Check What Matters Most.

(1)

Check What

Matters Most.

VANTAGE HEALTH PLAN

MARKETPLACE PLAN FINDER

HEALTH INSURANCE

SILVER COST SHARE

(2)

Please refer to the chart below to find out if you may qualify for lower

premiums and out-of-pocket costs for Marketplace insurance plans.

Eligibility for these subsidies is based on your 2015 estimated household annual income.

Healthcare savings chart

Number of people in your household

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You may qualify for lower

premiums on a Marketplace

insurance plan if your yearly

income is between...

You may qualify for lower

premiums AND lower

out-of-pocket costs for

Marketplace insurance

if your yearly income is

between...

$11,670

-$46,680

$15,730

-$62,920

$19,790

-$79,160

$23,850

-$95,400

$27,910

-$111,640

$31,970

-$127,880

$11,670

-$29,175

$15,730

-$39,325

$19,790

-$49,475

$23,850

-$59,625

$27,910

-$69,775

$31,970

-$79,925

See next row if your income is at the

lower end of this range.

(3)

$1 0 0 In di v idual ; $2 0 0 F amil y $5 0 0 In di v idual ; $1 ,0 0 0 F amil y $2 ,9 0 0 In di v idual ; $5 ,8 0 0 F amil y $1 ,8 5 0 In di v idual ; $3 ,7 0 0 F amil y $1 ,8 5 0 In di v idual ; $3 ,7 0 0 F amil y $4 ,5 5 0 In di v idual ; $9 ,1 0 0 F amil y $5 c o pa y pe r vi si t, n o d e d u c ti b le $1 0 c o pa y pe r vi si t, n o d e d u c ti b le $2 5 c o pa y pe r vi si t, n o d e d u c ti b le $1 5 c o pa y pe r vi si t, n o d e d u c ti b le $2 0 c o pa y pe r vi si t, n o d e d u c ti b le $7 5 c o pa y pe r vi si t, n o d e d u c ti b le $1 0 0 c o pa y pe r d ay f o r d ay s 1 - 3 $ 60 0 c o pa y pe r d ay f o r d ay s 1 - 3 $1 ,5 0 0 c o pa y pe r d ay f o r d ay s 1 - 3 C o ve red 1 0 0% C o ve red 1 0 0% C o ve red 1 0 0% $2 5 c o pa y $5 0 0 c o pa y $1 ,0 0 0 c o pa y $7 5 c o pa y $1 75 c o pa y $3 0 0 c o pa y $5 0 c o pa y pe r t e st $1 75 c o pa y pe r t e st $3 0 0 c o pa y pe r t e st 10 0% c o in su ra n ce u p t o $ 5 0 pe r d ay 10 0% c o in su ra n ce u p t o $ 17 5 pe r d ay 10 0% c o in su ra n ce u p t o $ 3 0 0 pe r d ay 5 % c o in su ra n ce 10% c o in su ra n ce 2 0% c o in su ra n ce 5 % c o in su ra n ce 10% c o in su ra n ce 2 0% c o in su ra n ce C o ve red 1 0 0%, n o d e d u c ti b le C o ve red 1 0 0%, n o d e d u c ti b le C o ve red 1 0 0%, n o d e d u c ti b le No R x de d u c ti b le & No se pa ra te pr e m iu m Lo w-C o st Ge n e ri cs : $3 c o p ay N o n-P re fe rr e d Ge n e ri cs : $5 c o p ay P re fe rr e d B ra n d : $1 0 c o pa y N o n-P re fe rr e d B ra n d : $3 0 c o p ay Sp e cia lt y D ru gs: 3 3 % co in su ra n ce, u p t o $ 15 0 pe r d ru g pe r mo n th R x O u t-o f-P o cket Ma xi mum : $4 0 0 In di vi dual ; $ 8 0 0 F amil y No R x de d u c ti b le & No se pa ra te pr e m iu m Lo w-C o st Ge n e ri cs : $3 c o pa y No n-P re fe rr e d Ge ne ri cs : $1 0 c o pa y P re fe rr e d B ra n d : $2 0 c o pa y No n-P re fe rr e d B ra n d : $ 6 5 c o pa y Sp e cia lt y D ru gs: 3 3 % co in su ra n ce, u p t o $ 15 0 pe r d ru g pe r mo n th R x O u t-o f-P o cket Ma xi mum : $4 0 0 In di vi dual ; $ 8 0 0 F amil y No R x d e d u c ti b le & No se pa ra te p re m iu m Lo w-C o st Ge n e ri cs : $3 c o pa y No n-P re fe rr e d Ge ne ri cs : $1 5 c o pa y P re fe rr e d B ra n d : $ 45 c o pa y No n-P re fe rr e d B ra n d : $9 5 c o pa y Sp e cia lt y D ru gs: 3 3 % co in su ra n ce, u p t o $ 15 0 pe r d ru g pe r mo n th R x O u t-o f-P o cket Ma xi mum : $ 6 5 0 In di vi dual ; $1 ,3 0 0 F amil y In cl u d ed w it h p la n ( see r ig h t pa n e l) In cl u d ed w it h p la n ( see r ig h t pa n e l) In cl u d ed w it h p la n ( see r ig h t pa n e l) In cl u d ed w it h p la n ( see r ig h t pa n e l) In cl u d ed w it h p la n ( see r ig h t pa n e l) In cl u d ed w it h p la n ( see r ig h t pa n e l)

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Deduc tible Medical Out-of-P ock et Maximum Medical Home -P ri mar y C a re P h y sician (M H -P C P ) Inpa tient Hospital R adiologist / A nesthesiologist Outpa tient Sur ger y S e rvic es Emer genc y Room Major Diagnostic T est (MRI, C T S c an, Str ess T est , B one Density S c an, P et S c an and O thers) X-R a ys

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(4)

VANTAGE VISION & DENTAL BENEFITS

INCLUDED IN ALL PLANS

Adult and Children Vision Benefits

All Silver Plans

Ŷ

Specialist copay for 1 routine eye exam per year

Ŷ

Children - 50% coinsurance for a 12-month supply

of contacts or 1 pair of basic glasses per year

Ŷ

Adults - 20% coinsurance with a maximum benefit

of $100 per year for a 12-month supply of contacts

or 1 pair of glasses.

Adult and Children Dental Benefits

All Silver Plans

Ŷ

100% coverage for routine dental exams and cleanings,

1 exam every 6 months

Ŷ

Children - Basic Dental Services (including cleaning

and bitewing x-rays) and Major Dental Services - 50%

coinsurance after deductible

(5)

Ŷ

Call us at (855) 545-3847 or TTY at (866) 524-5144 (for the hearing impaired)

Ŷ

Ask a Vantage representative about a one-on-one home visit

Ŷ

Come by our office

Ŷ

Visit our website at www.VantageHealthPlan.com/Marketplace

Phone & Website

Toll-Free: (855) 545-3847

TTY (866) 524-5144 (for the hearing impaired)

www.VantageHealthPlan.com/Marketplace

Monroe Location

130 DeSiard Street, Suite 300

Monroe, LA 71201

Shreveport Location

855 Pierremont Road, Suite 109

Shreveport, LA 71106

Baton Rouge Location

5778 Essen Lane, Suite B

Baton Rouge, LA 70810

Vantage Health Plan, Inc. is a Qualified Health Plan

in the Health Insurance Marketplace.

VHP866 R101714 Approved

CONTACT DETAILS