Vantage

Vantage Medical Home HMO

Administered by Vantage Health Plan

Vantage Medical Home HMO Benefit Snapshot

The Office of Group Benefits (OGB) offers multiple health plans, including the Vantage Medical Home HMO. The Medical Home HMO is a traditional HMO offered by Vantage Health Plan. This plan provides coverage through the Affinity Health Networks and a standard provider network.

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.

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.

Medical Coverage	Employee Only	Employee + Spouse	Employee + Child(ren)	Family
Deductible (In-Network)	$400	$800	$1,200	$1,200
Deductible (Out-of-Network)	$2,000	$4,000	$6,000	$6,000
MOOP (In-Network)	$3,500	$6,000	$8,500	$8,500
MOOP (Out-of-Network)	Unlimited	Unlimited	Unlimited	Unlimited
Co-payments - PCP (In-Network)	$20 AHN / $40 for PCP or $45 AHN / $65 Specialist
Coinsurance - (Out-of-Network)	50% coverage; subject to out-of-network deductible

The Vantage Medical Home HMO prescription drug benefit has five copayment levels. There is no prescription drug deductible.

Tier	Member Responsibility
Tier 1 Preferred Generics	$0 AHN / $15
Tier 2 Non-Preferred Generics	$40
Tier 3 Preferred Brand	$75
Tier 4 Non-Preferred Brand	$100
Tier 5 Specialty	$150

Enrollment forms can be submitted via email to nohrmbenefits@lsuhsc.edu. For secure transmission, employees should send these from their LSUHSC email. Forms can also be mailed or dropped off to our office at 433 Bolivar Street, Room 626.