Summary of Benefits and Coverage:
What the Plan Covers and Costs

You may have to pay a portion of the cost for your care. This may include a:

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

Benefits Summary: VIP Rx Carve Out (HMO) Medicare plan
Medical Care Your In-Network Cost
PCP office visit $0 copay
Specialist office visit $30 copay
Diagnostic lab/X-ray $0 copay
Routine physical exam $0 copay
Outpatient mental health $5 copay
Ambulatory surgery $0 copay
Ambulance $50 copay
Inpatient care $250 copay Days 1 - 7
$0 copay Days 8 - 90
Anesthesia $0 copay
Emergency room $100 copay (waived if admitted)
Routine hearing exam $15 copay
Routine vision exam $15 copay
Skilled nursing facility, non custodial $0 copay Days 1 - 20
$164 copay Days 21 - 100
Home health care, non custodial $0 copay
Private duty nursing $0 copay
Durable medical equipment 20% coinsurance