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Documents and Forms

Below are links to forms to help you manage your benefit plan. Don't see what you're looking for or have a question?
Contact us at 844.388.8268 (TTY 711).


Member Forms

Appointment of Representative Form

If you want a friend, relative, your doctor or other provider, or other person to be your representative, print and complete this form and return the signed form to Vibra Health Plan. The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf.

Authorization to Disclose Personal Health Information

This form is used to advise Vibra Health Plan of the person or persons you have chosen to have access to your personal health information.

Coordination of Benefits Form

Use this form to tell us if you have other health insurance besides Vibra Health Plan.

Coverage Determination Form

This form is to send a request for medicare prescription drug coverage determination.

Dental Claim Form

Use this form to request reimbursement for services.

Enhanced Coverage Annual Notice of Changes 2018

If you are currently enrolled as a member of the Enhanced Coverage PPO there can be changes from year to year. In this coming year, there will be some changes to the plan’s costs and benefits.

Enhanced Coverage Annual Notice of Changes 2019

If you are currently enrolled as a member of the Enhanced Coverage PPO there can be changes from year to year. In this coming year, there will be some changes to the plan’s costs and benefits.

Enhanced Coverage PPO Evidence of Coverage 2018

Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Vibra Health Plan Enhanced Coverage PPO which gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2018.

Enhanced Coverage PPO Evidence of Coverage 2019

Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Vibra Health Plan Enhanced Coverage PPO which gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2019.

Enrollment Application 2018

This is the individual enrollment form. Please contact Vibra Health Plan if you need information in another language or format (Braille).

Enrollment Periods

Enrollment in Medicare is limited to certain times, so it’s important to know when you can enroll in the different parts of Medicare. This tip sheet is designed to help you learn more about enrolling in Medicare Advantage Plans (Part C) and Medicare Prescription Drug Plans (Part D). The information includes who can enroll, when you can enroll, and how timing, such as enrolling late, can affect your costs.

Essential Coverage Annual Notice of Changes 2018

If you are currently enrolled as a member of the Essential Coverage PPO there can be changes from year to year. In this coming year, there will be some changes to the plan’s costs and benefits.

Essential Coverage Annual Notice of Changes 2019

If you are currently enrolled as a member of the Essential Coverage PPO there can be changes from year to year. In this coming year, there will be some changes to the plan’s costs and benefits.

Essential Coverage PPO Evidence of Coverage 2018

Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Vibra Health Plan Essential Coverage PPO which gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2018.

Essential Coverage PPO Evidence of Coverage 2019

Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Vibra Health Plan Essential Coverage PPO which gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2019.

Fitness Claim Form

Use this form to request for Vibra Health Plan to pay for our share of  the cost for wellness programs. Your coverage allows up to $90 per quarter for gym memberships, fitness classes, and exercise programs. ONLY for Enhanced Coverage PPO plan.

Formulary

The formulary may change at any time. You will receive notice if necessary. To request a printed copy, contact us at 844.388.8268 (TTY 711).

Member Claim Form

Use this form to submit claims and expenses for medical care or a  drug you received under the Essential Coverage PPO and Enhanced Coverage  PPO plans.

Medicare Part D Transition Policy

This policy describes the transition requirements published by the Centers for Medicare and Medicaid Services (CMS) which state that all Part D sponsors must provide an appropriate transition benefit for members.

Notice of Privacy Practices

This notice describes how protected health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Over the Counter Benefits

Save time and money in Over-the-Counter supplies

Pharmacy Directory 2018

You may request a copy of the pharmacy directory by calling us at 844.388.8268 (TTY 711), 8 AM to 8 PM, 7 days a week

Provider and Pharmacy Directory 2019

The 2019 directories can be found under the Provider Directories heading below. You may request a copy of the pharmacy and provider directories by calling us at 844.388.8268 (TTY 711), 8 AM to 8 PM, 7 days a week

Provider Directory 2018

You may request a copy of the provider directory by calling us at 844.388.8268 (TTY 711), 8 AM to 8 PM, 7 days a week

Redetermination Form

This form is to send a request for redetermination of medicare prescription drug denial.

Star Ratings 2019

Medicare Star Ratings help you know how good a job our plan is doing. You can use these star ratings to compare our plan's performance to other plans.

Star Ratings 2019 (Spanish)

Medicare Star Ratings help you know how good a job our plan is doing. You can use these star ratings to compare our plan's performance to other plans.

Summary of Benefits 2018

You can review all the benefits for each plan in one document.

Summary of Benefits 2019

You can review all the benefits for each plan in one document.

Transportation Claim Form

Use this form to submit claims and expenses for transportation.

Vision Claim Form

Use this form to request reimbursement for services.

Provider and Facility Forms

Authorization Requirements List – In Effect 1/1/18

This document outlines the authorization requirements that should be referenced by all providers when requesting a service or care delivery.

Authorization Form 2018

This document should be used by providers to submit their authorization requests for care/service delivery.

Facility Change Form

Use this form to submit any changes to your practice.


Provider Directories

Introduction, PCPs, OBGYNs, OP Mental Health, Hospitals, SNFs, Ancillary, Labs, UCCs, and Index

This directory provides a list of Vibra Health Plan's network providers.

Specialists Directory

This directory provides a list of Vibra Health Plan's network providers.

Dental and Vision Directory

This directory provides a list of Vibra Health Plan's network dental and vision providers.

Pharmacy Directory

This directory provides a list of Vibra Health Plan's network pharmacies.

Updated October 1, 2018
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