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2019 EmblemHealth VIP Essential (HMO) | EmblemHealth

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EmblemHealth VIP Essential (HMO)

This plan provides benefits Original Medicare does not cover, like comprehensive dental, hearing aids, vision, a SilverSneakers® membership, and acupuncture.

Depending on where you live, you will pay either $0 each month or a low set amount each month (a premium). You will pay $0 to see your primary care doctor and $45 to see specialists.

Available in the following counties: Orange, Rockland, Westchester, Dutchess, Putnam, Sullivan, Ulster.

Monthly Plan Premium (Amount you pay for your insurance every month):

Your level of extra help Premium
0% $68.00
25% $60.20
50% $52.40
75% $44.70
100% $36.90

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Plan Highlights

If you have questions, please call: 800-859-4880 daily from 8am to 8pm

Benefit Summary

Primary care doctor visit  $0
Specialist doctor visit  $45
Preventive care (Services that keep you healthy) $0
Urgently needed services  $50
Emergency room $90
Inpatient hospital coverage $370 per day 1-5
Diagnostic services/labs/imaging $0 or 20% of the total cost*
Foot care   $40
Dental services (no annual dollar limit) Comprehensive and preventive.
Hearing aid $1,800 allowance every 3 years
Routine eyewear $240 allowance every year
24-Hour nurse hotline Yes

SilverSneakers®		 Yes
Prescription drug Yes

*A 20% coinsurance (the percentage you pay for health services) may apply when services are provided in an Outpatient Hospital.

Drug Coverage

Having the medicines you need is an important part of staying healthy, which is why we take our pharmacy offerings very seriously. We strive to help you make sure you can afford the medicines you take. Our formulary gives you access to thousands of them, and our pharmacy network is large enough to provide the choices you need—close to home.

The EmblemHealth formulary (list of covered drugs) is organized into five tiers (levels):

    

Deductibleinfo

You Pay

Initial Coverage $0-$3,655

You Pay

Coverage Gap Over $3,655

You Pay

Catastrophic Over $5,100

You Pay
Tier 1 Preferred Generic Drugs No Deductible $0 37% of the total cost The greater of 5% or $3.40
Tier 2 Generic Drugs No Deductible $16 37% of the total cost The greater of 5% or $3.40
Tier 3 Preferred Brand Drugs $250 deductible applies $42 25% of the total cost The greater of 5% or $8.50
Tier 4 Non-Preferred Drugs $250 deductible applies $95 37%/25% of the total cost

The greater of 5% or $3.40 for generic or $8.50 for brand

 
Tier 5 Specialty Drugs $250 deductible applies 28% of the total cost 37%/25% of the total cost

The greater of 5% or $3.40 for generic or $8.50 for brand

 

You will pay the above cost-sharing when you use preferred pharmacies. You pay more when you use standard pharmacies. You may pay less if you get extra help.

Four Stages of Drug Coverage

DEDUCTIBLE

The deductible is the amount you pay before your plan starts to pay. This deductible is for retail and home delivery.

  • There is no deductible for Tier 1 (preferred generic) and Tier 2 (generic) drugs.

  • There is a $250 deductible for Tier 3 (preferred brand), Tier 4 (non-preferred drug) and Tier 5 (specialty tier) drugs.

INITIAL COVERAGE STAGE

After you’ve reached the deductible, you’ll enter the initial coverage phase.

In this phase, you and the plan share the costs of some of the covered drugs until your total drug costs, including deductible, reach $3,655. The total drug costs paid by both you and our Part D plan will help you reach the coverage gap.

COVERAGE GAP STAGE

The coverage gap (also called the “donut hole”) starts after the total yearly drug cost (along with what our plan has paid and what you have paid) reaches $3,655.

While in the coverage gap in 2019, you’ll pay 25% of the plan’s cost for brand-name drugs and 37% of the plan’s cost for generic drugs. You enter the catastrophic coverage phase once your yearly true out-of-pocket cost (Troop) reaches $5,100. The costs paid by you, and the manufacturer discount payment for brand-name drugs count toward your true out-of-pocket costs and help you get out of the coverage gap. Not everyone will reach the coverage gap.

CATASTROPHIC STAGE

After your yearly out-of-pocket drug costs reach $5,100, you pay the greater of: 5% of the cost or you pay $3.40 for generic (including brand-drugs treated as generic). You pay $8.50 for all other drugs.

 

Plan Documents

2019 EmblemHealth VIP Essential (HMO) | EmblemHealth

 

Medicare HMO and HMO-POS Provider Directories

HIP Health Plan of New York (HIP) is an HMO plan with a Medicare contract. Enrollment in HIP depends on contract renewal. HIP is an EmblemHealth company. This information is not a complete description of benefits. Call 877-344-7364/TTY: 711 for more information.

The SilverSneakers® fitness program is provided by Tivity Health, Inc., an independent company. © 2019. All rights reserved.

You will need the Adobe® Acrobat Reader software to view files in the Portable Document Format (PDF). If you don’t already have it, you can download a copy from Adobe® here.

Last Updated 09/24/19

Y0026_127476 Accepted 10/1/18

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© 2020 EmblemHealth. All Rights Reserved.

Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.