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Neighborhood Care

EmblemHealth VIP Go (HMO-POS)

This plan provides in-network and out-of-network coverage for select services and does not require referrals. You will pay $10 to see your primary care doctor and $45 to see specialists in-network. 

You will also get benefits Original Medicare does not cover, like comprehensive dental, hearing aids, vision, and a SilverSneakers® membership.

 

Available in the following counties: Suffolk

 

MONTHLY PLAN PREMIUM (Amount you pay for your insurance every month)

 

Your level of extra help Premium
0% $140.00
25% $132.40
50% $124.70
75% $117.10
100% $109.50

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Plan Highlights

Benefit Summary

Primary care doctor visit:  $10 In-Network / $30 Out-of-Network
Specialist doctor visit:  $45 In-Network/ $65 Out-of-Network
Preventive care: (Services that keep you healthy) $0
Urgently needed services: $50
Emergency room:  $90
Inpatient hospital coverage: $360 per day 1-5 In-Network /$565 per day 1-5 Out-of-Network
Diagnostic services/labs/imaging: $0 or 20%* In-Network / $0 or 20% Out-of-Network
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.

Medicare Pharmacy

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 s 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.

 

    

DEDUCTIBLE
(The amount you pay before your plan starts to pay)

 

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.

What drugs are covered in this plan?

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.

Drug Cost Calculator

Use our Cost Calculator tool to estimate your prescription drug costs. Enter the prescription drugs you take and we'll show you your monthly drug costs.

 

Medicare Provider Directories

 

Plan Documents

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. Out-of-network/non-contracted providers are under no obligation to treat EmblemHealth members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

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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