2022 Vantage STANDARD (HMO-POS)

Vantage STANDARD (HMO-POS) H2722-004 is a 2022 Medicare Advantage Plan or Part-C by Vantage Health Plan available to residents in Arkansas. This plan includes additional prescription drug (Part-D) coverage. The Vantage STANDARD (HMO-POS) has a monthly premium of $26.70 and has an in-network maximum out-of-pocket limit of $4,900 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $4,900 out-of-pocket. This can be a extremely nice safety net.

Vantage STANDARD (HMO-POS) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered.

Vantage Health Plan works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Vantage STANDARD (HMO-POS) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Vantage Health Plan and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Vantage Health Plan except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 Vantage Health Plan Medicare Advantage Plan Costs

Vantage STANDARD (HMO-POS) Part-C Premium

Vantage Health Plan charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H2722-004 Part-D Deductible and Premium

Vantage STANDARD (HMO-POS) has a monthly drug premium of $26.70 and a $480.00 drug deductible. This Vantage Health Plan plan offers a $26.70 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Vantage Health Plan above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $26.70 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Vantage Health Plan Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Vantage Health Plan plan does offer additional coverage through the gap.

Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Vantage STANDARD (HMO-POS) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $6.70 for 75% low income subsidy $13.30 for 50% and $20.00 for 25%.

H2722-004 Formulary or Drug Coverage

Vantage STANDARD (HMO-POS) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Vantage STANDARD (HMO-POS) H2722-004 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$5
Tier 2	$14	$14
Tier 3	$47	$47
Tier 4	$100	$100
Tier 5	25%	25%

*Initial Coverage Phase and 30 day supply

2021 Vantage STANDARD (HMO-POS) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	$0 copay
Diagnostic services	$0 copay (Out-of-Network)
Endodontics	$0 copay
Endodontics	$0 copay (Out-of-Network)
Extractions	$0 copay (Out-of-Network)
Extractions	$0 copay
Non-routine services	$0 copay (Out-of-Network)
Non-routine services	$0 copay
Periodontics	$0 copay (Out-of-Network)
Periodontics	$0 copay
Prosthodontics, other oral/maxillofacial surgery, other services	$0 copay
Prosthodontics, other oral/maxillofacial surgery, other services	$0 copay (Out-of-Network)
Restorative services	$0 copay
Restorative services	$0 copay (Out-of-Network)

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Deductible

$500 Out-of-network

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$75 copay
Diagnostic radiology services (e.g., MRI)	50% coinsurance (Out-of-Network)
Diagnostic tests and procedures	50% coinsurance (Out-of-Network)
Diagnostic tests and procedures	20% coinsurance
Lab services	$0 copay
Lab services	50% coinsurance (Out-of-Network)
Outpatient x-rays	20% coinsurance
Outpatient x-rays	50% coinsurance (Out-of-Network)

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Doctor Visits

Primary	$0 copay or 0-20% coinsurance per visit
Primary	50% coinsurance per visit (Out-of-Network)
Specialist	$35 copay or 0-20% coinsurance per visit
Specialist	50% coinsurance per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$65 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$50 copay
Foot exams and treatment	50% coinsurance (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

50% coinsurance (Out-of-Network)
$250 copay

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Hearing

Fitting/evaluation	Not covered
Hearing aids - inner ear	Not covered
Hearing aids - outer ear	Not covered
Hearing aids - over the ear	Not covered
Hearing exam	50% coinsurance (Out-of-Network)
Hearing exam	20% coinsurance

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Inpatient Hospital Coverage

$270 per day for days 1 through 7 $0 per day for days 8 through 90
50% per stay (Out-of-Network)

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Medical Equipment/Supplies

Diabetes supplies	0-20% coinsurance per item
Diabetes supplies	50% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	50% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	50% coinsurance per item (Out-of-Network)

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Medicare Part B Drugs

Chemotherapy	50% coinsurance (Out-of-Network)
Chemotherapy	20% coinsurance
Other Part B drugs	20% coinsurance
Other Part B drugs	50% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	$467 per day for days 1 through 4 $0 per day for days 5 through 90
Inpatient hospital - psychiatric	50% per stay (Out-of-Network)
Outpatient group therapy visit	50% coinsurance (Out-of-Network)
Outpatient group therapy visit	20% coinsurance
Outpatient group therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	20% coinsurance
Outpatient individual therapy visit	50% coinsurance (Out-of-Network)
Outpatient individual therapy visit	20% coinsurance
Outpatient individual therapy visit with a psychiatrist	20% coinsurance
Outpatient individual therapy visit with a psychiatrist	50% coinsurance (Out-of-Network)

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MOOP

$4,900 In-network

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Option

No

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

50% coinsurance per visit (Out-of-Network)
$250 copay per visit

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Preventive Care

$0 copay
50% coinsurance (Out-of-Network)

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Preventive Dental

Cleaning	$0 copay
Cleaning	$0 copay (Out-of-Network)
Dental x-ray(s)	$0 copay (Out-of-Network)
Dental x-ray(s)	$0 copay
Fluoride treatment	Not covered
Oral exam	$0 copay
Oral exam	$0 copay (Out-of-Network)

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Rehabilitation Services

Occupational therapy visit	20% coinsurance
Occupational therapy visit	50% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	50% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	20% coinsurance

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Skilled Nursing Facility

50% per stay (Out-of-Network)
$0 per day for days 1 through 20 $184 per day for days 21 through 100

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Transportation

$0 copay

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Vision

Contact lenses	$0 copay (Out-of-Network)
Contact lenses	$0 copay
Eyeglass frames	$0 copay
Eyeglass frames	$0 copay (Out-of-Network)
Eyeglass lenses	$0 copay
Eyeglass lenses	$0 copay (Out-of-Network)
Eyeglasses (frames and lenses)	$0 copay
Eyeglasses (frames and lenses)	$0 copay (Out-of-Network)
Other	Not covered
Routine eye exam	$0 copay
Routine eye exam	50% coinsurance (Out-of-Network)
Upgrades	$0 copay
Upgrades	$0 copay (Out-of-Network)

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Wellness Programs (e.g. fitness nursing hotline)

Covered

Ready to Enroll?

Click Here

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1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Vantage STANDARD (HMO-POS)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.