Vibra Health Plan Enhanced Complete (PPO) is a Medicare Advantage (Part C) Plan by Vibra Health Plan.
This page features plan details for 2022 Vibra Health Plan Enhanced Complete (PPO) H9408 – 005 – 0 available in Southcentral and Northeast Pennsylvania.
Vibra Health Plan Enhanced Complete (PPO) is offered in the following locations.
Vibra Health Plan Enhanced Complete (PPO) offers the following coverage and cost-sharing.
Insurer: | Vibra Health Plan |
Health Plan Deductible: | $0 |
MOOP: | $6,500.00 |
Drugs Covered: | Yes |
Ready to sign up for Vibra Health Plan Enhanced Complete (PPO) ?
Part B | Part C | Part D | Part B Give Back | Total |
---|---|---|---|---|
$170.10 | $7.10 | $19.90 | $0.00 | $197.10 |
Vibra Health Plan Enhanced Complete (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Deductible: | $0.00 |
Initial Coverage Limit: | $4,430.00 |
Catastrophic Coverage Limit: | $7,050.00 |
Drug Benefit Type: | Enhanced |
Gap Coverage: | No |
Formulary Link: | Formulary Link |
Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
---|---|---|---|---|
$19.90 | $14.90 | $9.90 | $5.00 | $0.00 |
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00. Once you reach that amount, you will enter the next coverage phase.
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
Drug Type | Cost Share |
---|---|
Generic drugs | 25% |
Brand-name drugs | 25% |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
Drug Type | Cost Share |
---|---|
Generic drugs | $3.95 copay or 5% (whichever costs more) |
Brand-name drugs | $9.85 copay or 5% (whichever costs more) |
Vibra Health Plan Enhanced Complete (PPO) also provides the following benefits.
In-Network: No |
Diagnostic services: | Not covered |
Endodontics: | In-Network: 50% coinsurance (limits may apply) |
Endodontics: | Out-of-Network: 50% coinsurance (limits may apply) |
Extractions: | In-Network: 50% coinsurance (limits may apply) |
Extractions: | Out-of-Network: 50% coinsurance (limits may apply) |
Non-routine services: | In-Network: 50% coinsurance (limits may apply) |
Non-routine services: | Out-of-Network: 50% coinsurance (limits may apply) |
Periodontics: | Not covered |
Prosthodontics, other oral/maxillofacial surgery, other services: | In-Network: 50% coinsurance (limits may apply) |
Prosthodontics, other oral/maxillofacial surgery, other services: | Out-of-Network: 50% coinsurance (limits may apply) |
Restorative services: | In-Network: 50% coinsurance (limits may apply) |
Restorative services: | Out-of-Network: 50% coinsurance (limits may apply) |
Cleaning: | Covered under office visit (limits may apply) |
Dental x-ray(s): | Covered under office visit (limits may apply) |
Fluoride treatment: | Not covered |
Office visit: | In-Network: $10.00 |
Office visit: | Out-of-Network: 50% coinsurance |
Oral exam: | Covered under office visit (limits may apply) |
Diagnostic radiology services (e.g., MRI): | In-Network: $245 copay (authorization required) |
Diagnostic radiology services (e.g., MRI): | Out-of-Network: 20% coinsurance (authorization required) |
Diagnostic tests and procedures: | In-Network: $0-20 copay (authorization required) |
Diagnostic tests and procedures: | Out-of-Network: 20% coinsurance (authorization required) |
Lab services: | In-Network: $0-20 copay (authorization required) |
Lab services: | Out-of-Network: 20% coinsurance (authorization required) |
Outpatient x-rays: | In-Network: $25 copay (authorization required) |
Outpatient x-rays: | Out-of-Network: 20% coinsurance (authorization required) |
Primary: | In-Network: $5 copay per visit |
Primary: | Out-of-Network: $5 copay per visit |
Specialist: | In-Network: $25 copay per visit |
Specialist: | Out-of-Network: $25 copay per visit |
Emergency: | $90 copay per visit (always covered) |
Urgent care: | $50 copay per visit (always covered) |
Foot exams and treatment: | In-Network: $25 copay |
