The Philippine Health Insurance Corporation’s (PhilHealth) YAKAP primary care program is being abused by some beneficiaries and providers, with patients reportedly receiving four antibiotics for one infection and duplicate drug formulations to fully consume the P20,000 outpatient benefit, PhilHealth President and CEO Edwin Mercado bared on Thursday, Nov. 20.

YAKAP is PhilHealth’s expanded primary care program that provides outpatient consultations, preventive services, and up to P20,000 worth of medicines annually to help reduce hospitalizations and lower out-of-pocket health expenses.

During a forum in Pasig City, Mercado said PhilHealth has been receiving reports of beneficiaries and providers over-utilizing the annual drug package as the year ends.

“Unfortunately, because it’s end of year… people are already over-utilizing their P20,000 limit, because they thought that it’s going to be end of year, ‘sayang’ (what a waste), even if us telling them… it zeroes out by midnight and then it reappears 12:01 with a new P20,000,” he said.

The PhilHealth chief noted that some patients had been prescribed drugs in quantities or combinations that exceeded legitimate clinical need.

“We’ve been seeing patients who were given four different antibiotics for one infectious disease,” he said.

Mercado added that PhilHealth also documented abuses involving hypertensive patients.

“We’ve been seeing people with one diagnosis for hypertension, but they have four different formulations of the same genetic or molecular type, just so they can maximize the P20,000.”

According to him, these incidents are among the reasons PhilHealth is enforcing “matalinong pagpapatupad (smart implementation)” of YAKAP, beginning with tighter provider reorientation, readiness assessments, and stricter standards for prescribing.

He underscored that the program’s controls must be strengthened before full rollout.

“These are things that we’re plugging, and precisely why we’re doing this phase implementation,” he said.

Mercado explained that part of the challenge stems from how beneficiaries enroll and interact with YAKAP providers, as well as misunderstandings about benefit periodicity. He noted that some believe the annual drug limit expires permanently at year-end, prompting excessive consumption.

He added that misuse undermines the program’s intent to lower out-of-pocket spending for essential outpatient medicines, which account for about 40 percent of Filipino households’ health expenses.

Mercado said PhilHealth is now working with pharmacies, provider groups, and IT teams to ensure accurate utilization tracking and to prevent inappropriate prescribing.

He stressed the need for provider accountability moving forward.

“These are just some of the areas that we want to focus in terms of reform and where we want and we need help,” he said.