VANTAGE MEDICAL HOME HMO PLAN

OGB Approved

Dear OGB Member:

Vantage Health Plan will continue to be a health plan option for eligible OGB Members in 2017.

• 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 2017 plan year, you do not need to do anything. Your coverage will continue for the 2017 plan year. See page 6 for the 2017 Vantage benefits.

• If you are not currently a Vantage Medical Home HMO Member and would like to enroll in Vantage for 2017, see below for enrollment options:

ACTIVE EMPLOYEES:

1. Visit www.groupbenefits.org to use the annual enrollment portal to enroll in the Vantage Medical Home HMO with the same covered dependents as your 2016 coverage, or

2. Contact your human resources department to enroll in the Vantage Medical Home HMO with the same or different covered dependents as your 2016 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 the Vantage Medical Home HMO with the same covered dependents as your 2016 coverage, or

2. Download and complete the OGB annual enrollment form and return it to the address listed on the form by November 15 to enroll in the Vantage Medical Home HMO with the same covered dependents as your 2016 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 dependent verification documentation (i.e., 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, 2016. Please don’t wait to make your 2017 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 Services

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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.

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 certain other services through Affinity Health Network (AHN)

Check WhatMatters Most.

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

Check WhatMatters Most.$167.72 monthly premium for employee-only coverage

CHECK WHAT MATTERS MOSTCheck WhatMatters Most.

Specialist copay for one routine eye exam per year, not subject to deductible.

Glasses/Contacts - 50% coinsurance for 12 pairs of contacts or 1 pair of glasses per year, not subject to deductible; maximum benefit of $100 for adults.

100% coverage for one routine dental exam and cleaning every 6 months and an annual x-ray, not subject to deductible

Basic and Intermediate/Major Dental Services - 50% coinsurance, maximum benefit of $500 for adults

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Vision Benefits

Dental Benefits

Vantage Vision & Dental

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Benefits

BENEFIT IN-NETWORK COVERAGE

MONTHLY PREMIUM (employee-only premium) $167.72Actives & Retirees after 3/1/15 Retirees prior to 3/1/15

IN-NETWORK MEDICAL DEDUCTIBLEINDIVIDUAL $400 $0

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

IN-NETWORK MEDICAL OUT-OF-POCKET MAXIMUM

INDIVIDUAL $2,500 $1,000INDIVIDUAL + 1 $5,000 $2,000

FAMILY $7,500 $3,000OFFICE VISITS:

MEDICAL HOME-PRIMARY CARE PROVIDER (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, $300 maximum copay per stay

PHYSICIAN PROFESSIONAL FEES 100% covered after deductible

RADIOLOGIST / PATHOLOGIST / ANESTHESIOLOGIST 100% covered after deductible

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 , Exam and an Annual X-ray Additional Dental Services

100% coverage at Vantage Allowable 50% coinsurance of Vantage Allowable; $500 maximum benefit for adults

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

In-Network Providers

Vantage members have access to thousands of In-Network providers. In-Network Providers cannot balance bill Members.

Please visit www.VHP-StateGroup.com and select “OGB Medical Home HMO” to search for In-Network providers by

name, city, or specialty.

■ Reduced Cost Share on many covered services

■ In-Network standard Cost Share on all other services

■ Regional network ■ In-Network Cost Share

■ Vantage’s Standard network ■ In-Network Cost Share

Verity Health Network ProvidersMembers 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 below. Residency and access is determined by the member’s primary address in Vantage’s records.

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

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The Vantage Wellness Program is designed to

encourage members to stay healthy. Wellness Program

participants have unlimited access to the tools and

resources online at Wellness.vhpla.com. Participants

can communicate with Wellness Coaches, Registered

Dietitians, and Tobacco Cessation Coaches by phone,

e-mail, or the Affinity Health Management Center.

*Qualifying members participating in the Tobacco Cessation Program may receive free Chantix.

Chantix must be prescribed by a physician.

What’s Available?

■ Free Nutritional Counseling

■ Free Diabetes Counseling

■ Free Tobacco Cessation Counseling

■ Free Access to Online Wellness Resource,

including an online exercise log and

educational videos

■ Free Smart Phone App

■ Free Annual Wellness Exams

■ Free Reward Opportunities

Health Maintenance

Weight Loss

Tobacco Cessation*

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Vantage Wellness

Vantage Medical Home HMO members are covered anywhere in the world for emergency care at in-network benefits.

www.VHP-StateGroup.com

VHP1550 082416 Not Approved

Your Medical Home-Primary Care Provider (MH-PCP) can be selected from our extensive list of In-Network providers. Simply go to www.VHP-StateGroup.com and select “OGB Medical Home HMO”, 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 provider. Affinity MH-PCP’s can also be located by clicking on the Affinity Health Network section. You can also call our Member Services Department at (318) 998-4434 or toll-free at (844) 536-7104 to select your MH-PCP.

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) 998-4434 Toll-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

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.

VHP1550 082416 Approved