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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:

  • Affordable monthly premiums as low as $01
  • Predictable Out-of-Pocket cost for Out-of-Network medical services
  • PCP copays as low as $5
  • $0 copay for Online Doctor Visits
  • Prescription Drug copays as low as $0
  • $0 plan deductibles
  • $0 Prescription Drug deductible
  • $0 cost for routine hearing exams and $400 hearing aid allowance
  • $0 routine vision exams with $125 eyewear allowance every two years
  • $30 to $35 monthly allowance for Over the Counter Drugs and Supplies (OTC)1
  • $0 copay for In-Home Support Services – 5 hours allowed per month1

1Varies by plan

2Must meet eligibility criteria

  • Monthly Fresh Produce benefit1,2
  • Routine Dental coverage at $10 cost and an annual allowance of up to $2,000 for comprehensive dental services including dentures
  • SilverSneakers® fitness membership at no additional cost
  • $0 copay for non-emergent routine transportation, up to 24 round trips1
  • Meals provided after hospital discharge1,2
  • Health education sessions with a certified coach
  • Nutritional / Dietary Benefits
  • Services Supporting Self-Direction
  • Transitional / Temporary Supports
  • Medical Nutritional Counseling
  • Member Rewards and Incentives for completing exams1

  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 Included. Included.
Medical Nutritional Therapy Included. Included.
Nutritional/Dietary Benefits Included. Included.
Fresh Produce Subscription Included. Not Included.
AmWell Online Doctors  Included. Included.
Health Coaching and Education Benefit Included. Included.
SilverSneakers- Fitness Benefit Included. Included.
Transitional Support Services Included. Included.
Services Supporting Self-Direction Included. Included.
 

Enroll Now

For more details, please review the Summary of Benefits

You can use these Star Ratings to compare our plan's performance to other plans.

Enroll Now

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. Search for medical, dental, and vision providers and locate SilverSneakers fitness centers.

Search for network pharmacies and 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 December 2, 2019
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