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Medical Home HMO

Administered by Vantage

2018 Summary of Benefits
2017 Summary of Benefits

Vantage 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 co-payments for certain covered services as indicated by “AHN.” This plan also includes Out-of-Network coverage.

Medical Coverage

  Employee Only Employee + 1 (Spouse or Child) Employee + Children Family
Deductible (Tier I) $400 $800 $1,200 $1,200
Deductible (Tier II & Out-of-Network) $1,500 $3,000 $4,500 $4,500
Out-of-pocket max (Tier I) $2,500 $5,000 $5,000 $7,500
Out-of-pocket max (Tier II & Out-of-Network) Unlimited Unlimited Unlimited Unlimited
Co-Payment PCP (Tier I) $10 AHN / $20 $10 AHN / $20 $10 AHN / $20 $10 AHN / $20
Co-Payment Specialist (Tier I) $34 AHN / $45 $35 AHN / $45 $35 AHN / $45 $35 AHN / $45
Coinsurance - PCP (Out-of-Network) 50% coverage; subject to out-of-network deductible
Coinsurance - Specialist (Out-of-Network) 50% coverage; subject to out-of-network deductible

 

Prescription Coverage

Tier Member Responsibility
Tier 1 Preferred Generics $5
Tier 2 Non-Preferred Generics $20
Tier 3 Preferred Brand $50
Tier 4 Non-Preferred Brand $80
Tier 5 Specialty $150

 

Tier I Providers

Members seeing Tier I providers pay the Tier I co-pays, co-insurance and deductible as listed in the Certificate of Coverage and Cost Share Schedule. Tier I consists of two networks:

  • A preferred provider network, Affinity Health Network (AHN), which has lower co-payments for certain covered services; and 
  • A standard provider network

Tier II Providers

Members who chose to see these providers will have to pay an additional 20% coinsurance in addition to their Tier I cost share, after the applicable deductible is met.

 

 

At times you may have to pay out of pocket for medical services or for prescriptions, particularly if you have received services from a non-network provider. In the event that you do pay out of pocket for services, you can be reimbursed for these services. You will need to complete and submit a claim form and a copy of the invoice to the appropriate carrier. You may submit a claim form (see below) along with a copy of the invoice to your health insurance carrier. Vantage will then reimburse you according to the plan's guidelines.