VANTAGE MEDICAL HOME HMO
Vantage’s Medical Home HMO is a patient-centered approach to providing cost-effective and comprehensive primary health care for children, youth and adults. This plan creates partnerships between the individual patient and his or her personal physician and, when appropriate, the patient’s family. This plan includes a preferred provider network, Affinity Health Network (AHN), which has lower copayments covered services as indicated by AHN. This plan also includes Out-of-Network coverage.
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MEDICAL COVERAGE
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Active Employees and Retirees
(on or after 3/1/2015) |
Single
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Employee
+ Spouse
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Employee
+ Children |
Family
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Deductible (In-Network)
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$400
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$800
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$1,200
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$1,200
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Deductible (Out-of-Network)
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$2,000
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$4,000
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$6,000
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$6,000
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Co-Payment – PCP (In-Network)
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$10 AHN/$25
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$10 AHN/$25
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$10 AHN/$25
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$10 AHN/$25
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Co-Payment – Specialist (In-Network)
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$35 AHN/$50
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$35 AHN/$50
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$35 AHN/$50
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$35 AHN/$50
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Co-Payment PCP (Out-of-Network)
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50% coverage; subject to deductible
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Co-Payment – Specialist (Out-of-Network)
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50% coverage; subject to deductible
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Out-of-Pocket Maximum (In-Network)
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$3,500
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$6,000
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$8,500
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$8,500
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Out-of-Pocket Maximum (Out-of-Network)
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$5,000 Benefit Maximum
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$15,000 Benefit Maximum
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$15,000 Benefit Maximum
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$15,000 Benefit Maximum
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Retirees – With or Without Medicare (Before 3/1/2015)
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Deductible (In-Network) Retiree
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$0
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$0
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$0
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$0
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Deductible (Out-of-Network)
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$2,000
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$4,000
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$6,000
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$6,000
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Co-Payment – PCP (In-Network)
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$10 AHN/$25
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$10 AHN/$25
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$10 AHN/$25
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$10 AHN/$25
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Co-Payment – Specialist (In-Network)
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$35 AHN/$50
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$35 AHN/$50
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$35 AHN/$50
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$35 AHN/$50
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Co-Payment PCP (Out-of-Network)
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50% coverage; subject to deductible
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Co-Payment – Specialist (Out-of-Network)
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50% coverage; subject to deductible
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Out-of-Pocket Maximum (In-Network) Retiree (with or without Medicare before 3/1/2015)
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$2,000
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$3,000
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$4,000
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$4,000
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Out-of-Pocket Maximum (Out-of-Network)
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$5,000 Benefit Maximum
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$15,000 Benefit Maximum
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$15,000 Benefit Maximum
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$15,000 Benefit Maximum
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In-Network Providers
Members seeing In-Network providers pay the In-Network copayments, coinsurance and deductible as listed in the Certificate of Coverage and Cost Share Schedule. The Vantage participating network consists of two networks:
- A preferred provider network, Affinity Health Network (AHN), which has lower copayments for certain covered services as indicated by “AHN”, and
- A standard provider network.
View providers in Vantage Health Plan’s networks at www.vantagehealthplan.com/OGBCommercial
PHARMACY BENEFITS
The Vantage Medical Home HMO prescription drug benefit has five copayment levels. There is no prescription drug deductible. You may view the Vantage Rx Formulary at: www.vantagehealthplan.com/OGBCommercial/Documents
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Tier
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Member Co-Pay
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Tier 1 Prescription Drugs
• Preferred Pharmacies
• All other Pharmacies
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100% Coverage
$15 copay
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Tier 2 Non-Preferred Generics
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$40
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Tier 3 Preferred Brand
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$65
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Tier 4 Non-Preferred Brand
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$100
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Tier 5 Specialty
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$150
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VANTAGE MEDICAL HOME HMO RESOURCES
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