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 caredoctor 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: Suffolk
| Your level of extra help | Premium |
|---|---|
| 0% | $143.00 |
| 25% | $133.90 |
| 50% | $124.70 |
| 75% | $115.60 |
| 100% | $106.40 |
Plan Highlights
If you have questions, please call: 800-447-9169 daily from 8am to 8pm
| Services | In-Network/Out-of-Network |
|---|---|
| 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 |
| Services | In-Network/Out-of-Network |
|---|---|
| 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 |
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 | 5% of the cost |
$3.60, $8.95 or 5% of the cost
|
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.
Summary of Plan Benefits
Evidence of Coverage
LIS Plan Summary
EmblemHealth Medicare Star Ratings
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.
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 12/31/2019
Y0026_ 127364 Accepted 10/1/19
