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SPECIAL COVERAGE

Enrollees 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
  • Hepatitis C

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 medications, tests and other services through the Special Coverage without a referral or needing their PCP to sign off.

Triple-S will let you know if you are qualified and will make sure that you get access to the services. Vital Special Coverage will begin when the enrollee 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. Contact us at 1-800-981-1352; TTY / TDD users should call 1-855-295-4040 if you want more information.

  • Effective on March 26, 2020, Plan Vital beneficiaries will have access to Hepatitis C treatment with the drug included in the Plan Vital Medications form.
  • 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;
    • OBG Obstetricians;
    • Post Organ Transplantation; and
    • Children with special needs. Except:
      • Asthma and diabetes (Part of the Disease Management Program),
      • Psychiatric disorders, and
      • 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 as a result of a felony committed by a beneficiary or negligence.
  • Chronic renal disease
  • Medications required for the ambulatory Treatment of Tuberculosis and Leprosy

SPECIAL COVERAGE FOR HIV-AIDS

If you have HIV or AIDS, your PCP must ask your Insurer to give you Special Coverage. Once your Insurer adds you to Special Coverage, they will mail you a letter letting you know that you can get services under Special Coverage. The letter will let you know when the Special Coverage starts and when it will stop.

Once you have the letter, you can get all services and treatments for your condition like prescription medicines, laboratory tests, x-rays and other services without your PCP needing to sign off.

You must get your prescription medicines for HIV/AIDS at the Department of Health’s Centers for Prevention and Treatment of Communicable Diseases. Here they are:

Centers for the Prevention and Treatment of Communicable Diseases (CPTET, for its acronym in Spanish)

REGION TELEPHONE / FAX ADDRESS
ARECIBO (787) 878-7895
Fax. (787) 881-5773
Fax. (787) 878-8288
Tel. (787) 879-3168
Antiguo Hosp. Distrito (Dr. Cayetano Coll y Toste)
Carretera 129 hacia Lares
Arecibo, PR 00614


PO Box 140370
Arecibo, PR 00614

BAYAMÓN (787) 787-5151
Ext. 2224, 2475
(787) 787-5154
Fax. (787) 778-1209
(787) 787-4211
Antigua Casa de Salud
Hosp. Regional Bayamón
Dr. Ramón Ruíz Arnau,
Ave. Laurel Santa Juanita
Bayamón, PR 00956
CAGUAS (787) 653-0550
Ext. 1142, 1150
Fax (787) 746-2898; 744-8645
Hosp. San Juan Bautista
PO Box 8548
Caguas, PR 00726-8548
CLINICA SATELITE
HUMACAO
(787) 285-5660 CDT de Humacao, Dr. Jorge Franceshi
Calle Sergio Peña Almodovar
Esq. Flor Gerena
Humacao, Puerto Rico 00791
CAROLINA CLETS (787)757-1800
Ext. 454, 459
Fax (787)765-5105
Hospital UPR Dr. Federico Trilla
P. O. Box 6021
Carolina, PR 00984-6021
Carretera 3, Km. 8.3
CLETS SAN JUAN (787)754-8118
(787)754-8128
(787)754-8127
P. O. Box 70184
San Juan, PR 00936-8523


Calle José Celso Barbosa
Centro Médico de PR
Bo. Monacillos, San Juan

FAJARDO (787)801-1992
(787)801-1995
Calle San Rafael # 55
Fajardo, PR 00738
MAYAGÜEZ (787)834-2115
(787)834-2118
Centro Médico de Mayagüez
Hospital Ramón Emeterio
Betances
Carr. #2 Suite 6
Mayagüez, PR 00680
PONCE (787)842-0948
(787)842-2000
Departamento de Salud
RegiOn Ponce
Antiguo Hosp. Distrito Ponce
Dr. José Gándara
Carretera Estatal 14
Bo. Machuelo
Ponce, PR 00731
CENTRAL OFFICE (787)765-2929
Ext. 4026, 4027
Fax (787)274-5523
P.O. Box 70184
San Juan, PR 00936
Ant. Hosp. Psiquiatría
Pabellón 1, primer piso, 4ta. Puerta – Terrenos de Centro Médico, Río Piedras

CARE MANAGEMENT

Some people with high needs and special conditions can receive Care Management. If you are eligible for Care Management, nurses, social workers and nutritionists are available to help you create a plan for your care. Your team will review your care plan with you at least once a year, if your health needs change, or if you ask for a review.

You can ask for help through this program by calling at 1-800-981-1352; TTY / TDD users should call 1-855-295-4040. Your doctor, your family, your hospital can also ask for you.

For more information call at 787-775-1352; TTY / TDD users should call 1-855-295-4040.

HIGH COST HIGH NEEDS PROGRAM

If you have certain conditions, you may benefit from your Insurer’s High Cost High Needs program to help you get all the care you need. This program is free.

If your PCP tells you that you have:

  • Cancer
  • End-Stage Renal Disease (ESRD)
  • Multiple Sclerosis (MS)
  • Rheumatoid Arthritis
  • Diabetes
  • Asthma
  • Severe Heart Failure
  • Hypertension
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Depression
  • Attention-Deficit/Hyperactivity Disorder (ADHD)
  • Substance Use Disorders
  • Serious Mental Illness (SMI)
  • Hemophilia
  • Autism

Your Insurer will offer you extra help with getting care. Your Insurer may want to send someone to your home to talk to you about your needs and learn which, doctors, tests or other help is needed. Talking to Triple-S about your needs will help us understand the best ways to help you.

 

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