Depending on where you live, you will pay either $0 each month or a low set amount each month (a premium). You will pay $0 to see your primary care doctor and $45 to see specialists.
This plan provides benefits Original Medicare does not cover, like comprehensive dental, hearing aids, vision, and a SilverSneakers® membership.
Available in the following counties: Richmond, Nassau
Provider Network: VIP Bold
| Your level of Extra Help | Premium |
|---|---|
| 0% | $55.00 |
| 25% | $44.40 |
| 50% | $33.90 |
| 75% | $23.30 |
| 100% | $12.70 |
If you have questions, please call: 800-447-9169 daily from
8 am to 8 pm.
| Type of Care | Copay |
|---|---|
| Primary care doctor visit: | $0 |
| Specialist doctor visit: | $45 |
| Preventive care (Services that keep you healthy): | $0 |
| Urgently needed services: | $50 |
| Emergency room: | $90 |
| Inpatient hospital coverage: | $492 per day 1-4, $0 each additional day |
| Lab services: | $0 or $15 |
| X-rays: | $40 |
| Type of Care | Copay |
|---|---|
| Foot care: | $40 |
| Dental services (no annual dollar limit): | Comprehensive and preventive |
| Hearing aid: | $1,800 every 3 years |
| Routine eyewear: | $240 plan 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-$3,980 You Pay |
COVERAGE GAP Over $3,980 You Pay |
CATASTROPHIC Over $6,550 You Pay |
|
|---|---|---|---|---|
| Tier 1 Preferred Generic Drugs | No Deductible | $2 | 25% of the cost | $3.70 or 5% of the cost |
| Tier 2 Generic Drugs | No Deductible | $15 | 25% of the cost | $3.70 or 5% of the cost |
| Tier 3 Preferred Brand Drugs | $295 | $42 | 25% of the cost | $9.20 or 5% of the cost |
| Tier 4 Non-Preferred Drugs | $295 | $95 | 25% of the cost | $3.70, $9.20 or 5% of the cost |
| Tier 5 Specialty Drugs | $295 | 27% of the cost | 25% of the cost | $3.70, $9.20 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. $0 Tier 1 preferred generics are available through mail order
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.
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 and a Coordination of Benefits Agreement with the New York State Department of Health. Enrollment in HIP depends on contract renewal. HIP is an EmblemHealth company.
SilverSneakers® is a registered trademark of Tivity Health, Inc. © 2020 Tivity Health, Inc. All rights reserved.
© 2020 Teladoc Health, Inc. All rights reserved. Teladoc is a registered trademark of Teladoc Health, Inc. and may not be used without written permission.
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 Update 10/01/2020
