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.