2016OGB STATE GROUPMedicare Retirees Information

VantageMedicareAdvantage

OGB 081915 NotApproved

Dear OGB Medicare Retiree:

Vantage Health Plan will continue to be a health plan option for eligible OGB members in 2016.

Note: If you would like to remain in your current Vantage Medicare Advantage Plan with the same covered dependents for the 2016 plan year, your coverage will continue.

If you are new to Vantage or want to change to another Vantage plan, you can enroll in one of three ways:

1. Visit www.groupbenefits.org to use the annual enrollment portal.

• Enter your Member ID from your current ID card and the last four digits of your Social Security Number

• Make your selection for the next plan year

• Important! Click Submit! You must click submit in order for your selection to be valid

• Print/save your confirmation page

2. Complete the annual enrollment form, found in your annual enrollment guide or on the OGB annual enrollment website, and return it to the address below by November 15, 2015.

3. To enroll in a health plan with different or newly-covered dependents, or to discontinue OGB coverage, submit a dated and signed letter to OGB that includes:

• the member’s social security number• new dependent’s name, birth date, and social security number• dependent verification documentation (i.e. marriage and/or birth certificate)• Mail To: OGB Eligibility Division P.O. Box 44036 Baton Rouge, LA 70804

If you have any questions, please call our Member Services Department at (844) 536-7103 or visit us online at www.VHP-StateGroup.com. We look forward to serving you.

Thank you,

William J. Justice

Welcome to Vantage!

Thank you for your interest in Vantage Medicare Advantage. The content found in this packet will provide you with the information you need to learn more about Vantage Medicare Advantage plans and help you enroll in a health plan that meets your needs.

The search tools on our OGB 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 Medicare Advantage plans. If you have any questions, please contact Vantage Health Plan at (844) 536-7103. For the hearing impaired, please call TTY (318) 361-2131 or toll-free TTY (866) 524-5144. Member Services is available seven days a week, 8:00 a.m. – 8:00 p.m. CST, from October 1, 2015 through February 14, 2016. For all other dates, Member Services are available Monday through Friday from 8:00 a.m. – 8:00 p.m. CST.

Thank you again for considering Vantage Medicare Advantage. We look forward to serving you!

Check what matters most:

$0 premium plan option

$0 – $15 medical home-primary care office visit copays, depending on your plan and the network used

No in-network medical deductibles

Annual wellness exam covered 100%

Prescription drug plan included with $4 or $5 Tier 1 copay for preferred generic drugs; no separate premium

$0 Tier 1 copay for preferred generic drugs through preferred mail order (90-day supply)

Worldwide emergency coverage

Dental, Vision, and Hearing benefits included

Wellness Visits and Healthways SilverSneakers® Fitness program included

Great local customer service

Quick Drug ListVantage Medicare Advantage members may save money on their prescription drugs each year with lower copays for Vantage Tier 1 Preferred (low cost) Generic and Tier 2 Generic Drugs. Compare your brand name drug cost to the Vantage copays for Tier 1 and Tier 2 Generics listed below. A sample of Vantage Tier 3 Preferred Drugs with a $25 or $47 copay are also listed below for reference.

Also available on our website is the Mail Order Form. Fax or mail your completed Mail Order Form to have your prescriptions delivered right to your home. You can call Saint John Pharmacy at (888) 316-4354 with your prescription information to transfer your medications. We can charge your debit or credit card for the applicable copay and shipping charges. Shipping is free for Vantage Members. Please allow 48 hours to transfer and process the prescription(s) and an additional 3-5 days for the U.S. Postal Service to deliver.

This information includes a sample of prescription drugs from the Vantage Medicare Advantage 2016 plan year formulary and copays for the Vantage Zero Premium, Vantage, and Vantage Premium (HMO-POS) plans. The Vantage Part D formulary has five copay/coinsurance levels, including Tier 4 Non-Preferred Brands with a $50 or $100 copay and Tier 5 Specialty Drugs with 20%, 25% or 33% coinsurance. A $125 deductible applies to Tiers 4 and 5 for the Vantage Zero Premium (HMO-POS) plan. See the comprehensive formulary for more details.

