EmblemHealth VIP Value (HMO)

You will pay $0 each month for the plan — a $0 premium. With EmblemHealth VIP Value, you will pay $15 to see your primary care doctor, and $50 to see specialists. You will also get benefits Medicare does not cover, like up to $450 yearly in routine eyewear. 

This plan offers Optional Supplemental benefits, where you have the option to add SilverSneakers® fitness and/or comprehensive dental benefits at a low cost.


Available in the following counties: New York, Queens, Nassau, Richmond, Suffolk, Orange, Rockland, Westchester, Dutchess, Putnam, Sullivan and Ulster


Provider Network: VIP Bold


Plan Option Premium
EmblemHealth VIP Value (HMO) $0.00
EmblemHealth VIP Value with Dental (HMO) $12.50
EmblemHealth VIP Value with Silver Sneakers (HMO) $15.00
EmblemHealth VIP Value with Dental & Silver Sneakers (HMO) $27.50


Plan Highlights


If you have questions, please call: 800-859-4880 daily from
8 am to 8 pm.

Benefit Summary

Type of Care Copay
Primary care doctor visit:  $15 
Specialist doctor visit: $50
Preventive care (Services that keep you healthy): $0
Urgently needed services: $65
Emergency room: $90
Inpatient hospital coverage: $393 per day 1-5; $0 each additional day
Lab Services: $0 or $15
X-rays: $35


Type of Care Copay
Foot care:  $50
Dental services (no annual dollar limit): Preventive Covered; Comprehensive optional supplemental benefit available
Hearing Aids: Not covered
Routine eyewear: $450 every year
Teladoc™: $45
24-Hour nurse hotline: Yes

Optional supplemental benefit available
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


You Pay

COVERAGE GAP  Over $3,980  

You Pay


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


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.


Plan Documents

Medicare HMO and HMO-POS Provider & Pharmacy Directories

EmblemHealth Plan Inc. 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 EmblemHealth depends on contract renewal. EmblemHealth Plan Inc. 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.


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Last Update 10/01/2020

Y0026_ 200570  Accepted 9/29/20