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.

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Plan Details

Vibra Health Plan Essential Advocate PPO
Monthly Premium $0
Medical Deductible $0
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
   

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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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