5 Copay $30 Copay

Prescription
PlanSavings
Design
- Regional
Drug
- MEDICAL
HOME HMO PLAN
See how Vantage can save you money on generic and brand name drugs. Look
at the chart below to determine what your cost savings would be on some of the
most commonly used drugs. Make sure to ask a Vantage representative to help you
compare your drug costs on all your prescription drugs.
Expen$ive
$5 Copay
BRAND NAMES
WITH VANTAGE
Compare to Vantage
TIER 1 GENERICS
Celexa
Citalopram
WITH VANTAGE
Cozaar / Hyzaar
Losartan / Losartan-HCTZ
TIER 2 PREFERRED BRANDS
Effexor XR
Venlafaxine ER
Flonase
Fluticasone Propionate
Levaquin
Levofloxacin
Lotrel
Amlodipine-benazepril
Lortab, Lorcet, Vicodin
Hydrocodone/Acetaminophen
Mobic
Meloxicam
Norvasc
Amlodipine
Paxil
Paroxetine
Pravachol
Pravastatin
Prevacid
Lansoprazole
Prilosec
Omeprazole
Protonix
Pantoprazole
Tenormin
Atenolol
Toprol XL
Metoprolol Succinate
Wellbutrin XL
Bupropion ER
Advair Diskus
Boniva Tablets
Byetta requires prior authorization
Byetta
Bystolic
Celebrex
Colcrys
Crestor
Cymbalta
Diovan/Diovan HCT
Evista
Exforge/Exforge HCT
Lipitor
Lovaza
Plavix
Pristiq
Pulmicort
Tamiflu
Zithromax
Azithromycin
Zocor
Simvastatin
YOU CAN ALSO BENEFIT FROM A
$30 Copay
The Vantage Medical Home HMO prescription drug benefit for State employees has four copay/coinsurance levels, including Tier 3 Non-Preferred
Brands with a $50 copay, and Tier 4 Specialty Drugs with 20% coinsurance. The drugs listed above are an example and do not represent the full
range of covered drugs available on the Vantage plan.
Select medications may have quantity limits and/or require prior authorization or step therapy.
VHP518
Page 2
OGB APPROVED 9/27/2011
Vantage Health Plan
·
130 DeSiard Street
·
(888) 823-1910
·
www.VHP-StateGroup.com