.
Until a formal Contract is prepared and executed, this Bid, together with your written
acceptance thereof and your Notice of Award, shall be binding upon us.
We understand that you are not bound to accept the lowest or any Bid you may receive.
We certify/confirm that we comply with the eligibility requirements as per ITB Clause 5 of
the Bidding Documents.
Dated this ________________ day of ________________ 20__.
Signature over printed name
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
Position
Page 36 of 44
Duly authorized to sign Bid for and on behalf of
____________________________Bidding Form No. 5
PRICE SCHEDULE
Name of Bidder ____________________________
1
Description
2
3
Quantity
Unit Price
Per
Quarter
PRINCIPAL MEMBERS
A. General Manager (DOT)
Age Bracket
00 – 65
00 – 65
64
C. Supervisors
Age Bracket
00 – 65
250
D. Rank and File
Age Bracket
00 – 65
559
874
DEPENDENTS
A. Chief Operating Officer (DOT)
Age Bracket
00 – 65
6
Applicable
Tax
Total Cost Per
Quarter
(Cols. 5 x 2)
Total Bid per Quarter (Principal Members)
1
B. Managers
Age Bracket
00 – 65
96
C. Supervisors
Age Bracket
00 – 65
398
D. Rank and File
Age Bracket
00 – 65
935
TOTAL
5
Total Unit Price
Per Quarter
(Col. 3 + 4)
1
B. Managers
Age Bracket
TOTAL
4
1,430
Total Bid per Quarter (Dependents)
TOTAL BID PER QUARTER
(Principal + Dependents)
GRAND TOTAL (Total Bid per Quarter x 4)
_____________________________________
_____________________________
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
Page 37 of 44
Signature over printed name
Position
Duly authorized to sign this Price Schedule for and on behalf of ___________________
Date: ___________________________
Bidding Form No. 6
PROPOSED RATES FOR
EMPLOYEE PAID DEPENDENTS
Name of Bidder _________________
For Employee-Paid Dependents
1
2
Description
Quantity
IMMEDIATE DEPENDENTS
A. Managers
Age Bracket
00 – 65
1
B. Supervisors
Age Bracket
00 – 65
1
C. Rank and File
Age Bracket
00 – 65
1
3
Unit Price
Per
Quarter
4
5
Applicable
Tax
Total Price
(Cols. 3 + 4)
6
Total Annual
Price
(Col. 5 x 4)
Proposed rates for immediate dependents shall follow the same rate as indicated in the submitted Price
Schedule of the SUPPLIER’s Financial Proposal
1
2
Description
Quantity
EXTENDED DEPENDENTS
A. Managers
Age Bracket
00 – 65
1
B. Supervisors
Age Bracket
1
00 – 65
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
3
Unit Price
Per
Quarter
4
5
Applicable
Tax
Total Price
(Cols. 3 + 4)
6
Total Annual
Price
(Col. 5 x 4)
Page 38 of 44
C. Rank and File
Age Bracket
00 – 65
1
________________________________
________________________________
Signature over printed name
Position
Duly authorized to sign this Proposed Rates for Employee Paid Dependents for and on behalf of
__________________________
Bidding Form No. 7
CONTRACT AGREEMENT FORM
THIS AGREEMENT made the _____ day of __________ 20_____ between Duty Free
Philippines Corporation (hereinafter called “the Entity”) of the one part and [name of Supplier]
of [city and country of Supplier] (hereinafter called “the Supplier”) of the other part:
WHEREAS the Entity invited Bids for certain goods and ancillary services, viz., [brief description
of goods and services] and has accepted a Bid by the Supplier for the supply of those goods
and services in the sum of [contract price in words and figures] (hereinafter called “the Contract
Price”).
NOW THIS AGREEMENT WITNESSETH AS FOLLOWS:
1. In this Agreement words and expressions shall have the same meanings as are respectively
assigned to them in the Conditions of Contract referred to.
2. The following documents shall be deemed to form and be read and construed as part of this
Agreement, viz.:
(a)
(b)
(c)
(d)
(e)
(f)
the Bid Form and the Price Schedule submitted by the Bidder;
the Schedule of Requirements;
the Technical Specifications;
the General Conditions of Contract;
the Special Conditions of Contract; and
the Entity’s Notification of Award.
3. In consideration of the payments to be made by the Entity to the Supplier as hereinafter
mentioned, the Supplier hereby covenants with the Entity to provide the goods and services
and to remedy defects therein in conformity in all respects with the provisions of the Contract
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
Page 39 of 44
4. The Entity hereby covenants to pay the Supplier in consideration of the provision of the
goods and services and the remedying of defects therein, the Contract Price or such other
sum as may become payable under the provisions of the contract at the time and in the
manner prescribed by the contract.
