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Here is a general list of some services that are not covered by Vital. You can call at 1-800-981-1352; TTY / TDD users should call 1-855-295-4040 for a full list.

NON-COVERED SERVICES

  • Services for non-covered illnesses or trauma
  • Services for automobile accidents covered by the Administration of Compensation for Automobile Accidents (ACAA, for its acronym in Spanish)
  • Accidents on the job that are covered by the State Insurance Fund Corporation
  • Services covered by another insurance or entity with primary responsibility (third party liability)
  • Specialized nursing services for the comfort of the Patient when they are not medically necessary
  • Hospitalizations for services that can be rendered on an outpatient basis
  • Hospitalization of a Patient for diagnostic services only
  • Expenses for services or materials for the Patient’s comfort such as telephone, television, admission kits, etc
  • Services rendered by Patient’s relative (parents, children, siblings, grandparents, grandchildren, spouse, etc.)
  • Organ and tissue transplants, except skin, bone and corneal transplants
  • Weight control Treatments (obesity or weight increase for aesthetic reasons)
  • Sports medicine, music therapy and natural medicine
  • Cosmetic surgery to correct physical appearance defects
  • Services, diagnostic tests ordered or provided by naturopaths, and iridologists
  • Health Certificates except for (i) venereal disease research laboratory tests, (ii) tuberculosis tests and (iii) any certification related to the eligibility for the Medicaid program
  • Mammoplasty or plastic reconstruction of breast for aesthetic purposes only
  • Outpatient use of fetal monitor
  • Services, Treatment or hospitalization as a result of induced, non-therapeutic abortions or their complications
  • Medications delivered by a provider that does not have a pharmacy license, with the exception of medications that are traditionally administered in a doctor’s office such as an injection
  • Epidural anesthesia services
  • Educational tests, educational services
  • Peritoneal dialysis or hemodialysis services (Covered under the Special Coverage)
  • New or experimental procedures not approved by ASES to be included in the Basic Coverage
  • Custody, rest and convalescence once the disease is under control or in irreversible terminal cases (hospice care for members under 21 is part of basic coverage)
  • Services covered under the Special Coverage
  • Services received outside the territorial limit of the Commonwealth of Puerto Rico, except for emergency services for Medicaid or CHIP beneficiaries
  • Judicial order for evaluations for legal purposes
  • Counseling services or referrals based on moral or religious objections of the Insurer are excluded
  • Travel expenses, even when ordered by the PCP, are excluded
  • Eyeglasses, contact lenses and hearing aids (for members over age 21)
  • Acupuncture services
  • Procedures for sex changes, including hospitalizations and complications
  • Treatment for infertility and/or related to conception by artificial means including tuboplasty, vasovasectomy, and any other procedure to restore the ability to procreate

EXCLUSIONS OF THE DENTAL COVERAGE

  • Preventive Services less, (1) prophylaxis child (cleaning) and (1) prophylaxis (cleaning) for adult every 6 months, topical application of fluoride varnish (1) one every 6 months, for children under 5 years old and is mutually exclusive of fluoride topical (one or the other), topical fluoride (1 every 6 months up to 19 years) and fissure sealant are covered in deciduous molars until the insured reaches 8 years of age and in permanent molars up to 14 years of age, all other services are excluded
  • Diagnostic Services less (1) comprehensive (initial) oral evaluation, (1) periodic oral evaluation (every 6 months) and (1) limited oral evaluation (emergency), (1) detailed and extensive evaluation, (1) series complete radiographic image “full mouth” (every 3 years) that includes (2) radiographic images of bitewings, (1) intraoral periapical radiographic image and (5) additional periapical radiographic images (per year), (1) ) single radiographic image of Bitewing per year, (2) two radiographic images of Bitewings per year, one (right / left), (1) panoramic radiographic image (every 3 years), all other services are excluded
  • Restorative services less resins, amalgams, composite resin posterior, (bucal surface only), Stainless steel crowns and protective restoration, all other services are excluded
  • Periodontics Services
  • Prosthesis Services, including (crowns, fixed bridges, removable partial dentures, complete dentures, inlays and onlays), implants, adjustments, repairs, re-cementation, etc. are excluded
  • Oral and Surgical Surgery less simple and surgical extractions all other services are excluded
  • General services less palliative treatment, moderate and deep intravenous sedation, hospital services and treatment of post-surgical complications. All other services are excluded.
  • Orthodontics. Only covered for children eligible for EPSDT as medically necessary to prevent and restore oral structures for health and function

PRESCRIPTION DRUG BENEFIT EXCLUSIONS

  • Medication prescribed for the treatment of Hepatitis C
  • Medications for the treatment of HIV / AIDS because they are covered under the contract of the ASES and the Department of Health (ADAP)
  • Medications delivered directly to Enrollees by a Provider that does not have a pharmacy license, except for medications that are traditionally administered in a doctor’s office, such as injections
  • Medications for anorexia, weight loss, or weight gain
  • Medications used to promote fertility
  • Medications used for cosmetic purposes or hair growth
  • Medications used to promote smoking cessation
  • Medications used for the symptomatic relief of cough and colds
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations
  • Nonprescription drugs, except, in the case of pregnant women when recommended in accordance with the Guideline referred to in section 1905(bb)(2)(A), agents approved by the Food and Drug Administration under the over-the-counter monograph process for purposes of promoting, and when used to promote, tobacco cessation
  • Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee
  • Medications when used for the treatment of sexual or erectile dysfunction, unless such agents are used to treat a condition, other than sexual or erectile dysfunction, for which the agents have been approved by the Food and Drug Administration
  • Any medication that does not contain a medically accepted indication
  • Products considered experimental or investigational for the treatment of certain conditions, for which the Food and Drug Administration has not authorized its use. Nor are investigational clinical studies or treatments (that is, clinical trials), devices, experimental or investigational drugs administered to be used as part of these studies, services or products that are provided for data collection and analysis, and not for direct management. of the patient, and items or services without costs for the insured person that is commonly offered by the sponsor of the investigation. This applies even if the beneficiary has enrolled in the study to treat a life-threatening illness for which there is no effective treatment and obtains the doctor’s approval for participation in the study because it offers the patient a potential benefit

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