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View plans and information for 2018 plans.

Benefit Information

Enhanced Coverage Annual Notice of Changes

If you are currently enrolled as a member of the Enhanced Coverage PPO there can be changes from year to year. In this coming year, there will be some changes to the plan’s costs and benefits.

Enhanced Coverage PPO Evidence of Coverage

Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Vibra Health Plan Enhanced Coverage PPO which gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2018.

Enrollment Application

This is the individual enrollment form. Please contact Vibra Health Plan if you need information in another language or format (Braille).

Essential Coverage Annual Notice of Changes

If you are currently enrolled as a member of the Essential Coverage PPO there can be changes from year to year. In this coming year, there will be some changes to the plan’s costs and benefits.

Essential Coverage PPO Evidence of Coverage

Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Vibra Health Plan Essential Coverage PPO which gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2018.

Prescription Drug Information

Coverage Determination Form

This form is to send a request for medicare prescription drug coverage determination.

Formulary

The formulary may change at any time. You will receive notice if necessary. To request a printed copy, contact us at 844.388.8268 (TTY 711).

Medicare Part D Transition Policy

This policy describes the transition requirements published by the Centers for Medicare and Medicaid Services (CMS) which state that all Part D sponsors must provide an appropriate transition benefit for members.

Pharmacy Directory

You may request a copy of the pharmacy directory by calling us at 844.388.8268 (TTY 711), 8 AM to 8 PM, 7 days a week

Redetermination Form

This form is to send a request for redetermination of medicare prescription drug denial.

Provider and Facility Forms

Authorization Requirements List – In Effect 1/1/18

This document outlines the authorization requirements that should be referenced by all providers when requesting a service or care delivery.

Authorization Form

This document should be used by providers to submit their authorization requests for care/service delivery.

Facility Change Form

Use this form to submit any changes to your practice.

Provider Directories

Introduction, PCPs, OBGYNs, OP Mental Health, Hospitals, SNFs, Ancillary, Labs, UCCs, and Index

This directory provides a list of Vibra Health Plan's network providers.

Specialists Directory

This directory provides a list of Vibra Health Plan's network providers.

Dental and Vision Directory

This directory provides a list of Vibra Health Plan's network dental and vision providers.

Pharmacy Directory

This directory provides a list of Vibra Health Plan's network pharmacies.

Receive extra help with Low-Income Subsidy (LIS)

If you receive Extra Help/Low-Income Subsidy (LIS) from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not receive Extra Help from Medicare. The amount of Extra Help you receive will determine your total monthly plan premium as a member of our plan.

This table shows you what your monthly plan premium for the Enhanced Coverage PPO will be if you receive Extra Help.

Your level of Extra Help 2019 Monthly premium for Enhanced Coverage PPO
100% $23.00
75% $32.20
50% $41.50
25% $50.70

The premiums listed above do not include a Part B premium amount, and if you qualify for Extra Help you are still required to pay the Part B premium.

Vibra Health Plan’s premium includes coverage for both medical services and prescription drug coverage.

If you are not receiving extra help, you can see if you qualify by reviewing the Centers for Medicare & Medicaid Services "best available evidence" policy for forms of evidence to establish the subsidy status, and by calling:

If you have any questions, please call Member Services at 844.388.8268 (TTY users call 711), from 8 AM -8 PM Eastern Time, 7 days a week.


Updated October 1, 2018
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