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed in
accordance with the laws of the Republic of the Philippines on the day and year first above
written.
Signed, sealed, delivered by
(for the Entity)
the
Signed, sealed, delivered by
(for the Supplier)
the
[ACKNOWLEDGEMENT]
Bidding Form No. 8
Motion for Reconsideration
Date of Issuance
Ma. Lourdes D. Velarde
Duty Free Philippines Corporation
Fiestamall, Columbia Complex,
Ninoy Aquino Avenue, Parañaque City
Dear Madame:
In relation to the results of the Bid Opening/Post-Qualification conducted for the bidding of the
(Name of Project) held on
(date and time) at
(venue)
, we would like
to request for reconsideration the decision of “Ineligibility” of our of our firm on the following
grounds:
We are hoping for your consideration.
Very truly yours,
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
Page 40 of 44
Name of the Representative of the Bidder
Position of the Representative
Name of the Bidder
Received by the BAC:
__________________________
Date:______________________
Annex A
DUTY FREE PHILIPPINES CORPORATION
MONTHLY UTILIZATION REPORT SAMPLE (PER AVAILMENT/MEMBER)
AS REPORTED BY MEDICAL INSTITUTIONS/PROFESSIONALS
PRINCIPAL
HOSPITAL & P
ID NUMBER
MEMBER’S
NAME
AGE
REF
NO.
DATE
CHECK IN
DATE
CHECK OUT
TYPE OF
AVAILMENT
NAME OF
PROVIDER
0000000001
Dela Cruz, Juan
60
001
1/27/2014
1/27/2014
EMERGENCY
SAN JUAN
0000000002
Cruz, Nena
36
002
1/27/2014
1/27/2014
OUTPATIENT
OLIVAREZ
0000000003
TAN, ANA
35
003
1/27/2014
1/30/2014
MATERNITY
MATUTE
0000000001
Dela Cruz, Juan
60
004
1/29/2014
1/31/2014
INPATIENT
SAN JUAN
CLASSIFICA
TION OF
THE
PROVIDER
HOSPITAL
L3
HOSPITAL
L1
HOSPITAL
HOSPITAL
L3
DIAGNOSIS
HYPERTENSION
ASTHMA
SINGLE
DELIVERY
HYPERTENSION
ROOM AND
BOARD
MEDICINES
& MEDICAL
SUPPLIES
2,000.00
3,000.00
0.00
1,500.00
6,000.00
20,000.00
4,000.00
4,000.00
PR
1
DEPENDENTS
HOSPITAL & P
ID NUMBER
MEMBER’S
NAME
AGE
REF
NO.
DATE
CHECK IN
DATE
CHECK OUT
TYPE OF
AVAILMENT
NAME OF
PROVIDER
0000000001
Dela Cruz, Maria
60
001
1/27/2014
1/27/2014
EMERGENCY
SAN JUAN
0000000002
Cruz, Ana
36
002
1/27/2014
1/27/2014
OUTPATIENT
OLIVAREZ
0000000003
Tan, Jose
35
003
1/27/2014
1/30/2014
INPATIENT
0000000002
Cruz, Ana
36
004
1/29/2014
1/31/2014
INPATIENT
CHINESE
GEN HOSP
OLIVAREZ
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
CLASSIFICA
TION OF
THE
PROVIDER
HOSPITAL
L3
HOSPITAL
L1
HOSPITAL
L3
HOSPITAL
L1
DIAGNOSIS
ROOM AND
BOARD
MEDICINES
& MEDICAL
SUPPLIES
2,000.00
3,000.00
0.00
1,500.00
CARDIO
6,000.00
30,000.00
ASTHMA
4,000.00
1,500.00
HYPERTENSION
ASTHMA
Page 41 of 44
PR
1
Annex B
DUTY FREE PHILIPPINES
QUARTERLY SUMMARY UTILIZATION REPORT SAMPLE
PRINCIPAL
ID NUMBER
MEMBER’S NAME
AGE
REF
NO.