Foot exams and treatment: | Out-of-Network: $25 copay |
Routine foot care: | Not covered |
In-Network: $250 copay | |
Out-of-Network: $250 copay |
$0.00 |
In-Network: No |
Fitting/evaluation: | In-Network: $0 copay (limits may apply) |
Fitting/evaluation: | Out-of-Network: 50% coinsurance (limits may apply) |
Hearing aids: | In-Network: $0 copay (limits may apply) |
Hearing aids: | Out-of-Network: $0 copay (limits may apply) |
Hearing exam: | In-Network: $25 copay |
Hearing exam: | Out-of-Network: $25 copay |
In-Network: $315 per stay (authorization required) | |
Out-of-Network: $315 per stay (authorization required) |
In-Network: $325 copay per visit (authorization required) | |
Out-of-Network: $325 copay per visit (authorization required) |
$11,000 In and Out-of-network $6,500 In-network |
Diabetes supplies: | In-Network: $0 copay per item |
Diabetes supplies: | Out-of-Network: 20% coinsurance per item |
Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 20% coinsurance per item (authorization required) |
Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 20% coinsurance per item (authorization required) |
Prosthetics (e.g., braces, artificial limbs): | In-Network: 20% coinsurance per item (authorization required) |
Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 20% coinsurance per item (authorization required) |
Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
Chemotherapy: | Out-of-Network: 20% coinsurance (authorization required) |
Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
Other Part B drugs: | Out-of-Network: 20% coinsurance (authorization required) |
Inpatient hospital – psychiatric: | In-Network: $315 per stay (authorization required) |
Inpatient hospital – psychiatric: | Out-of-Network: $315 per stay (authorization required) |
Outpatient group therapy visit with a psychiatrist: | In-Network: $25 copay |
Outpatient group therapy visit with a psychiatrist: | Out-of-Network: $25 copay |
Outpatient group therapy visit: | In-Network: $25 copay |
Outpatient group therapy visit: | Out-of-Network: $25 copay |
Outpatient individual therapy visit with a psychiatrist: | In-Network: $25 copay |
Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: $25 copay |
Outpatient individual therapy visit: | In-Network: $25 copay |
Outpatient individual therapy visit: | Out-of-Network: $25 copay |
No |
In-Network: $0 copay | |
Out-of-Network: 20% coinsurance |
Occupational therapy visit: | In-Network: $35 copay (authorization required) |
Occupational therapy visit: | Out-of-Network: $35 copay (authorization required) |
Physical therapy and speech and language therapy visit: | In-Network: $35 copay (authorization required) |
Physical therapy and speech and language therapy visit: | Out-of-Network: $35 copay (authorization required) |
In-Network: $0 per day for days 1 through 20 $188 per day for days 21 through 100 (authorization required) | |
Out-of-Network: $0 per day for days 1 through 20 $188 per day for days 21 through 100 (authorization required) |
In-Network: $0 copay (limits may apply) (authorization required) | |
Out-of-Network: $0 copay (limits may apply) (authorization required) |
Contact lenses: | In-Network: $0 copay (limits may apply) |
Contact lenses: | Out-of-Network: $0 copay (limits may apply) |
Eyeglass frames: | In-Network: $0 copay (limits may apply) |
Eyeglass frames: | Out-of-Network: $0 copay (limits may apply) |
Eyeglass lenses: | In-Network: $0 copay (limits may apply) |
Eyeglass lenses: | Out-of-Network: $0 copay (limits may apply) |
Eyeglasses (frames and lenses): | Not covered |
Other: | Not covered |
Routine eye exam: | In-Network: $20 copay (limits may apply) |
Routine eye exam: | Out-of-Network: 50% coinsurance (limits may apply) |
Upgrades: | Not covered |
Covered |
Ready to sign up for Vibra Health Plan Enhanced Complete (PPO) ?
SMID: MULTIPLAN_HCIHNDOGMED01_M
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