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EPSDT Program

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)
  • Adults with phenylketonuria (PKU)
  • Pulmonary Hypertension

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

  • 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;
    • 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