Coverage Request Form

Thank you for your interest in Vantage. After completing the form below, we will contact you within the next 1-2 business days. If you prefer to speak with someone instead, please call Toll-Free at (888) 823-1910. If you feel that waiting the standard timeframe for a decision could seriously harm a member’s life, health, or ability to regain maximum function, please ask for an expedited (fast) decision by contacting Vantage by phone or fax.

Request Type:
Name and Insurance Information:
Location:
Contact:
Drug and Provider Information:
Submitter (other than member):
Request:
Vantage Health Plan, Inc., Insurance  Health, Monroe, LA