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Extra benefits to help you stay healthy

All plans include pharmacy benefits, vision, hearing, dental, a member advocate and excellent customer service

All plans include pharmacy benefits, vision, hearing, dental, a member advocate, and excellent customer service.

Vibra Health Plan Enhanced Complete PPO Essential Advocate PPO
Monthly Premium $26 $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.
One eye exam per calendar year: 
In-network $20 copay / Out-of-network 50% coinsurance.
Eyeglass, Contacts & Frames Coverage $125 allowance towards eyeglasses, frames, or contact lenses every 2 years. $125 allowance towards eyeglasses, frames, or contact lenses every 2 years.
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
Part D Senior Saver Model During the initial and coverage gap stage, your out-of-pocket costs for select insulins will be a $5 copay for 30-day supply of our preferred insulin brands1.
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 $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. $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.
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.
Medical Nutritional Therapy $0 Copay $0 Copay
Nutritional/Dietary Benefits $0 Copay $0 Copay
Fresh Produce Subscription 
Limit one box per month
$0 Copay 
(Member must have diabetes, chronic lung disorder, congestive heart failure, or cardiovascular disease)
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
 

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1Select insulin cost-sharing does not apply to members who qualify for low income subsidy.


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.

Enter your zip code on the 2021 Vibra Health Plan Drug Comparison Lookup to see some of the plans available in your area.


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 October 1, 2020
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