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:

• Adults with Phenylketonuria (PKU)
• Aplastic Anemia
• Autism
• Cancer
• Cardiac Congestive Failure (CHF) Class III & Class IV, NYHA
• Children with Special Health Care Needs
• Chronic Hepatitis C (HCV)
• Chronic Kidney Disease
• Cystic Fibrosis
• Hemophilia
• HIV/AIDS
• Leprosy
• Multiple Sclerosis (MS) and Amyotrophic Lateral Sclerosis (ALS)
• Obstetrics
• Post-transplant (Excludes: cornea, bone, and skin)
• Primary Ciliary Dyskinesia (PCD), Immobile Cilia Syndrome, Kartagener Syndrome
• Pulmonary Hypertension
• Rheumatoid Arthritis
• Scleroderma
• Skin Cancer such as Invasive Melanoma or Squamous Cells with evidence of metastasis.
• Skin Cancer – Carcinoma IN SITU
• Systemic Lupus Erythematosus (SLE)
• Tuberculosis (Tb)

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 First Medical 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.

First Medical will let you know if you are qualified and will make sure that you get access to the services. The Vital Plan Special Coverage will begin when the enrollee reaches the limits of the Special Coverage for any other health plan.

Some services may have limits. Contact First Medical Call Center at 1-844-347-7800; TTY/TDD users should call 1-844-347-7805, if you want more information.

The benefits under the Special Coverage include the following list:

• 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 First Medical 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; 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

* Access to Hepatitis C treatment with the medication included in the Vital Plan Medication formulary.