Prescription Drug Benefits

The VIP Premier (HMO) Medicare High-Option plan includes an in-network prescription drug benefit. This benefit covers drugs that are prescribed by your network doctor. They can be filled at one of our network pharmacies or through our network home delivery service.

If you are a City of New York retiree, and do not get prescription drug coverage through your Union Welfare Fund, you must buy a rider. This makes sure that you can get prescription drug benefits you need with no annual limit. If you do not receive prescription drug coverage through your welfare fund, we will enroll you in this high-option plan.

You may have to pay a portion of the cost for these medicines. This may include a:

  • Copay – the amount you pay for drugs.
  • Deductible – the amount you pay for drugs before EmblemHealth starts to pay each year.
  • Coinsurance – The percentage you pay for drugs after your deductible when EmblemHealth begins to pay.

Drug Type Drug Benefit: With Rider
Tier 1 (Preferred generic drugs) $10 copay per 30-day supply
Tier 2 (Preferred brand drugs) $15 copay per 30-day supply
Tier 3 (Non preferred generic and brand drugs) $100 copay per 30-day supply
Tier 4 (Specialty drugs) 25% coinsurance per 30-day supply
Home delivery (preferred drugs) Tier 1 (Preferred generic drugs): $5 copay per 30-day supply

Tier 2 (Preferred brand drugs): $7.50 copay per 30-day supply

Tier 3 (Non preferred generic and brand drugs): $50 copay per 30-day supply

Tier 4 (Specialty drugs): 25% coinsurance per 30-day supply
Benefit limitsThe member pays copays and coinsurance as listed above for drug costs between $0 and $2,960. After reaching $2,960, the member is covered for generic and brand drugs, until the member qualifies for catastrophic coverage.
Catastrophic Catastrophic coverage is when a member reaches $3,700 of true out-of-pocket (TrOOP) costs for the calendar year. The member will then pay either a $3.30 copay for generic ($8.25 copay for brand drugs), or a 5% coinsurance, whichever is the greater amount.

See the Drug Formulary for the listing of preferred, non-preferred and specialty covered drugs.