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benefit overview


 

Group High Deductible Plan
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
      • Maternity Services
    • Routine Vision Examination
    • Immunizations and Inoculations
    • Screening Mammography
  • Office Diagnostic Services
    • Lab
    • X-ray

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.

 

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