Traditional Plus Plan (AAA4) - Vantage Medicare Advantage

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* Traditional Plus Plan(HMO)- AAA4

Part D included
Primary care covered at 100%
Suplemental Benefits for vision, hearing and dental are as follows:

VISION
20% coinsurance for one routine eye exam per year
20% coinsurance for 12 pairs of contacts per year and/or 1 pair of glasses with $100 maximum benefit

HEARING
20% coinsurance for one routine hearing exam per year
20% coinsurance for 1 hearing aid per year with $500 maximum benefit

DENTAL
20% coinsurance for an office visit that includes:

- 1 oral exam every 6 months
- 1 cleaning every 6 months

$100 maximum benefit for preventative dental every 6 months
20% coinsurance for dental x-ray per year with $50 maximum benefit
20% coinsurance for dental fillings and extractions with $275 maximum benefit per year

* Premium & co-insurance amounts will depend on your level of subsidy.

Evidence of Coverage

Summary of Benefits

Comprehensive Formulary

Abridged Formulary

Enrollment Election Form

The benefit information provided here is a brief summary, but not a comprehensive description of available benefits. For more information, contact the plan. Benefits may change on January 1, 2013.

Plan Information (2.25 MB)

AAA3 Premium Plan (HMO-POS)
-Premium: $99/mo.

AAA0 Zero Plan (HMO-POS)
-Premium: $0.00/mo.

AAA1 Value Plan (HMO-POS)
-Premium: $49.00/mo.

AAA4 Traditional Plus Plan (POS)
-Premium: $36.10/mo.

AAA6 Capitol Plan (HMO-POS)
-Premium: $0.00/mo.
The Capitol Plan is available only to residents in East Baton Rouge, West Baton Rouge, and Iberville Parishes

Vantage Office of Group Benefits Website

130 DeSiard Street, Suite 300
Monroe, LA 71201
(318)361-0900 · (888)823-1910
TTY (866)524-5144
(for the hearing impaired)
(318) 361-2159 FAX

October 15, 2011 through February 14, 2012:
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.

Last Updated 12/19/2011

H5576_4006_CY12 CMS APPROVED 1/17/2012