Vantage Health Plan. Nationwide Coverage. Nationwide Care. Nationwide Service OGB Medical Home HMO Plan. OGB Approved. VHP517 R Approved

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1 Vantage Health Plan 2016 OGB Medical Home HMO Plan Nationwide Coverage. Nationwide Care. Nationwide Service. VHP517 R Approved OGB Approved

2 Welcome to Vantage Dear OGB Member: Vantage Health Plan will continue to be a health plan option for eligible OGB Members in If you are a current Vantage Medical Home HMO Member and you would like to keep your Vantage plan with the same covered dependents for the 2016 plan year, you do not need to do anything. Your coverage will continue for the 2016 plan year. See page 6 for the 2016 Vantage benefits. If you are not currently a Vantage Medical Home HMO Member and would like to enroll in Vantage for 2016, see below for enrollment options: ACTIVE EMPLOYEES: 1. Visit to use the annual enrollment portal to enroll in Vantage Medical Home HMO with the same covered dependents as your 2015 coverage, or 2. Contact your human resources department to enroll in Vantage Medical Home HMO with the same or different covered dependents as your 2015 coverage. NOTE: A paper enrollment form will NOT be accepted from active employees. RETIREES: 1. Visit to use the annual enrollment portal to enroll in Vantage Medical Home HMO with the same covered dependents as your 2015 coverage, or 2. Complete the annual enrollment form and return it to the address provided by November 15 to enroll in Vantage Medical Home HMO with the same covered dependents as your 2015 coverage, or 3. Mail or fax a signed and dated letter to OGB with your change request, including any dependent changes. Be sure to include the primary plan member s social security number or OGB member ID number. If adding a dependent please include marriage certificate and/or birth certificate. Mail to: Office of Group Benefits, Annual Enrollment, P.O. Box 44036, Baton Rouge, LA or Fax to: (225) NOTICE: Annual Enrollment ends November 15, Please don t wait to make your 2016 plan selection! If you have any questions about the Vantage Medical Home HMO Plan, please call our Member Services Department at (318) or toll-free at (844) or visit us online at We look forward to serving you. Thank you, William J. Justice Director of Marketing and Member Services P1

3 Nationwide Coverage. Nationwide Care. Nationwide Service. Thank you for your interest in Vantage Health Plan, Inc. The content found in this booklet will provide you with the information you need to enroll in the Vantage Medical Home HMO Plan. CHECK WHAT MATTERS MOST $ monthly premium for employee-only coverage $20 Medical Home primary care office visit copays or $10 Medical Home primary care office visit copays through Affinity Health Network (AHN) Reduced copays for some services through Affinity Health Network (AHN) No Referrals Annual wellness exam covered 100% Prescription drug plan with $5 copay for low-cost preferred generic drugs - no deductible $0 copay for low-cost preferred generic drugs through Saint John Pharmacy mail order (90-day supply) Worldwide emergency coverage Dental and Vision coverage Great local customer service The search tools on our Vantage website, will allow you to find a provider or a retail pharmacy or to search for prescription drugs covered by Vantage. If you have any questions, please contact Vantage Health Plan at (318) or toll-free at (844) For the hearing impaired, please call toll-free TTY (866) Member Services is available Monday through Friday from 8:00 a.m. 5:00 p.m. CST. Thank you again for considering Vantage Health Plan. We look forward to serving you! P2

