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
Deductible $0
MOOP (maximum out-of-pocket) $7,500 annually, $11,300 combined
Primary care visit In-network $5 | Out-of-network $5
Specialist visit In-network $40 | Out-of-network $40
Inpatient hospital $250 copay per day for days 1-7
Emergency care in U.S. $90
Worldwide emergency coverage (annual) $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.
Routine eyewear 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).
Routine dental 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 
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)
Medical nutritional therapy 24 visits a year: In-network $0 copay / Out-of-network 50% coinsurance
Nutritional/Dietary benefits $0 Copay
Food and produce2 $20 allowance per month
(Member must have diabetes, chronic lung disorder, congestive heart failure or cardiovascular disease)
AmWell online doctors $0 Copay
Health coaching and education benefit $0 Copay
SilverSneakers® fitness program3 $0 Copay
Services supporting self-direction $0 Copay

Prescription drugs

Vibra Health Plan Essential Advocate PPO
Deductible $0
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
Coverage gap 25% for brand Rx and 25% for generic Rx

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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.

You must continue to pay your Medicare Part B premium if not otherwise paid for by Medicaid and another third party.

1Examples of qualifying food and produce retailers include Giant, Weis, and Walmart.

2Qualifying retailers: Walmart, Rite Aid, CVS, and Walgreens

3Must use a SilverSneakers facility

Updated October 1, 2021