2020 Vibra Health Plan Essential (PPO) H9408-001-000 in PA from Vibra Health Plan | HealthPocket

ZIP Code
County

Insurance Type	Medicare Advantage Plan (Part C w/ RX)
Insurance Provider	Vibra Health Plan
Plan ID	H9408-001-000
Plan Year	2020
CMS Rating
Plan Type	PPO
Annual Deductible	$0.00
Out-of-Pocket Maximum	6700

What To Know About This Plan	This plan has health and drug coverage

Why We Like This Plan	has both Health and Drug Coverage has no additional premium costs outside of your Medicare Part B premium has a copay of $0 for Tier 1 preferred generic drugs (30 day supply, preferred retail pharmacies)

Overview

Premium
Total monthly premium	$0.00
Health plan premium	$0.00
Drug plan premium	$0.00
Standard Part B premium	$135.50
Part B premium reduction	No
Deductible
Health plan deductible	$0
Drug plan deductible	$0.00
Estimated yearly costs
Estimated total yearly costs for care	$3,978.00
Out-of-pocket max
Out-of-pocket max	$10,000 In and Out-of-network $6,700 In-network

Benefits & costs

Doctor services
Primary doctor visit	In-network: $5 per visit Out-of-network: $5 per visit
Specialist visit	In-network: $40 per visit Out-of-network: $40 per visit
Tests, labs, & imaging
Diagnostic tests & procedures	In-network: $25 Out-of-network: $25
Lab services	In-network: $15 Out-of-network: $15
Diagnostic radiology services (like MRI)	In-network: $275 Out-of-network: $275
Outpatient x-rays	In-network: $50 Out-of-network: $50
Emergency care	$90 per visit (always covered)
Urgent care	$65 per visit (always covered)
Hospital services
Inpatient hospital coverage	In-network: $210 per day for days 1 through 8 $0 per day for days 9 through 90 Out-of-network: $210 per day for days 1 through 8 $0 per day for days 9 through 90
Outpatient hospital coverage	In-network: $325 per visit Out-of-network: $325 per visit
Skilled nursing facility
Skilled nursing facility	In-network: $0 per day for days 1 through 5 $0 per day for days 6 through 20 $172 per day for days 21 through 100 Out-of-network: $0 per day for days 1 through 5 $0 per day for days 6 through 20 $172 per day for days 21 through 100
Preventive services
Preventive services	In-network: $0 copay Out-of-network: 20%
Ambulance
Ground ambulance	In-network: $225 Out-of-network: $225
Therapy services
Occupational therapy visit	In-network: $40 Out-of-network: $40
Physical therapy & speech & language therapy visit	In-network: $40 Out-of-network: $40
Mental health services
Outpatient group therapy with a psychiatrist	In-network: $40 Out-of-network: $40
Outpatient individual therapy with a psychiatrist	In-network: $40 Out-of-network: $40
Outpatient group therapy visit	In-network: $40 Out-of-network: $40
Outpatient individual therapy visit	In-network: $40 Out-of-network: $40
Opioid treatment services
Opioid treatment services	Covered
Other services
Durable medical equipment (like wheelchairs & oxygen)	In-network: 20% per item Out-of-network: 20% per item
Prosthetics (like braces, artificial limbs)	In-network: 20% per item Out-of-network: 20% per item
Diabetes supplies	In-network: $0 per item Out-of-network: 20% per item

Extra benefits & costs

Hearing
Hearing exam	In-network: $40 Out-of-network: $40
Fitting/evaluation	In-network: $0 copay Out-of-network: 50%
Hearing aids - All types	In-network: $0 copay Out-of-network: $0 copay
Preventive dental
Oral exam	Covered under office visit
Cleaning	Covered under office visit
Fluoride treatment	Not covered
Dental x-rays	Covered under office visit
Comprehensive dental
Non-routine services	In-network: 50% Out-of-network: 50%
Diagnostic services	Not covered
Restorative services	In-network: 50% Out-of-network: 50%
Endodontics	In-network: 50% Out-of-network: 50%
Periodontics	Not covered
Extractions	In-network: 50% Out-of-network: 50%
Prosthodontics, other oral/maxillofacial surgery, other services	In-network: 50% Out-of-network: 50%
Vision
Routine eye exam	In-network: $20 Out-of-network: 50%
Contact lenses	In-network: $0 copay Out-of-network: $0 copay
Eyeglasses (frames & lenses)	Not covered
Eyeglass frames (only)	In-network: $0 copay Out-of-network: $0 copay
Eyeglass lenses (only)	In-network: $0 copay Out-of-network: $0 copay
Upgrades	Not covered
More benefits
Fitness benefit	Limited coverage
Over the counter drug benefits	Limited coverage
In-home support services	Not covered
Home and bathroom safety devices	Not covered
Meals for short duration	Not covered
Annual physical exams	Not covered
Telehealth	Not covered

