What the Plan Costs and Covers

Benefits At-a-Glance: EmblemHealth Medicare Advantage HMO

This is just a summary. It does not contain the full details of your EmblemHealth Medicare Advantage HMO plan.

High Option - In Network
Medical Care
PCP office visit $0 copay
Specialist office visit $0 copay
Preventive Care
Routine physical exam $0 copay
Women’s wellness services $0 copay
Other Services
Outpatient mental health $0 copay
Urgent care $0 copay
Ambulatory surgery $0 copay
Ambulance $0 copay
Prescription drugs $0 generic/$0 brand/$40 non-formulary copay
Hospital Services
Inpatient care $0 copay
Anesthesia $0 copay
Emergency room $0 copay

For complete details about the benefits available through these plans, please read the Federal RI 73-001.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.