EmblemHealth VIP Passport NYC (HMO)

This plan does not require referrals. You will pay $32 each month for the plan. With this plan, you will pay $10 to see your primary care doctor and $40 to see specialists in-network. You will also get benefits Medicare does not cover, like preventive dental, hearing aids, vision, a SilverSneakers® membership, and 20 acupuncture visits.

 

Available in the following counties: Bronx, Kings, Queens, Richmond, New York

 

Your level of extra help Premium
0% $32.00
25% $24.00
50% $16.00
75% $8.00
100% $0.00

Plan Highlights

  • No referrals required
  • 20 Acupuncture visits yearly at no extra cost
  • Preventive and comprehensive dental services
  • SilverSneakers® fitness program
If you have any questions,
please call 
1-800-447-9169 
daily from 8am to 8pm.

Benefit Summary

Type of Care Copay
Primary care doctor visit: $10
Specialist doctor visit: $40
Preventive care(Services that keep you healthy): $0
Urgently needed services: $30
Emergency room: $90
Inpatient hospital coverage: $393 per day 1-5, $0 each additional day
Lab Services: $0 or $15
X-Rays: $30
Type of Care Copay
Foot care: $40
Acupuncture: $0 per visit (20 visits per year)
Dental services (no annual dollar limit):

Comprehensive and preventive.

Hearing aid: $350 every year
Routine eyewear: $200 every year
SilverSneakers®: Yes
Teladoc $45
Prescription drug: 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-$3,880
You Pay
COVERAGE GAP 
Over $3,880
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 $295 $45 25% of the cost $8.95 or 5% of the cost 
Tier 4 Non-Preferred Drugs $295 $95 25% of the cost $3.60, $8.95 or 5% of the cost 
Tier 5 Specialty Drugs $295 27% 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.

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