Pulmonary hypertension: direct access, no referral or pre-authorisation

It is a short law — three articles — that puts pulmonary hypertension into the ASES special coverage and removes four obstacles at once: no referral, no authorisation, no plan pre-authorisation, and no countersignature or primary physician authorisation for the medicines and treatments the specialists recommend. And that last point does not stop at the condition itself: it also covers health conditions related to it.

The law addresses patients with the Pulmonary Hypertension condition within the Government of Puerto Rico Health Plan. It sets no diagnostic criteria or application requirements in its text: what it does is order that the condition be in the ASES special coverage and that access be direct. The reach of access without countersignature extends, by the text, to the medicines or treatments recommended by the specialists treating the patient for that condition “or for health conditions related to that disease.”

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1. 1

   Step 1: No referral, no authorisation, no pre-authorisation

   This is the sentence to take to the plan’s office. The law orders that there be established “direct access to providers and specialist physicians contracted within the Government of Puerto Rico Health Plan’s provider network, as well as to the medicines, treatments, therapies and tests effective and recommended to diagnose and treat Pulmonary Hypertension according to the patient’s specific needs, without need for a referral, authorisation or pre-authorisation from the plan.” The three obstacles are named one by one.

2. 2

   Step 2: Nor is the primary physician’s countersignature needed

   It is a separate obstacle and the law removes it in a sentence of its own: “Neither the countersignature nor the primary physician’s authorisation shall be required for access to medicines or treatments recommended by the specialists treating the patient for that condition or for health conditions related to that disease.”

3. 3

   Step 3: It reaches related conditions too

   It is the part most often lost at the pharmacy counter, and it is in the text: the waiver of countersignature and primary physician authorisation applies to the medicines or treatments the specialists recommend for pulmonary hypertension “or for health conditions related to that disease.” It is not locked to the principal diagnosis.

4. 4

   Step 4: What the direct access covers

   The law enumerates four things besides the specialists: “the medicines, treatments, therapies and tests effective and recommended to diagnose and treat Pulmonary Hypertension according to the patient’s specific needs.” Diagnostic tests are inside, not only treatment.

5. 5

   Step 5: Whose job it is to enforce

   The law does not leave compliance to chance: “The Health Insurance Administration shall ensure that insurers, as well as the contracted health service or insurance companies or organisations, comply with this Act’s provisions.” If the refusal comes from the insurer, ASES is the one with the duty to ensure.

6. 6

   Step 6: The next-contract clause

   It is worth knowing because it explains how it was implemented. The law provides the Administration shall include what it establishes within the health services the Government offers, “nevertheless, recognising the Health Services Administration’s existing contractual obligations, what is required here shall form part of the next health services contract the Government of the Commonwealth of Puerto Rico shall offer.” The law is from 2015 and the compilation we cite is revised to 2024, so that next contract came and went long ago; we reproduce the clause as written and do not assert which contract is in force today.

There is no application to make under this law: the direct access is exercised on the spot, before the provider or the pharmacy, and what helps is citing the article. If the insurer or the contracted organisation demands a referral, authorisation, pre-authorisation or the primary physician’s countersignature, the law places on ASES the duty to ensure they comply. If the plan denied you a medicine, our guide on medicines denied by the plan explains that route; and if your matter is a complaint as a patient, that has its guide too.

• Accepting a demand for a referral to the specialist: the law orders direct access without need for a referral, authorisation or plan pre-authorisation.
• Chasing the primary physician’s countersignature: the law provides it shall not be required for the medicines or treatments the specialists recommend.
• Believing it only covers pulmonary hypertension: the waiver also reaches health conditions related to that disease.
• Thinking direct access is only to physicians: the law names medicines, treatments, therapies and tests.
• Complaining only to the insurer: the law places on ASES the duty to ensure insurers and contracted organisations comply.
• Expecting a fine or a procedure from this law: it is three articles and carries neither.

These are the government pages this guide is based on.

• Administración de Seguros de Salud (ASES)

  ASES

  bvirtualogp.pr.gov