SPECIAL COVERAGE
Beneficiaries with special health care needs can get Special Coverage that will provide services for the care they need. The special health care needs are:
- Aplastic Anemia
- Rheumatoid Arthritis
- Autism
- Cancer
- Skin Cancer such as Invasive Melanoma or squamous cells with evidence of metastasis.
- Skin Cancer – Carcinoma IN SITU
- Chronic Renal Disease
- Scleroderma
- Multiple Sclerosis (MS) and Amiotrophic Lateral Sclerosis (ALS)
- Cystic Fibrosis
- Hemophilia
- Leprosy
- Systemic Lupus Erythematosus (SLE)
- Children with Special Health Needs
- Obstetric
- Tuberculosis (Tb)
- HIV/AIDS
- Adults with phenylketonuria (PKU)
- Pulmonary Hypertension
- Post-Transplant (Excludes cornea, bone, and skin transplant)
- Chronic Hepatitis C (HCV)
- Congestive Heart Failure (CHF): Class III & Class IV, NYHA
- Primary Ciliary Diskinesia (PCD), or Immotile Ciliary Syndrome, or Kartagener Syndrome
- Cleft palate and of Cleft lips
- IBD (Inflammatory Bowel Diseases)
Your PCP or your Primary Medical Group can give you more information on which people qualify for the special coverage. If you qualify for Special Coverage, they can also help you sign up for it.
People with Special Coverage can choose any provider that works with your Preferred Provider Network or your Insurer’s General Network. People with Special Coverage can get prescription drugs, tests and other services through the Special Coverage without a referral or needing their PCP to sign off.
Triple-S Salud will let you know if you are qualified and, will if you are qualified, they must make sure that you get access to the services. Plan Vital Special Coverage will begin when the beneficiary reaches the limits of the Special Coverage for any other health plan.
The benefits under Special Coverage include the list below. Some services may have limits. For more information call Triple-S Salud at 1-800-981-1352; TTY / TDD users should call 1-855-295-4040..
Coronary disease services and intensive care
- Maxillary surgery
- Neurosurgical and cardiovascular procedures
- Peritoneal dialysis and related services
- Clinical services and laboratory tests
- Neonatal intensive care unit services
- Chemotherapy, radiology and related services
- Gastrointestinal conditions, allergies and nutritional evaluation for autistic patients
- Procedures and diagnostic tests, when medically necessary
- Physical therapy
- General Anesthesia
- Hyperbaric chamber
- Immunosuppressive medicines and laboratory tests for patients who have received transplants
- Treatment for specific conditions after diagnosis:
- Positive HIV Factor and Acquired Immunodeficiency Syndrome (AIDS) – Ambulatory and hospitalization services are included. You do not need a Referral or Prior-Authorization from your Insurer or your PCP for visits and treatment at the Immunology Regional Clinics of the Health Department.
- Tuberculosis
- Leprosy
- Lupus
- Cystic fibrosis
- Cancer
- Hemophilia
- Aplastics Anemia
- Reumatoid Artritis
- Autism
- OBGyn Obstetricians
- Post Organ Transplantation
- Children with special needs. Except:
- Asthma and diabetes (Part of the Disease Management Program)
- Psychiatric disorders
- Catastrophic diseases for persons with Intellectual disabilities
- Scleroderma
- Multiple Sclerosis (MS) and Amyotrophic Lateral Sclerosis (ALS)
- Services for the Treatment of conditions resulting from self-inflicted damage or because of a felony committed by a beneficiary or negligence
- Chronic renal disease
- Drugs required for the ambulatory Treatment of Tuberculosis and Leprosy
- Hepatitis C treatment with the drug included in the Plan Vital Drug Formulary