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Neighborhood Care

EmblemHealth VIP Rx Saver (HMO)

This plan does not have an annual deductible on Tier 1, Tier 2, and Tier 3 drugs. You will pay $5 to see your primary care doctor and $35 to see specialists. 

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

 

Available in the following counties: Bronx

 

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

 

Your level of extra help Premium
0% (Full Premium) $55.00
25% $45.20
50% $35.30
75% $25.50
100% $15.70

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Plan Highlights

Benefit Summary

Primary care doctor visit $5
Specialist doctor visit $35.00
Preventive care (Services that keep you healthy) $0
Urgently needed services $50
Emergency room $90
Inpatient hospital coverage $275 per day 1-7. $0 for each additional day
Diagnostic services/labs/imaging

$0 or 20% of the 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.

Medicare Pharmacy

Having the medications 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 medications 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):

    

DEDUCTIBLE

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

You Pay

INITIAL COVERAGE

$0-$3,595

You Pay

COVERAGE GAP 

Over $3,595

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 No Deductible $42 25% of the total cost The greater of 5% or $8.50
Tier 4 Non-Preferred Drugs $395 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 $395 deductible applies 25% 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 and, Tier 3 (preferred brand).•   
  • There is a $395 deductible for 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 $3,595. 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 $3,595.

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 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.

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.

Y0026_127476 Accepted 10/1/18

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Last Updated 09/24/19

Y0026_127476 Accepted 10/1/18

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