2021 EmblemHealth VIP Value (HMO)

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2021 EmblemHealth VIP Value (HMO) | EmblemHealth

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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

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Plan Highlights

$0 monthly premium
No referrals required
$450 yearly in routine eyewear
Preventive dental services
Optional Supplemental Benefit for Comprehensive Dental available
Optional Supplemental Benefit for SilverSneakers® fitness program available
$0 Tier 1 preferred generics are available through mail order
Healthy Living PATH Program 24 Hour Health Information Line

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
SilverSneakers^®:	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	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.

View Medicare Formularies

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.

Calculate Drug Costs

Summary of Plan Benefits
Evidence of Coverage
LIS Plan Summary
EmblemHealth Medicare Star Ratings
Comprehensive and Preventive Dental Benefits
Pharmacy Directory
Annual Notice of Changes

Medicare HMO and HMO-POS Provider & Pharmacy Directories

View Provider and 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.

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Last Update 10/01/2020

Y0026_ 200570 Accepted 9/29/20

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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.