Drug coverage & costs

Part B drugs
Chemotherapy drugs	In-network: 20% Out-of-network: 20%
Other Part B drugs	In-network: 20% Out-of-network: 20%

All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

30 Day Supply	Preferred Retail Pharmacies Drug Cost	Standard Retail Pharmacies Drug Cost	Preferred Mail-Order Drug Cost	Standard Mail-Order Drug Cost
Tier 1: Preferred Generic	$0 copay	$15 copay	$0 copay	$15 copay
Tier 2: Generic	$0 copay	$20 copay	$0 copay	$20 copay
Tier 3: Preferred Brand	$40 copay	$47 copay	$40 copay	$47 copay
Tier 4: Non-Preferred Drug	$93 copay	$100 copay	$93 copay	$100 copay
Tier 5: Specialty Tier	33% coinsurance	33% coinsurance	33% coinsurance	33% coinsurance
Tier 6: Select Care Drugs	$0 copay	$7 copay	$0 copay	$7 copay

60 Day Supply	Preferred Retail Pharmacies Drug Cost	Standard Retail Pharmacies Drug Cost	Preferred Mail-Order Drug Cost	Standard Mail-Order Drug Cost
Tier 1: Preferred Generic	$0 copay	$30 copay	$0 copay	$30 copay
Tier 2: Generic	$0 copay	$40 copay	$0 copay	$40 copay
Tier 3: Preferred Brand	$80 copay	$94 copay	$80 copay	$94 copay
Tier 4: Non-Preferred Drug	$186 copay	$200 copay	$186 copay	$200 copay
Tier 5: Specialty Tier
Tier 6: Select Care Drugs	$0 copay	$14 copay	$0 copay	$14 copay

90 Day Supply	Preferred Retail Pharmacies Drug Cost	Standard Retail Pharmacies Drug Cost	Preferred Mail-Order Drug Cost	Standard Mail-Order Drug Cost
Tier 1: Preferred Generic	$0 copay	$45 copay	$0 copay	$45 copay
Tier 2: Generic	$0 copay	$60 copay	$0 copay	$60 copay
Tier 3: Preferred Brand	$120 copay	$141 copay	$120 copay	$141 copay
Tier 4: Non-Preferred Drug	$279 copay	$300 copay	$279 copay	$300 copay
Tier 5: Specialty Tier
Tier 6: Select Care Drugs	$0 copay	$21 copay	$0 copay	$21 copay

Staying healthy - screenings, tests and vaccines

Breast cancer screening	Not Rated
Colorectal cancer screening
Annual flu vaccine
Improving or maintaining physical health	Not Rated
Improving or maintaining mental health	Not Rated
Monitoring physical ability
Adult BMI assessment

Managing Chronic Conditions

Special needs plan care management	Not Rated
Care for older adults – medication review	Not Rated
Care for older adults – functional status assessment	Not Rated
Care for older adults – Pain screening	Not Rated
Osteoporosis management in women who had a fracture	Not Rated
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Controlling blood pressure	Not Rated
Rheumatoid arthritis management
Reducing the risk of falling
Plan all-cause readmissions

Member Experience with Health Plan

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan
Care Coordination

Member Complaints, and Changes in Health Plan's Performance

Complaints about the health plan
Members choosing to leave the health plan
Beneficiary access and performance problems
Health plan quality improvement

Health Plan Customer Service

Plan makes timely decision about appeals
Reviewing appeals decisions	Not Rated
Call center – foreign language interpreter and TTY/TDD availability - Medical	Not Rated

Drug Plan Customer Service

Call center – foreign language interpreter and TTY/TDD availability - Drugs
Appeals auto-forward
Appeals upheld

Member Complaints, and Changes in Drug Plan's Performance

Complaints about the drug plan	Not Rated
Members choosing to leave the drug plan
Beneficiary access and performance problems
Drug plan quality improvement

Member Experience with Drug Plan

Rating of drug plan
Getting needed prescription drugs

Drug Pricing and Patient Safety

MPF Price Accuracy
High risk medication
Part D medication adherence for diabetes
Part D medication adherence for hypertension
Part D medication adherence for cholesterol
Medication Therapy Management program completion rate
Statin Use in Persons with Diabetes	Not Rated

Physicians that accept Vibra Health Essential (PPO) for Pennsylvania

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COST:from $0	CMS Rating:

Lasso Healthcare (MSA)
COST:from $0	CMS Rating:Not Rated

Community Blue Medicare HMO Signature (HMO)
COST:from $0	CMS Rating:

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.