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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

 

Quick Links

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

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.

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.

 

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

Y0026_ 200570  Accepted 9/29/20

2021 EmblemHealth VIP Value (HMO) | EmblemHealth

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© 2020 EmblemHealth. All Rights Reserved.

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.