Listed below is an example of Vantage’s standard High Deductible benefits. (Please note actual benefits and/or limits may vary from plan to plan and from employer to employer. Exclusions and limitations may apply.)
Medical Benefits
- Primary Care Physician Office Visits
- Specialty Care Office Visits
- Preventive Care
- Annual Prostate Examination
- Annual Physical Examination
- Well Baby/Child Care
- Gynecological Examination
- Routine Vision Examination
- Immunizations and Inoculations
- Screening Mammography
- Office Diagnostic Services
Outpatient Care*
- Major Diagnostic Testing
- Diagnostic X-ray
- Lab
- Bone Density Screening
- Outpatient Surgery
Inpatient Care*
- Inpatient Semi-Private Room
- Medically Necessary Services and Supplies
- Physician Services
Emergency Services (covered in or out of the service area)
For accidental injury or sudden onset of an acute illness, seek emergency care at a participating facility, if possible. Emergency criteria include, but are not limited to, the following:
- Severe pain, sudden onset
- Severe hemorrhage
- Respiratory distress
- Accidental injuries
- Obvious severe emotional distress requiring treatment with IM or IV medications
- Unconsciousness
- Convulsions
Ambulance
- Local ground transportation to a hospital in a covered medical emergency
- Air ambulance covered at the discretion of Vantage*
- Transfers from a non-participating hospital to a participating hospital or from a hospital to other medical facility or home if medically necessary
Durable Medical Equipment and Supplies*
- Lifetime maximum of $50,000 applies
- Artificial limbs, eyes, braces and appliances to replace physical organs or parts, or to aid in their function, if medically necessary as a result of injury or illness, but is limited to initial issue of such appliance
- Oxygen and rental of equipment for its administration
- Rental, not to exceed purchase price, of:
- Wheelchair, crutches, canes or walkers
- Hospital bed
- Home ventilation equipment for treatment of chronic and acute respiratory failure
Prescription Drugs
There is no pharmacy coverage
Mental Health Services*
- Outpatient Mental Health Services
- Inpatient Mental Health Services
- Outpatient Alcohol/Chemical Dependency
- Inpatient Alcohol/Chemical Dependency
Other Covered Services*
- Extended Care
- Skilled Nursing Facility
- Home Health Care
- Hospice Care
- Rehabilitation Facility
- Accidental Dental
- Anesthesia and Hospitalization for Dental Procedures
- Physical Therapy
- Occupation and Speech Therapy
- Allergy Services
- Cardiac Rehabilitation
- Nutritional Counseling
- Low Protein Foods for Treatment of Inherited Metabolic Diseases
- Hearing Impaired Interpreter Expense
- Hearing Aid for Minor Member
- Diabetes Management Equipment, Supplies and Training
The Deductible must be met each contract year before medical or pharmacy benefits are payable under the Plan.
Pre-authorizations are MEMBER responsibilities and MUST BE obtained by the Physician or MEMBER before receiving services in order to be covered.
*Services require pre-authorization by Vantage.
Eligibility for Student Coverage
Full-time student dependents under the age of 24 may be covered by the Plan for services provided by participating providers within the Vantage service area.
