EmblemHealth VIP Gold Plus (HMO)

You will pay $0 for many medical services, such as when you see your primary care doctor or specialists, or get urgently needed services.

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, Dutchess, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Sullivan, Ulster, Westchester

 

Your level of extra help Premium
0% $301.00
25% $291.90
50% $282.70
75% $273.60
100% $264.40

Benefit Summary

Type of Care Copay
Primary care doctor visit: $0
Specialist doctor visit: $0
Preventive care(Services that keep you healthy): $0
Urgently needed services: $0
Emergency room: $90
Inpatient hospital coverage: $195 per day 1-10, $0 each additional day
Lab Services $0 or $15
X-Rays:  $0 or 20% of the cost
Type of Care Copay
Foot care: $0
Dental services (no annual dollar limit): Comprehensive and preventive
Hearing aid: $3,000 every 3 years
Routine eyewear: $150 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 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 COVERAG

E$0-$3,785

You Pay

COVERAGE GAP

Over $3,785

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 $10 25% of the cost $3.60 or 5% of the cost
Tier 3 Preferred Brand Drugs $200 $40 25% of the cost $8.95 or 5% of the cost 
Tier 4 Non-Preferred Drugs $200 $95 25% of the cost $3.60, $8.95 or 5% of the cost 
Tier 5 Specialty Drugs $200 29% 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.


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