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Matters Most.
PLATINUM
GOLD
SILVER
BRONZE
VANTAGE HEALTH PLAN
H E A LT H IN SURA N CE
MARKETPLACE PLAN FINDER
PICK YOUR PLAN
“Thanks, Vantage,
for making it so easy!”
Vantage Platinum
Best benefits that Vantage offers!
No deductibles and lowest copay
amounts
Vantage Gold
Low office visit and hospital copays
with a medical-only deductible
Vantage Silver
Great plan for comprehensive
coverage with reasonable out-ofpocket costs
Vantage Bronze
Pay nothing after you have
met your deductible
2015 VANTAGE MARKETPLACE PLAN Finder
VANTAGE MARKETPLACE
PLATINUM (AAA011)
BENEFITS
VANTAGE MARKETPLACE
GOLD (AAA012)
VANTAGE MARKETPLACE
SILVER (AAA013)
Deductible
None
$750 Individual; $1,500 Family
$2,900 Individual; $5,800 Family
Office Visit/
Medical Home-Primary Care Physician (MH-PCP)
$10 copay per visit
$15 copay per visit, no deductible
$25 copay per visit, no deductible
Office Visit / Specialist
$30 copay per visit
$45 copay per visit, no deductible
$75 copay per visit, no deductible
Inpatient Hospital
$300 copay per day for days 1 - 3
$600 copay per day for days 1 - 3
$1,500 copay per day for days 1 - 3
Radiologist / Anesthesiologist
Covered 100%
Covered 100%
Covered 100%
Outpatient Surgery Services
$200 copay
$400 copay
$1,000 copay
Emergency Room
$100 copay
$200 copay
$300 copay
(MRI, CT Scan, Stress Test, Bone Density Scan, Pet
Scan and Others)
$100 copay per test
$200 copay per test
$300 copay per test
X-Rays (Outside Physician’s Office)
100% coinsurance up to $100 per day
100% coinsurance up to $200 per day
100% coinsurance up to $300 per day
Home Health & Hospice
20% coinsurance
20% coinsurance
20% coinsurance
Radiation & Chemotherapy
20% coinsurance
20% coinsurance
20% coinsurance
Flu Shots
Covered 100%
Covered 100%, no deductible
Covered 100%, no deductible
No Rx deductible & No separate premium
No Rx deductible & No separate premium
No Rx deductible & No separate premium
Low-Cost Generics:
Non-Preferred Generics:
Preferred Brand:
Non-Preferred Brand:
Specialty Drugs:
Low-Cost Generics:
Non-Preferred Generics:
Preferred Brand:
Non-Preferred Brand:
Specialty Drugs:
Low-Cost Generics:
Non-Preferred Generics:
Preferred Brand:
Non-Preferred Brand:
Specialty Drugs:
Major Diagnostic Test
Prescription Drugs
$3 copay
$15 copay
$45 copay
$95 copay
33% coinsurance,
up to $150 per drug per month
$3 copay
$15 copay
$45 copay
$95 copay
33% coinsurance,
up to $150 per drug per month
$3 copay
$15 copay
$45 copay
$95 copay
33% coinsurance,
up to $150 per drug per month
Rx Out-of-Pocket Maximum: $500 Individual; $1,000 Family
Rx Out-of-Pocket Maximum: $900 Individual; $1,800 Family
Rx Out-of-Pocket Maximum: $1,200 Individual; $2,400 Family
Medical Out-of-Pocket Maximum
$6,100 Individual; $12,200 Family
$5,700 Individual; $11,400 Family
$5,400 Individual; $10,800 Family
Dental
Included with plan (see right panel)
Included with plan (see right panel)
Included with plan (see right panel)
Vision
Included with plan (see right panel)
Included with plan (see right panel)
Included with plan (see right panel)
This comparison is not a complete comparison.
