||Vibra Health Plan Essential PPO|
|Primary Care Copay||In-network $5 | Out-of-network 40% coinsurance|
|Specialist Copay||In-network $40 | Out-of-network 40% coinsurance|
|Routine Vision Coverage||One eye exam per calendar year:
In-network $20 copay / Out-of-network 50% coinsurance.
|Eyeglass, Contacts & Frames Coverage||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 ($300 allowance every 3 years for hearing aids).|
|Preferred Pharmacy Initial Coverage (tiered coverage 1/2/3/4/5/6)||$4 | $15 | $42 | $95 | 33% | $0|
|Standard Pharmacy Initial Coverage (tiered coverage 1/2/3/4/5/6)||$15 | $20 | $47 | $100 | 33% | $5|
|Gap Coverage||37% 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
For more details, please review the Summary of Benefits
You can use these Star Ratings to compare our plan's performance to other plans.
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.