Enrollees with special health care needs caused by serious illnesses may be enrolled into Special Coverage Registry to receive Special Coverage services.

Your PCP, the personnel designated by your PMG or the case coordinator of your PMG can instruct you on the conditions that qualify for the special coverage. Any of them can help you to be included in the Special Coverage by sending all the necessary information on your medical condition your Health Plan.

Once enrolled in special coverage, Enrollees have the freedom to choose the providers for these services among the providers in the Preferred Provider Network of their PMG or your Health Plan’s General Network, differential diagnostic interventions up to the verification of the final diagnosis are not part of the Special Coverage.

Medications, laboratory test, diagnostic test and other related procedures specified in this coverage as necessary for ambulatory treatment or convalescence are part of this coverage and do not require referrals from your PCP or Health Plan. Your Health Plan must identify the Enrollees included under this coverage to facilitate Access to the contracted services. The GHP Special Coverage will be activated when the Enrollee reaches the limit of any other Special Coverage the Enrollee may have under any other plan.

The purpose of this coverage is to facilitate the effective management of beneficiaries with special health condition that require specialized medical attention. This coverage will become effective when the diagnosis is confirmed through the results of tests or procedures performed.

The benefits under this coverage are:

• Coronary disease services and intensive care, without limitations.
• Maxillary surgery, with a Referral.
• Neurosurgical and cardiovascular procedures, including pacemakers, valves and any other instrument or artificial device (requires Preauthorization).
• Peritoneal dialysis, hemodialysis and related services (requires Preauthorization).
• Clinical and pathological laboratory test that must be sent outside Puerto Rico for their processing (requires Preauthorization).
• Neonatal intensive care unit services, without limitations.
• Treatment with radioisotopes, chemotherapy, radiotherapy and cobalt.
• Gastrointestinal conditions, allergies and nutritional evaluation for autistic Patients.
• The following procedures and diagnostic tests, when medically necessary (require Preauthorization):
• Computerized tomography;
• Magnetic resonance tests;
• Cardiac catheterisms;
• Holter Test;
• Doppler Test;
• Stress Test;
• Lithotripsy;
• Electromyography;
• Tomography test (SPECT);
• Ocular Pletismography test (OPG);
• Impedance Pletismography (IPG);
• Other neurological cerebral-vascular and cardiovascular tests, invasive or non-invasive;
• Nuclear Medicine tests;
• Diagnostic Endoscopies; and
• Genetic Studies.
  
• Physical therapy – up to 15 additional treatments per condition per beneficiary a year, when ordered by an Orthopedist, Physiatrist or Chiropractor (requires Preauthorization from your Health Plan).
• General Anesthesia.
• General anesthesia for dental treatment to children with special needs.
• Hyperbaric chamber.
• Immunosuppressive drugs and laboratory tests required for the maintenance treatment of Patients who have been operated to receive any transplant, which assure the stability of the beneficiary’s health and the emergencies that may arise after this surgery.
• Treatment for the following conditions after being confirmed by the results of laboratory tests and the diagnosis has been established:
• Positive HIV Factor and Acquired Immunodeficiency Syndrome (AIDS) – Ambulatory and hospitalization services are included. You do not need a Referral or Preauthorization from your Health Plan or your PCP for the 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 Transplant; and
• Children with special needs, except:
• Asthma and diabetes, which are included in the Disease Management Program,
• Psychiatric disorders, and
• Intellectual disabilities, behavior manifestations will be managed by the mental health providers under the basic coverage, with the exception of a catastrophic disease.
• Scleroderma.
• Multiple Sclerosis and Amiotrofic Sclerosis Lateral (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 in levels 3, 4 and 5. (Levels 1 and 2 are included in the Basic Coverage). The following is a description of the stages of chronic renal disease:
  • Level 3 - GFR (glomerular filtration - ml / min. per 1.73 m² per corporal surface area) between 30 and 59, a moderate decrease in kidney function
  • Level 4 - GFR between 15 and 29, a serious decrease in kidney function
  • Level 5 - GFR under 15, renal failure with probability of dialysis or kidney transplantation.
• The medications required for the ambulatory treatment of tuberculosis and leprosy are included under the Special Coverage. Medications required for the ambulatory Treatment or hospitalization for beneficiaries diagnosed with AIDS or that are HIV positive are covered under the Special Coverage, except protease inhibitors, which will be provided by the Clinics for the Prevention and Treatment of Sexually Transmitted Diseases ( CPTET, for its acronym in Spanish).