Vantage Traditional Plus (HMO-POS) - $33.10 per month

No Referrals

Low Medical Home Primary Care Physician (MH-PCP) Office visit copay

Part D prescription coverage included

Suplemental Benefits for vision, hearing and dental are as follows:

Vision

Member pays 50% coinsurance for 12 pairs of contacts and/or 1 pair of glasses with $100 maximum benefit per year
Annual Routine Hearing Exam - Maximum benefit of $40 lifetime after age 65
Hearing Aid - 20% coinsurance with a maximum benefit of $300 per year

Dental

100% coverage for preventive dental care. Cleanings, x-rays, and oral exams with a maximum benefit of $200 every six months
100% coverage with a maximum benefit of $450 per year for extractions, fillings, dentures, and dental plates.

* Premium & co-insurance amounts will depend on your level of subsidy.

Evidence of Coverage
Summary of Benefits
Comprehensive Formulary
Updated August 1, 2019
Enrollment Election Form

The benefit information provided is a brief summary, not a complete description of benefits. Premiums and co-payments/co-insurance amounts may change on January 1 of each year.

This page was last updated:8/12/2019