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