Documents and 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 Requirements List

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.

Vibra Health Plan Enhanced PPO to Vibra Health Plan Essential PPO Annual Notice of Changes 2020

If you are currently enrolled as a member of the Vibra Health Plan 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.

Vibra Health Plan Enhanced Complete PPO Evidence of Coverage 2020

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 healthcare and prescription drug coverage from January 1 – December 31, 2020.

Enrollment Application

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.

Vibra Health Plan Essential PPO Annual Notice of Changes 2020

If you are currently enrolled as a member of the Vibra Health Plan 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.

Vibra Health Plan Essential PPO Evidence of Coverage 2020

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 healthcare and prescription drug coverage from January 1 – December 31, 2020.

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

Part B Step Therapy Drug List 2020

Provider and Pharmacy Directory 2020

The 2020 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

Redetermination Form

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

Summary of Benefits 2020

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

Vision Claim Form

Use this form to request reimbursement for services.