The Philippine Health Insurance Corporation (PhilHealth) said Friday it will implement new quality standards and a maximum claim limit for surgeons performing specific eye procedures effective Nov. 15, 2025, to enhance member protection and guarantee high-quality care.
The national health insurer issued PhilHealth Circular No. 2025-0021, which sets clear clinical guidelines for Pterygium Excision with Graft and Ocular Surface Reconstructive Surgeries (OSR).
It said the initiative, which also limits the amount eye surgeons can claim, aims to standardize care, prevent complications and align with President Ferdinand R. Marcos Jr.’s health agenda to ease the burden on Filipinos with these conditions.
“This is our step to ensure that every PhilHealth member receives the highest possible standard of eye care,” said PhilHealth president and chief executive Dr. Edwin Mercado.
“We are working with expert doctors and strengthening our monitoring systems to successfully fulfill PhilHealth’s mandate to deliver quality benefits,” he said.
Pterygium, commonly known as “pugita sa mata,” is a triangular, fleshy growth on the eye’s surface that can extend onto the cornea. Surgery is necessary when the condition causes vision problems and irritation.
PhilHealth currently covers pterygium excision with graft (RVS 65426) and P59,085 for ocular surface reconstruction (RVS 65780, 65781, 65782).
A study at the Philippine General Hospital found that about 2 percent of new eye patients were diagnosed with pterygium, with most aged around 47 years.
Slightly more women, 53 percent, were affected. The study noted that 42 percent of patients worked outdoors, exposing them to sunlight and dust, which are key risk factors.
The new policy requires that quality measures such as accredited facilities, qualified surgeons, proper surgical techniques, and post-operative care be observed to ensure patient safety and effective treatment.
Under the circular, the maximum claim limit for eye surgeons will help ensure patient safety and proper utilization of benefits.
However, this limit does not apply to procedures performed by residents-in-training in accredited government and private health facilities with a Philippine Board of Ophthalmology-accredited residency training program, a move to promote continuous quality training standards.
The guidelines were developed in consultation with experts from the Philippine Academy of Ophthalmology and the Philippine Cornea Society Inc.
