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EPSDT Program

Non-covered Services

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

Some non-covered services are:

  1. Services for non-covered illnesses or trauma.
  2. Services for automobile accidents covered by the Administration of Compensation for Automobile Accidents (ACAA, for its Spanish acronym).
  3. Accidents on the job that are covered by the State Insurance Fund Corporation.
  4. Services covered by another insurance or entity with primary responsibility (third party liability).
  5. Specialized nursing services for the comfort of the Patient when they are not medically necessary.
  6. Hospitalizations for services that can be rendered on an outpatient basis.
  7. Hospitalization of a Patient for diagnostic services only.
  8. Expenses for services or materials for the Patient’s comfort such as telephone, television, admission kits, etc.
  9. Services rendered by Patient’s relative (parents, children, siblings, grandparents, grandchildren, spouse, etc.).
  10. Organ and tissue transplants, except skin, bone and corneal transplants.
  11. Weight control Treatments (obesity or weight increase for aesthetic reasons).
  12. Sports medicine, music therapy and natural medicine.
  13. Cosmetic surgery to correct physical appearance defects.
  14. Services, diagnostic tests ordered or provided by naturopaths, and iridologists.
  15. 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.
  16. Mammoplasty or plastic reconstruction of breast for aesthetic purposes only.
  17. Outpatient use of fetal monitor.
  18. Services, treatment or hospitalization as a result of induced, non-therapeutic abortions or their complications.
  19. 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.
  20. Epidural anesthesia services.
  21. Educational tests, educational services.
  22. Peritoneal dialysis or hemodialysis services (Covered under the Special Coverage).
  23. New or experimental procedures not approved by ASES to be included in the Basic Coverage.
  24. 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).
  25. Services covered under the Special Coverage.
  26. Services received outside the territorial limit of the Commonwealth of Puerto Rico, except for emergency services for Medicaid or CHIP beneficiaries.
  27. Judicial order for evaluations for legal purposes.
  28. Counseling services or referrals based on moral or religious objections of the First Medical are excluded.
  29. Travel expenses, even when ordered by the PCP, are excluded.
  30. Eyeglasses, contact lenses and hearing aids (for members over age twenty-one (21)).
  31. Acupuncture services.
  32. Procedures for sex changes, including hospitalizations and complications.
  33. Treatment for infertility and/or related to conception by artificial means including tuboplasty, vasovasectomy, and any other procedure to restore the ability to procreate.
  34. Rebetron or any drug for treating Hepatitis C. For any drug therapy for Hepatitis C should be referred by your doctor to the Department of Health.

Other services that Vital does not cover are:

  1. Judicially ordered evaluations for legal purposes.
  2. Psychological, psychometric, and psychiatric tests and evaluations to obtain employment or insurance, or for purposes of litigation.
  3. Differential diagnostic interventions up to the confirmation of pregnancy.
  4. Orthodontic services for cosmetic purposes.