Vantage Health Plan2016 OGB Medical Home HMO Plan

Nationwide Coverage. Nationwide Care. Nationwide Service.

VHP517 R090415 Approved

OGB Approved

Dear OGB Member:

Vantage Health Plan will continue to be a health plan option for eligible OGB Members in 2016.

• If you are a current Vantage Medical Home HMO Member and you would like to keep your Vantage plan with the same covered dependents for the 2016 plan year, you do not need to do anything. Your coverage will continue for the 2016 plan year. See page 6 for the 2016 Vantage benefits.

• If you are not currently a Vantage Medical Home HMO Member and would like to enroll in Vantage for 2016, see below for enrollment options:

ACTIVE EMPLOYEES:

1. Visit www.groupbenefits.org to use the annual enrollment portal to enroll in Vantage Medical Home HMO with the same covered dependents as your 2015 coverage, or

2. Contact your human resources department to enroll in Vantage Medical Home HMO with the same or different covered dependents as your 2015 coverage.

NOTE: A paper enrollment form will NOT be accepted from active employees.

RETIREES:

1. Visit www.groupbenefits.org to use the annual enrollment portal to enroll in Vantage Medical Home HMO with the same covered dependents as your 2015 coverage, or

2. Complete the annual enrollment form and return it to the address provided by November 15 to enroll in Vantage Medical Home HMO with the same covered dependents as your 2015 coverage, or

3. Mail or fax a signed and dated letter to OGB with your change request, including any dependent changes. Be sure to include the primary plan member’s social security number or OGB member ID number. If adding a dependent please include marriage certificate and/or birth certificate. Mail to: Office of Group Benefits, Annual Enrollment, P.O. Box 44036, Baton Rouge, LA 70804 or Fax to: (225) 342-9917.

NOTICE: Annual Enrollment ends November 15, 2015. Please don’t wait to make your 2016 plan selection!

If you have any questions about the Vantage Medical Home HMO Plan, please call our Member Services Department at (318) 998-4434 or toll-free at (844) 536-7104 or visit us online at www.VHP-StateGroup.com. We look forward to serving you.

Thank you,

William J. JusticeDirector of Marketing and Member ServicesP1

Welcome to Vantage

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The search tools on our Vantage website, www.VHP-StateGroup.com, will allow you to find a provider or a retail pharmacy or to search for prescription drugs covered by Vantage. If you have any questions, please contact Vantage Health Plan at (318) 998-4434 or toll-free at (844) 536-7104. For the hearing impaired, please call toll-free TTY (866) 524-5144. Member Services is available Monday through Friday from 8:00 a.m. – 5:00 p.m. CST.

Thank you again for considering Vantage Health Plan. We look forward to serving you!

Thank you for your interest in Vantage Health Plan, Inc. The content found in this booklet will provide you with the information you need to enroll in the Vantage Medical Home HMO Plan.

Nationwide Coverage. Nationwide Care. Nationwide Service.

Check WhatMatters Most.

$0 copay for low-cost preferred generic drugs through Saint John Pharmacy mail order (90-day supply)

Check WhatMatters Most.Prescription drug plan with $5 copay for low-cost preferred generic drugs - no deductible

Check WhatMatters Most.Great local customer service

Check WhatMatters Most.Dental and Vision coverage

Check WhatMatters Most.Worldwide emergency coverage

Check WhatMatters Most.Annual wellness exam covered 100%

Check WhatMatters Most.No Referrals

Check WhatMatters Most.Reduced copays for some services through Affinity Health Network (AHN)

Check WhatMatters Most.

$20 Medical Home primary care office visit copays or $10 Medical Home primary care office visit copays through Affinity Health Network (AHN)

Check WhatMatters Most.$156.72 monthly premium for employee-only coverage

CHECK WHAT MATTERS MOSTCheck WhatMatters Most.

Quick Drug List

The Vantage Medical Home HMO prescription drug benefit for OGB members has five copay levels, including Tier 4 Non-Preferred Brands with a $80 copay and Tier 5 Specialty Drugs with a $150 copay per prescription. The drugs listed above are an example and do not represent the full range of covered drugs available on the Vantage Medical Home HMO Plan.

Prior Authorization and Quantity Limits are applicable for some drugs.

