One benefit to Vantage’s Medicare Advantage plans is that a network of providers is already contracted with the plan throughout Louisiana. These physicians, hospitals and specialty medical facilities have already agreed to provide health care services to treat Medicare Advantage members.
|
Covered Benefit
|
Vantage Premium HMO-POS
|
Vantage HMO-POS PLAN
|
Vantage Basic HMO-POS
|
|
Plan Year Deductible
|
N/A
|
N/A
|
N/A
|
|
Maximum Out-of-Pocket Expense
|
$3,500
|
$4,900
|
$5,900
|
|
Office Visit
Primary Care/ Specialist
|
$0 Primary Care copay and $40 or $25 AHN* Specialist co-pay per visit
|
$0 Primary Care copay and $45 or $35 AHN* Specialist copay per visit
|
$0 Primary Care copay and $50 or $35 AHN* Specialist copay per visit
|
|
Emergency Room
|
$90 ER copay per visit – worldwide coverage; waive if admitted
|
$90 ER copay per visit – worldwide coverage; waive if admitted
|
$90 ER copay per visit – worldwide coverage; waive if admitted
|
|
Inpatient Hospital
|
100% coverage after $250 copay per day for days 1-7 or $0 copay for day 1, $250 copay per day AHN* for days 2-7
|
100% coverage after $270 copay per day for days 1-7 or $0 copay for day 1, $270 copay per day AHN* for days 2-7
|
100% coverage after $318 copay per day for days 1-7 or $0 copay for day 1, $318 copay per day AHN* for days 2-7
|
|
Prescription Drugs (Part D)
|
|
Tier 1 – Preferred Generics
|
$5 copay
|
$5 copay
|
$7 copay
|
|
Tier 2 – Generics
|
$14 copay
|
$14 copay
|
$15 copay
|
|
Tier 3 -Preferred Brand
|
$47 copay
|
$47 copay
|
$47 copay
|
|
Tier 4 – Non-Preferred Brand
|
$100 copay
|
$100 copay, after $275 deductible
|
$100 copay, after $445 deductible
|
|
Tier 5 – Specialty
|
33% coinsurance
|
28% coinsurance, after $275 deductible
|
25% coinsurance, after $445 deductible
|
|
Additional Benefits
|
|
|
|
|
Preventative Dental
|
100% coverage with maximum benefit of $700 every six months
|
100% coverage with maximum benefit of $500 every six months
|
100% coverage with maximum benefit of $150 every six months
|
|
Comprehensive Dental
|
100% coverage with maximum benefit of $1,000 every year for comprehensive dental
|
100% coverage with maximum benefit of $600 every year for comprehensive dental
|
100% coverage with maximum benefit of $400 every year for comprehensive dental
|
|
Routine Hearing Exam
|
100% coverage with maximum benefit of $40 every year
|
100% coverage with maximum benefit of $40 every year
|
100% coverage with maximum benefit of $40 every year
|
|
Eyewear
|
0% coinsurance with maximum benefit of $200 every year
|
0% coinsurance with maximum benefit of $200 every year
|
0% coinsurance with maximum benefit of $200 every year
|