4 Quick Drug List Vantage may save you money on your prescription drugs each year with low copays for Tier 1 Low-Cost Preferred Generic and Tier 2 Non-Preferred Generic Drugs. Compare your brand name drug cost to the Vantage copays for Tier 1 and Tier 2 Generics listed below. A sample of Tier 3 Preferred Brand Drugs with a $50 copay is also listed below for reference. EXPENSIVE BRAND NAME DRUGS: Amoxil Deltasone tablets Desyrel Elavil Estrace tablets Glucotrol Hydrodiuril Lasix Tenormin Zestril/Prinivil Zocor VANTAGE TIER 1 LOW-COST PREFERRED GENERICS amoxicillin prednisone tablets trazodone amitriptyline estradiol tablets glipizide hydrochlorothiazide (HCTZ) furosemide atenolol lisinopril simvastatin VANTAGE TIER 3 PREFERRED BRAND DRUGS Advair Bystolic Incruse Ellipta Januvia Lantus, Lantus Solostar Nasonex Novolin Premarin tablets Ventolin HFA Xarelto Zetia $5 Copay $50 Copay EXPENSIVE BRAND NAME DRUGS: Flexeril Glucophage Lipitor Mobic Neurontin Norvasc Pravachol Prilosec Singulair Zithromax VANTAGE TIER 2 NON-PREFERRED GENERICS cyclobenzaprine metformin atorvastatin meloxicam gabapentin amlodipine pravastatin omeprazole montelukast azithromycin $20 Copay The Vantage Medical Home HMO prescription drug benefit for OGB members has five copay levels, including Tier 4 Non-Preferred Brands with a $80 copay and Tier 5 Specialty Drugs with a $150 copay per prescription. The drugs listed above are an example and do not represent the full range of covered drugs available on the Vantage Medical Home HMO Plan. Prior Authorization and Quantity Limits are applicable for some drugs. Remember: A 90-day mail order supply of Tier 1 low-cost preferred generic drugs is available at no cost from Saint John Pharmacy. Also available on our website is the Mail Order Form. Fax or mail your completed Mail Order Form to have your prescriptions delivered right to your home. You can also call Saint John Pharmacy at (888) with your prescription information to transfer your medications. Basic shipping is free for Vantage Members. We can charge your debit or credit card for the applicable copay and expedited shipping charges. Please allow 48 hours to transfer and process the prescription(s) and an additional 5 business days for the U.S. Postal Service to deliver. P3

5 Vantage Wellness The Vantage Wellness Program is designed to encourage members to stay healthy. What s Available? Free Nutritional Counseling Free Diabetes Counseling Free Tobacco Cessation Counseling Free Access to Online Wellness Resources Free Smart Phone App Free Annual Wellness Exams Free Reward Opportunities 3 Program Options 1 Health Maintenance 2 Tobacco Cessation 3 Weight Loss For those who do not use tobacco and are at a healthy Body Mass Index (BMI). Maintain a weekly exercise log View educational wellness videos Remain tobacco-free Maintain a healthy weight Communicate with coaches by phone, , or at one of our Affinity Case Management Clinics For those who need to quit using tobacco. Same requirements as Health Maintenance and become tobacco-free Communicate with a Tobacco Cessation Coach by phone, , or at one of our Affinity Case Management Clinics Free Chantix for Vantage Members* *Free to those who qualify. Chantix must be prescribed by a physician. For those who need to lose weight. Same requirements as Health Maintenance and lose at least one pound per month Communicate with a Registered Dietitian by phone, , or at one of our Affinity Case Management Clinics Sign up today! VantageWellness.com Group Sign-Up Code = Spouse/Family/Friend Sign Up Code = 00910A Member ID = 11 digit ID number (see Member ID card) Call (318) to schedule an appointment with a Registered Dietitian or Tobacco Cessation Coach at one of our Affinity Case Management Clinics. P4

6 In-Network Providers Vantage members have access to a large number of nationwide providers in several networks. Please visit and search providers by name, city, or specialty. Call the Vantage Member Services department at (318) or toll-free at (844) for more information about our provider networks. How does it work? Tier I Providers Preferred Network Vantage Tier I Providers Reduced Cost Share on many covered services In-Network Tier I Cost Share on all other services Cannot balance bill members Vantage s standard network In-Network Tier I Cost Share Cannot balance bill members Tier II Network Verity Health Tier I Providers* Regional network In-Network Tier I Cost Share Cannot balance bill members Nationwide secondary network 20% Coinsurance in addition to In-Network Tier I Cost Share Cannot balance bill members * Members who live in the following parishes may access the Verity network and the Vantage standard network: Acadia, Ascension, Assumption, East Baton Rouge, East Feliciana, Evangeline, Iberia, Iberville, Lafayette, Lafourche, Livingston, Pointe Coupee, St. Helena, St. James, St. Landry, St. Martin, St. Mary, Terrebonne, Vermilion, West Baton Rouge and West Feliciana parishes. These parishes are also highlighted in the Verity map above. Residency and access is determined from the member s primary address in Vantage s records. P5