Prior Authorization and Quantity Limits are applicable for some drugs.

Expensive Brand Name Drugs:

Vantage Tier 1 Preferred Generics

Coumadin WafarinDesyrel Trazodone (50, 100 & 150 mg tabs)Glucophage MetforminHydrodiuril Hydrochlorothiazide (HCTZ)Lopressor Metoprolol tartrateMobic Meloxlcam tabsPrinivil, Zestril lisinopril

Tenormin AtenololVasotec EnalaprilZocor SimvastatinZoloft Sertraline tabsZyloprim Allopurinol

Vantage Tier 3 Preferred BrandAdvairAvodartAzorColcrysCoreg CRExforge/ExforgeHCTHumalong, NovologHumulin, NovolinLanutsProventil HFA/Ventolin HFASpirivaTribenzor

Expensive Brand Name Drugs:

Vantage Tier 2 Generics

Coumadin WafarinDesyrel Trazodone (50, 100 & 150 mg tabs)Glucophage MetforminHydrodiuril Hydrochlorothiazide (HCTZ)Lopressor Metoprolol tartrateMobic Meloxlcam tabsPrinivil, Zestril lisinopril

Tenormin AtenololVasotec EnalaprilZocor SimvastatinZoloft Sertraline tabsZyloprim Allopurinol

$4 or $5 Copay $25 or $47 Copay

$10 Copay

Get fit your way™

Indoors Online

Home or On the Go

Outside

H5576_4010_23_CY2015 CMS Accepted VANTLA_23 11.14

Vantage Health Plan, Inc. is a health plan with a Medicare contract. Enrollment in Vantage Health Plan, Inc. depends on contract renewal.

SilverSneakers® and SilverSneakers Steps® are registered trademarks of Healthways, Inc. © 2014 Healthways, Inc.facebook.com/silversneakers

Healthways SilverSneakers® Fitness program gives you options.Work out when, where, and how you want – at no extra cost. Check out all the ways to use this innovative program o� ered as one of your Vantage Medicare Advantage bene� ts.

Work out indoors • more than 12,000 fi tness

locations• all basic amenities and

SilverSneakers group exercise classes

• easy enrollment with your SilverSneakers ID card

Step it up wherever you are • SilverSneakers Steps® for at

home or on the go• designed for your lifestyle and

fi tness level• choice of general fi tness,

strength, walking, or yoga kit

Go outside with FLEX™ • tai chi, yoga, walking groups,

and more• at local parks, recreation centers,

and churches (in select states)• online class locator and

enrollment

Connect online • tools to assess your health and

track your activity• expert advice plus meal plans

and healthy recipes• support from the SilverSneakers

community

To fi nd fi tness locations, request your SilverSneakers ID card, enroll in FLEX classes, order a Steps kit, or get additional details, visit silversneakers.com or call SilverSneakers Customer Service at 1-888-423-4632 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. EST.

Sign up for SilverSneakers today!

Benefit Comparison

PRESCRIPTION DRUGS

• $0 Tier 1 preferred generic drugs through preferred mail order (90-day supply)

VISION

• 100% coverage for one routine eye exam every year

• Member pays 20% coinsurance for 12 pairs of contacts per year and/or one pair of glasses per year with a $100 maximum benefit

HEARING

• $40 maximum benefit for routine hearing test screening after the age of 65

DENTAL

• Vantage & Vantage Premium (HMO-POS) Plans: 100% coverage for preventive dental care: cleaning, oral exam, and x-ray; a maximum benefit of $150 per 6 months; 100% coverage for dentures and dental plates; maximum benefit of $300 per year

