Plan Details
Costs and Other Important Information
Benefits
$325 for days 1 through 5
$0 for days 6 through 90
Out-of-Network:
50% per stay
$350 per visit
Out-of-Network:
50% per visit
In-Network:
$20 or 0-20% per visit
Out-of-Network:
50% per visit
Specialist:
In-Network:
$50 or 0-20% per visit
Out-of-Network:
50% per visit
$0 copay
Out-of-Network:
50%
$80 per visit (always covered)
Urgent care:
$65 per visit (always covered)
In-Network:
$350
Out-of-Network:
50%
Lab services:
In-Network:
$0 copay
Out-of-Network:
50%
Diagnostic radiology services (e.g., MRI):
In-Network:
$350
Out-of-Network:
50%
Outpatient x-rays:
In-Network:
$350
Out-of-Network:
50%
$405 for days 1 through 4
$0 for days 5 through 90
Out-of-Network:
50% per stay
Outpatient group therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
50%
Outpatient individual therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
50%
Outpatient group therapy visit:
In-Network:
$40
Out-of-Network:
50%
Outpatient individual therapy visit:
In-Network:
$40
Out-of-Network:
50%
$0 for days 1 through 20
$167 for days 21 through 100
Out-of-Network:
50% per stay
In-Network:
$40
Out-of-Network:
50%
Physical therapy and speech and language therapy visit:
In-Network:
$40
Out-of-Network:
50%
$250
Out-of-Network:
$250
$0 copay
In-Network:
$50
Out-of-Network:
50%
Routine foot care:
Not covered
In-Network:
20% per item
Out-of-Network:
50% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:
20% per item
Out-of-Network:
50% per item
Diabetes supplies:
In-Network:
0-20% per item
Out-of-Network:
50% per item
In-Network:
20%
Out-of-Network:
50%
Other Part B drugs:
In-Network:
0-20%
Out-of-Network:
50%
Coverage Area for AAA0 Vantage STANDARD (HMO-POS)
State | Louisiana |
---|---|
County | East Baton Rouge |
Cost Sharing Information
All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit
30 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
---|---|---|---|
Tier 1: Preferred Generic | Not offereds | $4 copay | $0 copay |
Tier 2: Non-Preferred Generic | Not offered | $12 copay | Not offered |
Tier 3: Preferred Brand Name | Not offered | $47 copay | Not offered |
Tier 4: Non-Preferred Brand Name | Not offered | 25% coinsurance | Not offered |
Tier 5: Specialty Tier | Not offered | 28% coinsurance | Not offered |
90 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
---|---|---|---|
Tier 1: Preferred Generic | Not offered | $12 copay | $0 copay |
Tier 2: Non-Preferred Generic | Not offered | $36 copay | $36 copay |
Tier 3: Preferred Brand Name | Not offered | $141 copay | $141 copay |
Tier 4: Non-Preferred Brand Name | Not offered | 25% coinsurance | 25% coinsurance |
Tier 5: Specialty Tier |
CMS Ratings
Staying healthy - screenings, tests and vaccines
Managing Chronic Conditions
Member Experience with Health Plan
Member Complaints, and Changes in Health Plan's Performance
Health Plan Customer Service
Drug Plan Customer Service
Member Complaints, and Changes in Drug Plan's Performance
Member Experience with Drug Plan
Drug Pricing and Patient Safety
Physician Finder
Physicians that accept AAA0 Vantage STANDARD (HMO-POS) for Louisiana