Dental Services

The Vital Plan offers dental services. You can see any dentist that accepts the Vital Plan. You can find information about participating dentists at the First Medical’s Provider Directory. When you sign up with First Medical, they will mail you a Provider Directory. You can find the Providers list in the Provider Directory section. Your Primary Medical Group and First Medical Service Offices also have a copy of the list.

For questions about your dental benefits, call First Medical at 1-844-347-7800; TTY/TDD users should call 1-844-347-7805.

Mental Health, Alcohol and Drug Abuse Services

The Vital Plan offers mental health, alcohol and substances abuse services. You do not have to see your PCP first to see a doctor or other provider for mental health, alcohol or substances abuse services. You can ask for these services whenever you feel like you need them.

The Vital Plan wants to make it easy for you to get physical and mental health, alcohol, and substance abuse services in the same place. This is called integrated care.

Your Primary Medical Group is one place you can go to get mental health, alcohol or drug abuse services. Your Primary Medical Group must have a psychologist and/or a social worker available at least from four (4) to sixteen (16) hours per week, during regular business hours.

If you get mental health, alcohol or drug abuse services at another place (like a mental health clinic or a psychiatric hospital); they must have services from a PCP in the office at least part of the time to care for your physical health needs.

If you need help finding mental health, alcohol and substance abuse services, call First Medical Health Plan’s Medical Advise Line at 1-844-347-7801; TTY/TDD users should call 1-844-347-7805.

Pharmacy Services

The Vital Plan covers prescription medicines. If you need medicine, your provider will write you a prescription to take to a participating pharmacy. You can choose any pharmacy that works with First Medical. You can find a list of participating pharmacies in your First Medical’s Provider Directory. Or you can call First Medical at 1-844-347-7800; TTY/TDD users should call 1-844-347-7805.

Prescription medicines are free for children up to the age of twenty (20) and for pregnant women that are Medicaid or CHIP beneficiaries. Other adults will need to pay for prescription drugs. For more information on payments for prescription medicines, look at Part 4 of your Beneficiary Manual.

Your Covered Medication Formulary (CMF) is the list of medicines the Vital Plan covers. This list helps your doctor prescribe medicines for you. Brand-name and generic medicines are on the CMF. A generic version of a medicine is the first choice. If a generic version of a medicine is available, your doctor has to prescribe the generic version.

If you have a chronic condition, your doctor can write a prescription for a ninety (90) days supply of some medicines. This way, you only have to pay for the medicine once instead of paying three times (1 payment per month).

If you need a copy of the Covered Medication Formulary, please feel free to contact First Medical Customer Service at 1-844-347-7800; TTY/TDD users should call 1-844-347-7805, Monday through Friday from 7:00 a.m. to 7:00 p.m. First Medical will send you free of charge, the Covered Medication Formulary in five (5) business days from the date of your request.

You can also access the Medication Form on the Vital Plan Coverage through the following website:

Covered Medication Formularies (FMCs)

• Dental Form
• HIV-AIDS Form
• Integrated Emergency Form (FEI by its spanish acronym)
• List of Medications by Exception (LME by its spanish acronym)
• Mental Health Form
• Nephrology Form
• OB-GYN Form
• Oncology Form
• Physical Health Sub-Form

Non-covered Services

Here is a general list of some services that are not covered by the Vital Plan. If you need more information about the services not covered by the Vital Plan, you can call First Medical at 1-844-347-7800; TTY/TDD users should call 1-844-347-7805.

Some non-covered services are:

• Services for non-covered illnesses or trauma.
• Services for automobile accidents covered by the Administration of Compensation for Automobile Accidents (ACAA, for its Spanish acronym).
• 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 twenty-one (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 First Medical are excluded.
• Travel expenses, even when ordered by the PCP, are excluded.
• Eyeglasses, contact lenses and hearing aids (for members over age twenty-one (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.