2015 VANTAGE MARKETPLACE PLAN Finder
VANTAGE MARKETPLACE
BENEFITS
GOLD (AAA012)
Deductible
$750 Individual;
$1,500 Family
VANTAGE
VANTAGEMARKETPLACE
MARKETPLACE
SILVER
PLATINUM
(AAA013)
(AAA011)
VANTAGE MARKETPLACE
BRONZE
GOLD (AAA012)
(AAA014)
VANTAGE VISION & DENTAL BENEFITS
INCLUDED IN ALL PLANS
VANTAGE MARKETPLACE
SILVER (AAA013)
Adult and Children Vision Benefits
Platinum,
Gold, and
Silver
Plans
$2,900 Individual;
$5,800
Family
Ŷ Specialist copay for one routine eye exam per year
None
$2,900 Individual; $5,800 Family
$6,600
$750 Individual;
Individual;$1,500
$13,200
Family
Family
$15 copay per visit, no deductible
$25 copay
copay per
per visit
visit, no deductible
$10
$45
$15 copay per visit, no deductible
copay per
visit,coinsurance
no deductible
Ŷ$25Children
- 50%
for 12 pairs of contacts
or 1 pair of glasses per year
$45 copay
perVisit
visit, no
deductible
Office
/ Specialist
$75 copay per visit
visit, no deductible
$30
$80
$45 copay per visit, no deductible
$600 copay
per day
for days 1 - 3
Inpatient
Hospital
$1,500copay
copayper
perday
dayforfordays
days1 1- 3- 3
$300
0%
coinsurance
deductible
$600
copay per after
day for
days 1 - 3
copay- per
no deductible
Ŷ$75Adults
20%visit,
coinsurance
with a maximum benefit of
$100 for 12 pairs of contacts or 1 pair of glasses per year
$1,500 copay per day for days 1 - 3
Bronze Plan
Covered
100%
Radiologist
/ Anesthesiologist
Covered 100%
100%
Covered
0%
coinsurance
Covered
100% after deductible
100%
ŶCovered
Specialist
copay for one routine eye exam per year
$400 copay
Outpatient Surgery Services
$1,000copay
copay
$200
0%
coinsurance
after deductible
$400
copay
Ŷ Children - 0% coinsurance after deductible for 12 pairs
$1,000
copay or 1 pair of glasses per year
of contacts
$200 copay
Emergency Room
$300 copay
copay
$100
0%
coinsurance
after deductible
$200
copay
Ŷ$300
Adults
- 100% coverage for 12 pairs of contacts or 1 pair
copay
of glasses per year with a maximum benefit of $100
$200 copay
test Stress Test, Bone Density Scan, Pet
(MRI, per
CT Scan,
Scan and Others)
$300 copay
copay per
per test
test
$100
0%
coinsurance
after deductible
$200
copay per test
100% X-Rays
coinsurance
up to $200
per day Office)
(Outside
Physician’s
100% coinsurance
coinsurance up
up to
to $100
$300 per
per day
day
100%
0%
coinsurance
after
100%
coinsurance
updeductible
to $200 per day
20% coinsurance
Home Health & Hospice
20% coinsurance
coinsurance
20%
0%
20%coinsurance
coinsuranceafter deductible
20% coinsurance
Radiation & Chemotherapy
20% coinsurance
coinsurance
20%
0%
20%coinsurance
coinsuranceafter deductible
Covered
no deductible
Flu100%,
Shots
Covered 100%
100%, no deductible
Covered
Covered 100%, no deductible
ŶCovered
Adults100%,
- 100%nocoverage
for bitewing x-rays, 1 set of
deductible
x-rays per year with a maximum benefit of $50
No Rx deductible & No separate premium
No Rx
Rx deductible
deductible && No
No separate
separate premium
premium
No
No Rx deductible & No separate premium
Low-Cost Generics:
$3 copay
Non-Preferred Generics:
$15 copay
Preferred Brand:
$45 copay
Prescription
Drugs
Non-Preferred Brand:
$95 copay
Specialty Drugs:
33% coinsurance,
up to $150 per drug per month
Low-Cost Generics:
Generics:
