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 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

  • 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

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

Benefit Summary

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

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 5% of the cost

 

$3.60, $8.95 or 5% of the cost

 

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 HMO and HMO-POS Provider Directories

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.

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Last Updated 10/1/19

Y0026_ 127364 Accepted 10/1/19