AdvairBystolicIncruse ElliptaJanuviaLantus, Lantus SolostarNasonexNovolinPremarin tabletsVentolin HFAXareltoZetia

AmoxilDeltasone tabletsDesyrelElavilEstrace tabletsGlucotrolHydrodiurilLasixTenorminZestril/PrinivilZocor

EXPENSIVEBRAND NAME DRUGS:

VANTAGE TIER 1 LOW-COST PREFERRED GENERICS

VANTAGE TIER 3 PREFERRED BRAND DRUGS

amoxicillinprednisone tablets trazodoneamitriptylineestradiol tabletsglipizide hydrochlorothiazide (HCTZ)furosemideatenolollisinopril simvastatin

$5 Copay $50 Copay

EXPENSIVEBRAND NAME DRUGS:

VANTAGE TIER 2NON-PREFERREDGENERICS

FlexerilGlucophageLipitorMobicNeurontinNorvascPravacholPrilosecSingulairZithromax

cyclobenzaprinemetforminatorvastatinmeloxicamgabapentinamlodipinepravastatinomeprazole montelukast azithromycin

$20 Copay

Also available on our website is the Mail Order Form. Fax or mail your completed Mail Order Form to have your prescriptions delivered right to your home. You can also call Saint John Pharmacy at (888) 316-4354 with your prescription information to transfer your medications. Basic shipping is free for Vantage Members. We can charge your debit or credit card for the applicable copay and expedited shipping charges. Please allow 48 hours to transfer and process the prescription(s) and an additional 5 business days for the U.S. Postal Service to deliver.

Remember: A 90-day mail order supply of Tier 1 low-cost preferred generic drugs is available at no cost from Saint John Pharmacy.

Vantage may save you money on your prescription drugs each year with low copays for Tier 1 Low-Cost Preferred Generic and Tier 2 Non-Preferred Generic Drugs. Compare your brand name drug cost to the Vantage copays for Tier 1 and Tier 2 Generics listed below. A sample of Tier 3 Preferred Brand Drugs with a $50 copay is also listed below for reference.

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Vantage Wellness

The Vantage Wellness Program is designed to encourage members to stay healthy.

What’s Available?

3 Program Options

For those who do not use tobacco and are at a healthy Body Mass Index (BMI).

For those who need to lose weight.

■ Maintain a weekly exercise log

■ View educational wellness videos

■ Remain tobacco-free

■ Maintain a healthy weight

■ Communicate with coaches by phone, e-mail, or at one of our Affinity Case Management Clinics

■ Same requirements as Health Maintenance and lose at least one pound per month

■ Communicate with a Registered Dietitian by phone, e-mail, or at one of our Affinity Case Management Clinics

■ Free Nutritional Counseling

■ Free Diabetes Counseling

■ Free Tobacco Cessation Counseling

■ Free Access to Online Wellness Resources

■ Free Smart Phone App

■ Free Annual Wellness Exams

■ Free Reward Opportunities

1 3Health Maintenance Weight Loss

For those who need to quit using tobacco.

■ Same requirements as Health Maintenance and become tobacco-free

■ Communicate with a Tobacco Cessation Coach by phone, e-mail, or at one of our Affinity Case Management Clinics

2 Tobacco Cessation

Free Chantix® for Vantage Members**Free to those who qualify. Chantix® must be prescribed by a physician.

Sign up today!

Call (318) 361-2138 to schedule an appointment with a Registered Dietitian or Tobacco Cessation Coach at one of our Affinity Case Management Clinics.

Group Sign-Up Code = 00910Spouse/Family/Friend Sign Up Code = 00910AMember ID = 11 digit ID number (see Member ID card)

VantageWellness.com

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Vantage members have access to a large number of nationwide providers in several networks. Please visit www.VHP-StateGroup.com and search providers by name, city, or specialty.

Call the Vantage Member Services department at (318) 998-4434 or toll-free at (844) 536-7104 for more information about our provider networks.

In-Network Providers

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How does it work?

Tier I Providers Preferred Network

Tier II Network

■ Reduced Cost Share on many covered services

■ In-Network Tier I Cost Share on all other services

■ Cannot balance bill members

■ Nationwide secondary network

■ 20% Coinsurance in addition to In-Network Tier I Cost Share

■ Cannot balance bill members

* Members who live in the following parishes may access the Verity network and the Vantage standard network: Acadia, Ascension, Assumption, East Baton Rouge, East Feliciana, Evangeline, Iberia, Iberville, Lafayette, Lafourche, Livingston, Pointe Coupee, St. Helena, St. James, St. Landry, St. Martin, St. Mary, Terrebonne, Vermilion, West Baton Rouge and West Feliciana parishes. These parishes are also highlighted in the Verity map above. Residency and access is determined from the member’s primary address in Vantage’s records.