7 BENEFIT IN-NETWORK TIER 1 COVERAGE MONTHLY PREMIUM (employee-only premium) $ Actives & Retirees after 3/1/15 Retirees prior to 3/1/15 INDIVIDUAL $400 $0 TIER 1 MEDICAL DEDUCTIBLE INDIVIDUAL + 1 $800 $0 FAMILY $1,200 $0 INDIVIDUAL $2,500 $1,000 TIER 1 MEDICAL OUT-OF-POCKET MAXIMUM INDIVIDUAL + 1 $5,000 $2,000 FAMILY $7,500 $3,000 OFFICE VISITS: MEDICAL HOME-PRIMARY CARE PHYSICIAN (MH-PCP) SPECIALIST $20 copay per visit or $10 copay at AHN per visit $45 copay per visit or $35 copay at AHN per visit WELLNESS AND PREVENTIVE CARE LAB SERVICES MAJOR DIAGNOSTIC TESTS X-RAY AND OTHER HOSPITAL OUTPATIENT SERVICES OUTPATIENT SURGERY SERVICES EMERGENCY ROOM 100% covered 100% covered $50 per test or $0 per test at AHN 100% covered $100 copay or $50 copay at AHN $150 copay per visit - waived if admitted INPATIENT HOSPITAL $100 copay per day for days 1-3 or $50 per day at AHN for days 1-3 PHYSICIAN PROFESSIONAL FEES (inpatient) RADIOLOGIST / PATHOLOGIST / ANESTHESIOLOGIST PRESCRIPTION DRUGS No deductible VISION SERVICES: Routine Vision Exam Glasses and Contacts DENTAL SERVICES: Routine Preventive Cleaning Routine Bitewing X-rays Additional Dental Services 100% covered* 100% covered* Tier I Preferred Generic Mail Order (90-day supply)... $0 Copay at AHN Tier I Preferred Generics... $5 copay Tier II Non-Preferred Generics... $20 copay Tier III Preferred Brands... $50 copay Tier IV Non-Preferred Brands... $80 copay Tier V Specialty... $150 copay $45 copay per visit or $35 copay at AHN per visit 50% coinsurance; $100 maximum benefit for adults 100% coverage of Vantage Allowable 100% covered; $50 maximum benefit for adults 50% coinsurance after deductible; $500 maximum benefit for adults *Subject to Tier 1 Medical Deductible Tier II and Out-of-Network Benefits are available. See Cost Share Schedule. P6

8 Customer Service Frequently Asked Questions 1. How do I choose a Medical Home- Primary Care Physician? Your Medical Home-Primary Care Physician (MH-PCP) can be selected from our extensive list of physicians. Simply go to and select OGB Medical Home, click on Find a Provider. Select I m Looking Around, enter your ZIP code and select Plans Issued Through Your Employer and search for Family Practice, Internal Medicine, or Pediatric physicians. MH-PCPs can also be located by clicking on the Affinity or Verity logos. You can also call our Member Services Department at (318) or toll-free at (844) to select your MH-PCP. 2. Am I covered while traveling outside of Louisiana? Vantage Medical Home HMO members are covered anywhere in the world for emergency care as an in-network benefit. Vantage Medical Home HMO members also have access to the Vantage Tier II Nationwide Network. For a complete list of Vantage Tier II Providers, go to Contact Information Need to contact someone today? You can call us at (318) or toll-free at (844) or send an to memberservices@vhpla.com. For more information, you can also visit our website at Here you will find helpful resources which include forms, enrollment information, and information on how to locate a Vantage provider. General Contact Information: Monroe Headquarters: 130 DeSiard Street, Suite 300 Monroe, LA Local: (318) Toll-free: (844) Shreveport Office: 855 Pierremont Road, Suite 109 Shreveport, LA (844) Baton Rouge Office: 5778 Essen Lane, Suite B Baton Rouge, LA (844)