• Vantage Zero Premium (HMO-POS) Plan: 100% coverage for preventive dental care: cleaning, oral exam, and x-ray; a maximum benefit of $200 per year

EXAMPLES OF COVERED BENEFITSVANTAGE ZERO PREMIUM

(HMO-POS)No Medical Deductible

VANTAGE(HMO-POS)

No Medical Deductible

VANTAGE PREMIUM(HMO-POS)

No Medical Deductible

LAB & HOME HEALTH 100% covered – no deductible 100% covered – no deductible 100% covered – no deductible

RADIOLOGIST / ANESTHESIOLOGIST 100% covered – no deductible 100% covered – no deductible 100% covered – no deductible

FLU SHOTS 100% covered – no deductible 100% covered – no deductible 100% covered – no deductible

PHYSICIAN PROFESSIONAL FEES (INPATIENT) 100% covered – no deductible 100% covered – no deductible 100% covered – no deductible

OFFICE VISITMEDICAL HOME – PRIMARY CARE PHYSICIAN (MH-PCP) $15 copay per visit or $5 AHN* $10 copay per visit or $0 AHN* $5 copay per visit or $0 AHN*

OFFICE VISIT / SPECIALIST $50 copay per visit or $40 AHN* $40 copay per visit or $30 AHN* $20 copay per visit or $10 AHN*

EMERGENCY ROOM $75 ER copay per visit – worldwide coverage

$75 ER copay per visit – worldwide coverage

$50 copay per visit – worldwidecoverage

MAJOR DIAGNOSTIC TESTS, X-RAYS & OTHER HOSPITAL OUTPATIENT SERVICES Up to $200 per day or $100 AHN* Up to $175 per day or $75 AHN* $0 copay

OUTPATIENT SURGERY SERVICES $450 copay per visit or $200 AHN* $300 copay per visit or $150 AHN* $0 copay

INPATIENT HOSPITAL $345 per day, for days 1 – 5 or $200 per day, for days 1 – 5 AHN*

$300 per day, for days 1 – 5 or $150 per day, for days 1 – 5 AHN* $50 per day, for days 1 –10

PRESCRIPTION DRUGS (PART D)

Tier 1 Preferred Mail Order GenericsTier 1 Preferred GenericsTier 2 GenericsTier 3 Preferred BrandTier 4 Non-Preferred BrandTier 5 Specialty

$0 copay, preferred mail order**$4 copay, no deductible$10 copay, no deductible $47 copay, no deductible$100 copay after $125 deductible25% coinsurance after $125 deductibleNo coverage through the coverage gapNo separate premium

$0 copay, preferred mail order**$4 copay, no deductible$10 copay, no deductible $47 copay, no deductible$100 copay, no deductible 33% coinsurance, no deductibleCoverage through the coverage gapNo separate premium

$0 copay, preferred mail order** $5 copay, no deductible$10 copay, no deductible$25 copay, no deductible$50 copay, no deductible20% coinsurance, no deductibleCoverage through the coverage gapNo separate premium

OUT-OF-POCKET MAXIMUM $6,700 $3,000 $2,000

*Affinity Health Network (AHN) includes providers who offer preferred cost-sharing on certain services. AHN providers are listed in the provider directory.**A preferred mail order copay of $0 for Tier 1 preferred generic drugs is available from the preferred mail order pharmacy, Saint John Pharmacy, for a 90-day supply.