Low-Cost
Non-Preferred Generics:
Generics:
Non-Preferred
Preferred Brand:
Brand:
Preferred
Non-Preferred Brand:
Brand:
Non-Preferred
Specialty Drugs:
Drugs:
Specialty
Low-Cost Generics:
$3 copay
Non-Preferred Generics:
$15 copay
Preferred Brand:
$45 copay
100% coinsurance up to out-of-pocket maximum
Non-Preferred Brand:
$95 copay
Specialty Drugs:
33% coinsurance,
up to $150 per drug per month
Rx Out-of-Pocket Maximum: $900 Individual; $1,800 Family
Rx Out-of-Pocket
Out-of-Pocket Maximum:
Maximum: $500
$1,200Individual;
Individual;$1,000
$2,400
Family
Rx
Family
Rx Out-of-Pocket Maximum: $900 Individual; $1,800 Family
No Rx deductible & No separate premium
Low-Cost
Generics:
$3 copay
Bronze
Plan
Non-Preferred Generics:
$15 copay
Brand: for routine$45
copay
ŶPreferred
100% coverage
dental
exams and cleanings,
Non-Preferred
Brand:
1 exam every
6 months $95 copay
Specialty Drugs:
33% coinsurance,
Ŷ Children - Basic Dental Services
cleaning
up to (including
$150 per drug
per month
bitewing x-rays)
and Major
Services
- 0%Family
Rx and
Out-of-Pocket
Maximum:
$1,200Dental
Individual;
$2,400
coinsurance after deductible
$5,700Medical
Individual;Out-of-Pocket
$11,400 Family Maximum
$5,400Individual;
Individual; $10,800
$6,100
$12,200 Family
$0
afterIndividual;
the deductible
$5,700
$11,400 Family
Included
with plan (see right panel)
Dental
Included with
with plan
plan (see
(see right
right panel)
panel)
Included
Included with plan (see right panel)
Included
with plan (see right panel)
Vision
Included with
with plan
plan (see
(see right
right panel)
panel)
Included
Included with plan (see right panel)
Office Visit/
Medical Home-Primary Care Physician (MH-PCP)
Major Diagnostic Test
This comparison is not a complete comparison.
$3 copay
copay
$3
$15 copay
copay
$15
$45 copay
copay
$45
$95 copay
copay
$95
33% coinsurance,
coinsurance,
33%
up to
to $150
$150 per
per drug
drug per
per month
month
up
$300 copay per test
Adult and Children Dental Benefits
Platinum, Gold, and Silver Plans
100% coinsurance up to $300 per day
Ŷ 100% coverage for routine dental exams and cleanings,
1 exam every 6 months
20% coinsurance
Ŷ Children - Basic Dental Services (including cleaning
and bitewing x-rays) and Major Dental Services - 50%
20% coinsurance
coinsurance after deductible
Individual;
$10,800 Family
Ŷ$5,400
Adults
- 100% coverage
for bitewing x-rays, 1 set of
x-rays per year with a maximum benefit of $50
Included with plan (see right panel)
Included with plan (see right panel)
NEED MORE INFORMATION?
Ŷ Call us at (855) 545-3847 or TTY at (866) 524-5144 (for the hearing impaired)
Ŷ Ask a Vantage representative about a one-on-one home visit
Ŷ Come by our office
Ŷ Visit our website at www.VantageHealthPlan.com/Marketplace
CONTACT DETAILS
Phone & Website
Toll-Free: (855) 545-3847
TTY (866) 524-5144 (for the hearing impaired)
www.VantageHealthPlan.com/Marketplace
Monroe Location
130 DeSiard Street, Suite 300
Monroe, LA 71201
Shreveport Location
855 Pierremont Road, Suite 109
Shreveport, LA 71106
Baton Rouge Location
5778 Essen Lane, Suite B
Baton Rouge, LA 70810
Vantage Health Plan, Inc. is a Qualified Health Plan
in the Health Insurance Marketplace.
VHP721 R101714 NotApproved