All plans include pharmacy benefits, vision, hearing, dental, a member advocate, and excellent customer service.
Extra benefits to help you stay healthy
What advantages does a Vibra PPO Plan provide?
With affordable monthly premiums, you get the peace of mind, convenience, and value that comes from knowing that you’re covered by one comprehensive plan. When you enroll in a Vibra PPO plan, you can get:
| Enhanced Complete Coverage PPO | Essential Coverage PPO | |
|---|---|---|
| Monthly Premium | $25 | $0 |
| Medical Deductible | $0 | $0 |
| Primary Care Copay | In-network $5 | Out-of-network $5 | In-network $5 | Out-of-network $5 |
| Specialist Copay | In-network $25 | Out-of-network $25 | 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 / $125 allowance toward eyeglasses frames or contact lenses every 2 years. |
One eye exam per calendar year: In-network $20 copay / Out-of-network 50% coinsurance / $125 allowance toward eyeglasses frames or contact lenses every 2 years. |
| Eyeglass, Contacts & Frames Coverage | Plan provides coverage for contact lenses, eyeglass frames, and standard eyeglass lenses. Please refer to Summary of Benefits for details. | Plan provides coverage for contact lenses, eyeglass frames, and standard eyeglass lenses. Please refer to Summary of Benefits for details. |
| Hearing Coverage | In-network $0 copay / Out-of-network 50% coinsurance copay for routine hearing exams and hearing aid fitting and evaluations ($400 allowance every 3 years for hearing aids). | In-network $0 / Out-of-network 50% coinsurance for routine hearing exam and hearing aid fitting evaluation ($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 | $0 | $0 | $40 | $93 | 33% | $0 |
| Standard Pharmacy Initial Coverage (tiered coverage 1/2/3/4/5/6) | $15 | $20 | $47 | $100 | 33% | $7 | $15 | $20 | $47 | $100 | 33% | $7 |
| Coverage Gap Coverage | 25% Generic Drugs / 25% Brand | 25% Generic Drugs / 25% Brand |
| Out-of-pocket Max | $5,800 in-network, $10,000 Combined | $6,700 in-network, $10,000 Combined |
| Dental Coverage | 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 |
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 | $35 monthly allowance for over-the-counter (OTC) drugs and supplies. Unused allowance may not be carried over from the one month to the next. | $30 monthly allowance for over-the-counter (OTC) drugs and supplies. Unused allowance may not be carried over from the one month to the next. |
| Transportation Benefit | 24 plan approved round trips. | Not Included. |
| Meals Benefit - Post Hospital Discharge | 2 meals per day for 7 days. | Not Included. |
| In-home Support Services: Grandkids on Demand | 5 hours per month included. | Not Included. |
| Landmark Health | $0 Copay | $0 Copay |
| Medical Nutritional Therapy | $0 Copay | $0 Copay |
| Nutritional/Dietary Benefits | $0 Copay | $0 Copay |
| Fresh Produce Subscription | $0 Copay | Not Included. |
| AmWell Online Doctors | $0 Copay | $0 Copay |
| Health Coaching and Education Benefit | $0 Copay | $0 Copay |
| SilverSneakers- Fitness Benefit | $0 Copay | $0 Copay |
| Transitional Support Services | $0 Copay | $0 Copay |
| Services Supporting Self-Direction | $0 Copay | $0 Copay |
|
For more details, please review the Summary of Benefits You can use these Star Ratings to compare our plan's performance to other plans. |
For more details, please review the Summary of Benefits You can use these Star Ratings to compare our plan's performance to other plans. |
Easy access to online tools and resources
Get the information you need, when you need it.
Find network providers and pharmacies. Search for medical, dental, and vision providers and locate SilverSneakers fitness centers.
View formularies. Look up prescription costs and learn how to obtain medications, request formulary exceptions, and enroll in our free medication therapy management program for members with chronic diseases.
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.
Updated February 28, 2020
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