All plans include pharmacy benefits, vision, hearing, dental, and excellent customer service
Enter your zip code on the 2022 Vibra Health Plan Comparison Tool to see a more inclusive list of plan benefit options.
| Vibra Health Plan | Essential Advocate PPO | Enhanced Complete PPO |
|---|---|---|
| Monthly premium | $0 | $27 |
| Deductible | $0 | $0 |
| MOOP (maximum out-of-pocket) | $7,500 annually, $11,300 combined | $6,500 in-network, $11,000 combined |
| Primary care visit | In-network $5 | Out-of-network $5 | In-network $5 | Out-of-network $5 |
| Specialist visit | In-network $40 | Out-of-network $40 | In-network $25 | Out-of-network $25 |
| Inpatient hospital | $250 copay per day for days 1-7 | $315 copay per admit |
| Emergency care in U.S. | $90 | $90 |
| Worldwide emergency coverage (annual) | $20,000 maximum annual benefit - combined for emergency and urgent care coverage | $20,000 maximum annual benefit - combined for emergency and urgent care coverage |
| Routine vision | 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. |
| Routine eyewear | Up to $125 combined allowance, every year | Up to $125 combined allowance, every year |
| Routine hearing | 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). | In-network $0 / Out-of-network 50% coinsurance for routine hearing exam and hearing aid fitting evaluation ($800 allowance every 3 years for hearing aids). |
| Routine dental | Two cleanings per calendar year (cleaning and x-rays covered): In-network $10 copay / Out-of-network 50% coinsurance. | Two cleanings per calendar year (cleaning and x-rays covered): In-network $10 copay / Out-of-network 50% coinsurance. |
| Comprehensive dental services | In-network and Out-of-Network: $2,000 maximum combined plan benefit per calendar year. 50% coinsurance for the following covered services: Palliative emergency treatment Periapical x-rays Amalgam and composite fillings Simple (nonsurgical) extractions Endodontics Major restorative (crowns, inlays, onlays) prosthodontics (including dentures) Adjustment and repairs of prosthetics |
In-network and Out-of-Network: $2,000 maximum combined plan benefit per calendar year. 50% coinsurance for the following covered services: Palliative emergency treatment Periapical x-rays Amalgam and composite fillings Simple (nonsurgical) extractions Endodontics Major restorative (crowns, inlays, onlays) prosthodontics (including dentures) Adjustment and repairs of prosthetics |
| Flexible debit card for OTC drugs and supplies1 | $25 plan allowance per month - retail or mail order (cannot be carried over month to month) | $25 plan allowance per month - retail or mail order (cannot be carried over month to month) |
| Transportation benefit | Not Included. | $0 Copay/24 plan approved round trips |
| In-home support services: PaPa on Demand | Not Included. | $0 Copay/5 hours per month included. |
| Medical nutritional therapy | 24 visits a year: In-network $0 copay / Out-of-network 50% coinsurance | 24 visits a year: In-network $0 copay / Out-of-network 50% coinsurance |
| Nutritional/Dietary benefits | $0 Copay | $0 Copay |
| Food and produce2 | $20 allowance per month (Member must have diabetes, chronic lung disorder, congestive heart failure or cardiovascular disease) |
$20 allowance per month (Member must have diabetes, chronic lung disorder, congestive heart failure or cardiovascular disease) |
| AmWell online doctors | $0 Copay | $0 Copay |
| Health coaching and education benefit | $0 Copay | $0 Copay |
| SilverSneakers® fitness program3 | $0 Copay | $0 Copay |
| Services supporting self-direction | $0 Copay | $0 Copay |
| Vibra Health Plan | Essential Advocate PPO | Enhanced Complete PPO |
|---|---|---|
| Deductible | $0 | $0 |
| 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 | 25% for brand Rx and 25% for generic Rx | 25% for brand Rx and 25% for generic Rx |
| Part D Insulin Saver (Insulin) | 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 brands.4 | |
1Qualifying retailers: Walmart, Rite Aid, CVS, and Walgreens
2Examples of qualifying food and produce retailers include Giant, Weis, and Walmart
3Must use a SilverSneakers facility
4Select insulin cost-sharing does not apply to members who qualify for low income subsidy.
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 if not otherwise paid for by Medicaid and another third party.
Updated October 1, 2021
H9408_WBST22_M
