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Plan Details


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

 

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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, 2018
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