Listed below is an example of Vantage’s standard HMO 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
• 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
Pharmacy coverage must be elected by your company. Your pharmacy plan, if selected, is mandatory generic meaning if a brand drug is available in generic and you receive the brand drug, you pay the co-payment and the difference between the cost of the brand drug. Vantage reserves the right to change its formulary and which tier drugs are listed anytime.

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

Referrals and 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.