Vantage Health Plans

Freedom Silver 4500

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $4,500 Family: $13,500 Per Person: $4,500
Prescription Drug Deductible	Individual: $1,000 Family: $3,000 Per Person: $1,000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Office visit copay, if applicable, covers most services perfomed in an office setting that do not require pre-authorization.
Specialist	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Office visit copay, if applicable, covers most services perfomed in an office setting that do not require pre-authorization.

Prescription Drug Information

Preferred Brand Drugs	CoPay: $60.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Quantity limits, authorizations and step therapy limits may apply.
Non Preferred Brand Drugs	CoPay: $100.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Quantity limits, authorizations and step therapy limits may apply.
Generic Drugs	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Quantity limits, authorizations and step therapy limits may apply.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Specialty drugs may be limited to a thirty (30) day supply. Quantity limits, authorizations and step therapy limits may apply.

Inpatient Coverage

Hospital Services	CoPay: $1500.00 Copay per Day after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Copays, if applicable, are per day for first three days only.
Inpatient Services	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $450.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: The ER Copay is waived if the visit results in an inpatient admission.
Urgent Care Facility	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $4500.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Minimum stay of 48 hours
Pre and Postnatal Office Visit	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: $75.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year

Major Dental Care

Routine Dental Checkups for Children	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Limit Quantity: 2 Limit Unit : Visit(s) per Year
Routine Dental Checkups for Adults	CoPay: Not Applicable CoInsurance: No Charge Covered: Covered Limit Quantity: 2 Limit Unit : Visit(s) per Year Benefit Explanation: Covers exam and cleaning
Basic Dental Care - Adult	CoPay: Not Applicable CoInsurance: 0.00% Covered: Covered Benefit Explanation: An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care.
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered
Major Dental Care - Adult	CoPay: Not Applicable CoInsurance: 0.00% Covered: Covered Benefit Explanation: An added benefit. Combined $1,000 maximum coverage per benefit period for Adult Basic and Major Dental Care.
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered

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