Verity Health Tier I Providers*

■ Regional network

■ In-Network Tier I Cost Share

■ Cannot balance bill members

Vantage Tier I Providers

■ Vantage’s standard network

■ In-Network Tier I Cost Share

■ Cannot balance bill members

Benefits

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BENEFIT IN-NETWORK TIER 1 COVERAGE

MONTHLY PREMIUM (employee-only premium) $156.72Actives & Retirees after 3/1/15 Retirees prior to 3/1/15

TIER 1 MEDICAL DEDUCTIBLEINDIVIDUAL $400 $0

INDIVIDUAL + 1 $800 $0FAMILY $1,200 $0

TIER 1 MEDICAL OUT-OF-POCKET MAXIMUMINDIVIDUAL $2,500 $1,000

INDIVIDUAL + 1 $5,000 $2,000FAMILY $7,500 $3,000

OFFICE VISITS:MEDICAL HOME-PRIMARY CARE PHYSICIAN (MH-PCP)SPECIALIST

$20 copay per visit or $10 copay at AHN per visit$45 copay per visit or $35 copay at AHN per visit

WELLNESS AND PREVENTIVE CARE 100% covered

LAB SERVICES 100% covered

MAJOR DIAGNOSTIC TESTS $50 per test or $0 per test at AHN

X-RAY AND OTHER HOSPITAL OUTPATIENT SERVICES 100% covered

OUTPATIENT SURGERY SERVICES $100 copay or $50 copay at AHN

EMERGENCY ROOM $150 copay per visit - waived if admitted

INPATIENT HOSPITAL $100 copay per day for days 1-3 or $50 per day at AHN for days 1-3

PHYSICIAN PROFESSIONAL FEES (inpatient) 100% covered*

RADIOLOGIST / PATHOLOGIST / ANESTHESIOLOGIST 100% covered*

PRESCRIPTION DRUGS – No deductible

Tier I Preferred Generic Mail Order (90-day supply) .............. $0 Copay at AHNTier I Preferred Generics ...................................................................... $5 copayTier II Non-Preferred Generics ........................................................... $20 copayTier III Preferred Brands ..................................................................... $50 copayTier IV Non-Preferred Brands ............................................................. $80 copayTier V Specialty ................................................................................ $150 copay

VISION SERVICES:Routine Vision ExamGlasses and Contacts

$45 copay per visit or $35 copay at AHN per visit50% coinsurance; $100 maximum benefit for adults

DENTAL SERVICES:Routine Preventive Cleaning Routine Bitewing X-raysAdditional Dental Services

100% coverage of Vantage Allowable 100% covered; $50 maximum benefit for adults50% coinsurance after deductible; $500 maximum benefit for adults

*Subject to Tier 1 Medical Deductible

Tier II and Out-of-Network Benefits are available. See Cost Share Schedule.

Customer Service

For more information, you can also visit our website at www.VHP-StateGroup.com. Here you will find helpful resources which include forms, enrollment information, and information on how to locate a Vantage provider.

General Contact Information:

Monroe Headquarters:

130 DeSiard Street, Suite 300Monroe, LA 71201Local: (318) 998-4434Toll-free: (844) 536-7104

Shreveport Office:

855 Pierremont Road, Suite 109 Shreveport, LA 71106 (844) 536-7104

Baton Rouge Office:

5778 Essen Lane, Suite BBaton Rouge, LA 70810(844) 536-7104

www.VHP-StateGroup.com

Frequently Asked Questions

Contact Information

Need to contact someone today? You can call us at (318) 998-4434 or toll-free at (844) 536-7104 or send an e-mail to memberservices@vhpla.com.

2. Am I covered while traveling outside of Louisiana?

1. How do I choose a Medical Home-Primary Care Physician?

Your Medical Home-Primary Care Physician (MH-PCP) can be selected from our extensive list of physicians. Simply go to www.VHP-StateGroup.com and select “OGB Medical Home”, click on “Find a Provider”. Select “I’m Looking Around”, enter your ZIP code and select “Plans Issued Through Your Employer” and search for Family Practice, Internal Medicine, or Pediatric physicians. MH-PCPs can also be located by clicking on the Affinity or Verity logos. You can also call our Member Services Department at (318) 998-4434 or toll-free at (844) 536-7104 to select your MH-PCP.

Vantage Medical Home HMO members are covered anywhere in the world for emergency care as an in-network benefit. Vantage Medical Home HMO members also have access to the Vantage Tier II Nationwide Network. For a complete list of Vantage Tier II Providers, go to www.VHP-StateGroup.com/Tier2Providers.