EOC's
(evidence of coverage)
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*AAA6 Capitol Plan (HMO-POS) EOC
Premium: $ 0.00/mo.
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* The Capitol Plan is available
only to residents in East Baton Rouge, West Baton Rouge, and Iberville Parishes
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SB's
(summary of benefits)
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*AAA6 Capitol Plan (HMO-POS) SB
Premium: $ 0.00/mo.
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* The Capitol Plan is available
only to residents in East Baton Rouge, West Baton Rouge, and Iberville Parishes
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Drug Formularies
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*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
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Abridged Formularies
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*AAA6 Capitol Plan (HMO-POS)
Premium: $ 0.00/mo.
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* The Capitol Plan is available
only to residents in East Baton Rouge, West Baton Rouge, and Iberville Parishes
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Reference Materials
Changes in Formulary Drugs
Vantage Medicare Provider Directory
Pharmacy Directory
PA Criteria
Quantity Limits
Step Therapy
2012 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
for prescriptions:
Medicare Prescription Drug Determination 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.
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