Plan Finder

Enrollment Application

Medicare & You 2010

EOC's (evidence of coverage)   Premium Plan (HMO-POS) EOC   Premium: $ 96.40/mo.   Zero Plan (HMO-POS) EOC   Premium: $ 0.00/mo.   AAA1 Value (HMO-POS) EOC   Premium: $ 47.00/mo.   AAA2 Basic Plan (HMO-POS) EOC   Premium: $ 67.00/mo.   AAA4 Traditional Plus Plan (HMO-POS) EOC   Premium: $ 96.40/mo.   AAA5 SNP Plan (HMO-POS) EOC   Premium: $ 0.00/mo.

SB's (summary of benefits)   Premium Plan (HMO-POS) SB   Premium: $ 96.40/mo.   Zero Plan (HMO-POS) SB   Premium: $ 0.00/mo.   AAA1 Value (HMO-POS) SB   Premium: $ 47.00/mo.   AAA2 Basic Plan (HMO-POS) SB   Premium: $ 67.00/mo.   AAA4 Traditional Plus Plan (HMO-POS) SB   Premium: $ 96.40/mo.   AAA5 SNP Plan (HMO-POS) SB   Premium: $ 0.00/mo.

Premium Plan:

Premium Plan Comprehensive Formulary   Premium: $ 96.40/mo.

Zero Plan:

Zero Plan Comprehensive Formulary   Premium: $ 0.00/mo.

AAA1 Value Comprehensive Formulary   Premium: $ 47.00/mo.

AAA2 Basic Plan Comprehensive Formulary   Premium: $ 67.00/mo.

AAA4 Traditional Plus Plan Comprehensive Formulary   Premium: $96.40/mo.

AAA5 SNP Plan Comprehensive Formulary   Premium: $ 0.00/mo.

Reference Materials

Vantage Medicare Provider Directory

Pharmacy Directory

PA Criteria

Quantity Limits

Step Therapy

2010 Low Income Subsidy (LIS) Premiums and Copays

Links

Centers for Medicare and Medicaid Services (CMS) Best Available Evidence (BAE)

Maps

Medicare Coverage Map

Policies

Privacy Policy

Coverage Determination and Related Forms

Complete and submit the correct form below or call (888)823-1910, or for the hearing impaired, please call (866)524-5144.

for general users:
Model Coverage Determination Request Form

for doctors:
Model Coverage Determination Request Form for Physicians

other:
Appointment of Representative Form

As a member of Vantage Medicare Advantage, you have the right to request a coverage determination, which includes the right to request an expedited coverage determination, an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. You may ask us for an expedited (fast) coverage determination or appeal either verbally or in writing if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state, Louisiana Health Care Review, Inc. (225)926-6353 or (800)433-4958.