001
004
002
003
005
008
006
0011
1/27/2014
1/29-31/2014
1/27/2014
1/27-30/2014
2/1-5/2014
2/12/2014
2/1-3/2014
2/25-27/2014
HYPERTENSION
HYPERTENSION
ASTHMA
MATERNITY
DENGUE
DIABETES
CANCER
CANCER
00012
3/2 -7/2014
DIABETIS
0000000001
Dela Cruz, Juan
60
0000000002
0000000003
0000000013
Cruz, Nena
TAN, Ana
Santos, Rey
36
35
46
0000000021
Reyes, Theresa
35
0000000031
Delas Alas, Luis
49
DATE OF
AVAILMENT
DIAGNOSIS
TOTAL BILLING
2,480.00
6,400.00
1,600.00
1,800.00
10,000.00
3,000.00
120,000.00
60,000.00
48,000.00
T o t a l (Quarterly Utilization)
TOTAL UTILIZATI
PER
MEMBER/ILLNESS
8,880.00
MBL
RUNN
170,000.00
1
1,600.00
18,000.00
10,000.00
3,000.00
180,000.00
190,000.00
40,000.00
190,000.00
190,000.00
190,000.00+38,
000.00
1
1
1
48,000.00
269,400.00
220,000.00
1
DEPENDENTS
ID NUMBER
MEMBER’S NAME
AGE
REF
NO.
DATE OF
AVAILMENT
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
xxx
DIAGNOSIS
TOTAL BILLING
xxx
xxx
xxx
xxx
T o t a l (Quarterly Utilization)
TOTAL UTILIZATI
PER
MEMBER/ILLNESS
xxx
xxx
xxx
Submitted by:
______________________
SUPPLIER’s Representative
Date: _________________
Annex 1 of Section IX
PROPOSED RATES FOR
EMPLOYEE PAID DEPENDENTS
Name of Bidder _________________
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
Page 42 of 44
MBL
xxx
xxx
RUNN
For Employee-Paid Dependents
1
2
Description
Quantity
IMMEDIATE DEPENDENTS
A. Managers
Age Bracket
00 – 65
66 – 70
B. Supervisors
Age Bracket
C. Rank and File
Age Bracket
3
Unit Price
Per
Quarter
4
5
Applicable
Tax
Total Price
(Cols. 3 + 4)
6
Total Annual
Price
(Col. 5 x 4)
1
1
00 – 65
66 – 70
1
1
00 – 65
66 – 70
1
1
Proposed rates for immediate dependents shall follow the same rate as indicated in the submitted Price
Schedule of the SUPPLIER’s Financial Proposal
1
2
Description
Quantity
EXTENDED DEPENDENTS
A. Managers
Age Bracket
00 – 65
66 – 70
B. Supervisors
Age Bracket
C. Rank and File
Age Bracket
3
Unit Price
Per
Quarter
4
5
Applicable
Tax
Total Price
(Cols. 3 + 4)
6
Total Annual
Price
(Col. 5 x 4)
1
1
00 – 65
66 – 70
1
1
00 – 65
66 – 70
1
1
________________________________
Signature over printed name
________________________________
Position
Duly authorized to sign this Proposed Rates for Employee Paid Dependents for and on behalf of
__________________________
IX. EMPLOYEE PAID DEPENDENTS
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
Page 43 of 44
1.
The PRINCIPAL MEMBERS- may opt to enrol additional dependents. These
dependents are those not included in the Matrix of Members (Principal and
Dependents)
1.1
IMMEDIATE DEPENDENTas described under 1.2, 1.3, and 1.4 of
the Technical Specifications.
1.1.1
1.2
Immediate dependents of single principal memberwho gets married during the contract period shall continue
to be classified as immediate dependent/s of the former
single principal members until the expiration of the
contract, if he/she opts to continue coverage.
EXTENDED DEPENDENT– those who are financially dependent on
the principal member, not categorized as immediate dependents,
subject to the same limitations stated in the Technical Specifications.
1.2.1
Parents of married principal members- who were
covered by our previous HMOs for the last three (3) years.
2.
The premiums of these members shall be paid by the principal member
through the PROCURING ENTITY and are not included as part of the
Approved Budget for the Contract (ABC).
3.
A separate agreement shall be entered into by the SUPPLIER and
PROCURING ENTITY to cover this Section. The bidding documents shall be
supplementary to the said agreement unless specifically provided otherwise
in this Section.
4.
Proposed rates for this Section shall be prepared by the SUPPLIER as a
required submission under 13.1(a) of the Instruction to Bidders (ITB).
5.
Proposed rates for immediate dependents shall follow the same rate as
indicated in the submitted Price Schedule of SUPPLIER’s Financial Proposal.
6.
The utilization under this section shall not be considered in computing the
utilization of company paid members.
Employee Paid Dependents
Provision of DFPC Healthcare Services 2015
Page 44 of 44