EXAMPLES OF COVERED BENEFITSVANTAGE ZERO PREMIUM

(HMO-POS)No Medical Deductible

VANTAGE(HMO-POS)

No Medical Deductible

VANTAGE PREMIUM(HMO-POS)

No Medical Deductible

LAB & HOME HEALTH 100% covered – no deductible 100% covered – no deductible 100% covered – no deductible

RADIOLOGIST / ANESTHESIOLOGIST 100% covered – no deductible 100% covered – no deductible 100% covered – no deductible

FLU SHOTS 100% covered – no deductible 100% covered – no deductible 100% covered – no deductible

PHYSICIAN PROFESSIONAL FEES (INPATIENT) 100% covered – no deductible 100% covered – no deductible 100% covered – no deductible

OFFICE VISITMEDICAL HOME – PRIMARY CARE PHYSICIAN (MH-PCP) $15 copay per visit or $5 AHN* $10 copay per visit or $0 AHN* $5 copay per visit or $0 AHN*

OFFICE VISIT / SPECIALIST $50 copay per visit or $40 AHN* $40 copay per visit or $30 AHN* $20 copay per visit or $10 AHN*

EMERGENCY ROOM $75 ER copay per visit – worldwide coverage

$75 ER copay per visit – worldwide coverage

$50 copay per visit – worldwidecoverage

MAJOR DIAGNOSTIC TESTS, X-RAYS & OTHER HOSPITAL OUTPATIENT SERVICES Up to $200 per day or $100 AHN* Up to $175 per day or $75 AHN* $0 copay

OUTPATIENT SURGERY SERVICES $450 copay per visit or $200 AHN* $300 copay per visit or $150 AHN* $0 copay

INPATIENT HOSPITAL $345 per day, for days 1 – 5 or $200 per day, for days 1 – 5 AHN*

$300 per day, for days 1 – 5 or $150 per day, for days 1 – 5 AHN* $50 per day, for days 1 –10

PRESCRIPTION DRUGS (PART D)

Tier 1 Preferred Mail Order GenericsTier 1 Preferred GenericsTier 2 GenericsTier 3 Preferred BrandTier 4 Non-Preferred BrandTier 5 Specialty

$0 copay, preferred mail order**$4 copay, no deductible$10 copay, no deductible $47 copay, no deductible$100 copay after $125 deductible25% coinsurance after $125 deductibleNo coverage through the coverage gapNo separate premium

$0 copay, preferred mail order**$4 copay, no deductible$10 copay, no deductible $47 copay, no deductible$100 copay, no deductible 33% coinsurance, no deductibleCoverage through the coverage gapNo separate premium

$0 copay, preferred mail order** $5 copay, no deductible$10 copay, no deductible$25 copay, no deductible$50 copay, no deductible20% coinsurance, no deductibleCoverage through the coverage gapNo separate premium

OUT-OF-POCKET MAXIMUM $6,700 $3,000 $2,000

*Affinity Health Network (AHN) includes providers who offer preferred cost-sharing on certain services. AHN providers are listed in the provider directory.**A preferred mail order copay of $0 for Tier 1 preferred generic drugs is available from the preferred mail order pharmacy, Saint John Pharmacy, for a 90-day supply.

Need more information?

Monroe Location130 DeSiard Street, Suite 300

Monroe, LA 71201

(844) 536-7103

TTY (866) 524-5144

(for the hearing impaired)

Shreveport Location855 Pierremont Rd., Suite 109

Shreveport, LA 71106

(844) 536-7103

TTY (866) 524-5144

(for the hearing impaired)

Baton Rouge Location5778 Essen Ln., Suite B

Baton Rouge, LA 70810

(844) 536-7103

TTY (866) 524-5144

(for the hearing impaired)

Hours of Operation:October 1, 2015 through February 14, 2016: Seven (7) Days a Week 8:00 a.m. - 8:00 p.m.All other dates: Monday through Friday 8:00 a.m. - 8:00 p.m.

www.VHP-StateGroup.com

Healthways and SilverSneakers are registered trademarks of Healthways, Inc. and/or its subsidiaries. © 2015.All rights reserved.VHP1007 081915 Approved

• Ask your former agency’s HR department• Come by our office• Call our Member Services Department at (844) 536-7103

or TTY at (866) 524-5144 (for the hearing impaired)• Visit our website at www.VHP-StateGroup.com

Vantage contact information: