Vibra Health Plan
Essential Advocate PPO
This zero monthly premium plan covers all your Medicare Part A and Part B healthcare costs, plus additional benefits – known as Part C. It also includes a prescription drug plan (Part D), hearing, dental and vision coverage, and a fitness benefit.
|Vibra Health Plan||Essential Advocate PPO|
|Primary Care Copay||In-network $5 | Out-of-network $5|
|Specialist Copay||In-network $40 | Out-of-network $40|
|Routine Vision Coverage||One eye exam per calendar year:
In-network $20 copay / Out-of-network 50% coinsurance.
|Eyeglass, Contacts & Frames Coverage||$125 allowance toward eyeglass frames or contact lenses every 2 years.|
|Hearing Coverage||In-network $0 copay / Out-of-network 50% coinsurance for routine hearing exams and hearing aid fitting and evaluations ($400 allowance every 3 years for hearing aids).|
|Preferred Pharmacy Initial Coverage (tiered coverage 1/2/3/4/5/6)||$0 | $0 | $40 | $93 | 33% | $0|
|Standard Pharmacy Initial Coverage (tiered coverage 1/2/3/4/5/6)||$15 | $20 | $47 | $100 | 33% | $7|
|Gap Coverage||25% Generic Drugs / 25% Brand|
|Out-of-pocket Max||$6,700 In-network / $10,000 Combined|
|Enhanced Dental Coverage
Limit 2 Visit per Contract (Calendar) Year
|In-network $10 | Out-of-network 50% coinsurance
Visit Includes: Exam, Cleaning, 2 Bitewing X-Rays, Excludes Fluoride Treatments
Medicare-Covered Benefits: Physician Specialist Copay
In-network and Out-of-Network:
Wrap-Around: $2,000 Max Plan Allowance per Contract (Calendar) Year After:
50% Coinsurance Palliative Emergency Treatment
50% Coinsurance Amalgam and Composite Fillings
50% Coinsurance Simple Extractions
50% Coinsurance Endodontics
50% Coinsurance Major Restorative (Crowns, Inlays, Onlays)
50% Coinsurance Prosthodontics
50% Coinsurance Adjustments and Repairs of Prosthetics
Out-of-network Coinsurance Applied to Charges
|Over-the-counter||$25 monthly allowance for over-the-counter (OTC) drugs and supplies. Unused allowance may not be carried over from the one month to the next.|
|Medical Nutritional Therapy||$0 Copay|
|Nutritional/Dietary Benefits||$0 Copay|
|AmWell Online Doctors||$0 Copay|
|Health Coaching and Education Benefit||$0 Copay|
|SilverSneakers- Fitness Benefit||$0 Copay|
|Transitional Support Services||$0 Copay|
|Services Supporting Self-Direction||$0 Copay|
When you receive care covered by your benefit plan from a provider outside of our network, you are only responsible for paying your share of the cost, not the entire cost.
This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.
You must continue to pay your Medicare Part B premium.