2021 EmblemHealth VIP Dual Reserve (HMO D-SNP)

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2021 EmblemHealth VIP Dual Reserve (HMO D-SNP) | EmblemHealth

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EmblemHealth VIP Dual Reserve (HMO D-SNP)

This is a special needs plan (HMO D-SNP) for people enrolled in both Medicare and New York State Medicaid. You may pay as little as $0 each month for this plan based on your Low-Income Subsidy (LIS) level. You pay $0 for covered services in this plan.

You will also get benefits Medicare does not cover, like $155 for over-the-counter (OTC) items monthly.

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

Provider Network: VIP Reserve

Level of Extra Help	Premium
0%	$42.30
25%	$31.70
50%	$21.20
75%	$10.60
100%	$0.00

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Plan Highlights

$0 monthly premium plan (based on Low Income Subsidy level)
No referrals required
$155 monthly over-the-counter (OTC) Medicare card
$0 copays for covered services
Healthy Living PATH Program 24 Hour Health Information Line

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

Benefit Summary

Type of Care	Copay
Primary care doctor visit:	$0
Specialist doctor visit:	$0
Preventive care:	$0
Urgently needed services:	$0
Emergency room:	$0
Inpatient hospital coverage:	$0
Lab services:	$0

Type of Care	Copay
Foot care:	$0
Dental services:	Not covered
Hearing Aids:	Not Covered
Routine eyewear:	Not Covered
24-hour nurse hotline:	Yes
SilverSneakers^®:	Not covered
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-$4,130 You Pay	COVERAGE GAP Over $4,130 You Pay	CATASTROPHIC Over $6,550 You Pay
$0	Generics: $0/$1.30/$3.70 Brands: $0/$4.00/$9.20 Depending on your level of Extra Help	Generics: $0/$1.30/$3.70 Brands: $0/$4.00/$9.20 Depending on your level of Extra Help	$0

DEDUCTIBLE

(The amount you pay before your plan starts to pay)

You Pay

INITIAL COVERAGE

$0-$4,130

You Pay

COVERAGE GAP

Over $4,130

You Pay

CATASTROPHIC

Over $6,550

You Pay

Generics: $0/$1.30/$3.70

Brands: $0/$4.00/$9.20

Depending on your level of Extra Help

Generics: $0/$1.30/$3.70

Brands: $0/$4.00/$9.20

Depending on your level of Extra Help

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.

Drug Cost Calculator

Summary of Plan Benefits
Evidence of Coverage
LIS Plan Summary
EmblemHealth Medicare Star Ratings
Pharmacy Directory

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.