2020 EmblemHealth VIP GO (HMO-POS)

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2020 EmblemHealth VIP GO (HMO-POS) | EmblemHealth

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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 Medicare does not cover, like comprehensive dental, hearing aids, vision, and a SilverSneakers® membership.

Available in the following counties: Albany, Bronx, Broome, Columbia, Delaware, Dutchess, Greene, Kings, Nassau, New York, Orange, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Sullivan, Ulster, Warren, Washington, Westchester

Your level of extra help	Premium
0%	$71.00
25%	$61.90
50%	$52.70
75%	$43.60
100%	$34.40

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Plan Highlights

In-Network and Out-of-Network coverage for select services
No referrals required
Comprehensive and preventive dental services
Copay as low as $0 for preferred generic drugs
SilverSneakers® fitness program
Healthy Living PATH Program 24 Hour Health Information Line

If you have questions, please call: 800-447-9169 daily from 8am to 8pm

Benefit Summary

Type of Care	Copay
Primary care doctor visit:	$10 / $30
Specialist doctor visit:	$45 / $65
Preventive care (Services that keep you healthy)	$0 / $0
Urgently needed services:	$50 / $50
Emergency room:	$90 / $90
Inpatient hospital coverage:	$360 per day 1-5/$565 per day 1-5, $0 each additional day
Lab Services:	$0 or $15
X-Rays:	$40 / $40

Type of Care	Copay
Foot care:	$40 / $40
Dental services (no annual dollar limit):	Comprehensive and preventive
Hearing aid:	$1,800 every 3 years
Routine eyewear:	$240 every year
24-Hour nurse hotline:	Yes
Teladoc™	$45
SilverSneakers^®:	Yes
Prescription drugs:	Yes

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.

	DEDUCTIBLE (The amount you pay before your plan starts to pay) You Pay:	INITIAL COVERAGE $0-$3,835 You Pay:	COVERAGE GAP Over $3,835 You Pay:	CATASTROPHIC Over $6,350 You Pay:
Tier 1 Preferred Generic Drugs	No Deductible	$0	25% of the cost	$3.60 or 5% of the cost
Tier 2 Generic Drugs	No Deductible	$18	25% of the cost	$3.60 or 5% of the cost
Tier 3 Preferred Brand Drugs	$250	$45	25% of the cost	$8.95 or 5% of the cost
Tier 4 Non-Preferred Drugs	$250	$95	25% of the cost	$3.60, $8.95 or 5% of the cost
Tier 5 Specialty Drugs	$250	28% of the cost	25% of the cost	$3.60, $8.95 or 5% of the cost

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.

Set up Home Delivery and Refills for Prescription Drugs

Have your prescriptions and refills delivered directly to your home through Express Scripts, Inc. (ESI), our home-delivery pharmacy.

Additional Pharmacy Information

Learn more about how to get money back for a drug, our Medication Management Therapy program, how to get help paying for Part D drugs through the Extra Help program (as known as Low Income Subsidy) and much more.

View Medicare Formularies

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.

Calculate Drug Costs

Summary of Plan Benefits
Evidence of Coverage
LIS Plan Summary
EmblemHealth Medicare Star Ratings
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Comprehensive and Preventive Dental Benefits
Pharmacy Directory
2020 Annual Notice of Change

Medicare HMO and HMO-POS Provider Directories

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Health Insurance Plan of Greater New York (HIP) is an HMO/HMO-POS/HMO D-SNP plan with a Medicare contract. HIP has a contract with the New York Medicaid Program for HMO D-SNP. 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.

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Last Updated 10/1/19

Y0026_ 127364 Accepted 10/1/19

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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.