This plan provides in-network and out-of-network coverage for select services. You will pay $10 to see your primary care doctor and $45 to see specialists in-network. You will also get benefits Medicare does not cover, like comprehensive dental, hearing aids, vision, and a SilverSneakers® membership.
Available in the following counties: Suffolk
Provider Network: VIP Bold
| Your level of Extra Help | Premium |
|---|---|
| 0% | $144.00 |
| 25% | $133.40 |
| 50% | $122.90 |
| 75% | $112.30 |
| 100% | $101.70 |
Plan Highlights
If you have questions, please call: 800-447-9169 daily from
8 am to 8 pm.
| Services | In-Network/Out-of-Network |
|---|---|
| Primary care doctor visit: | $10 / $30 |
| Specialist doctor visit: | $45 / $65 |
| Preventive care (Services that keep you healthy): | $0 / $0 |
| Urgently needed services: | $50 / $50 |
| Emergency room: | $90 / $90 |
| Inpatient hospital coverage: | $360 per day 1-5 /$565 per day 1-5, $0 each additional day |
| Lab Services: | $0 or $15 |
| X-rays: | $40 / $40 |
| Services | In-Network/Out-of-Network |
|---|---|
| Foot care: | $40 / $40 |
| Dental services (no annual dollar limit): | Comprehensive and preventive |
| Hearing Aids: | $1,800 every 3 years |
| Routine eyewear: | $240 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-$3,935 You Pay: |
COVERAGE GAP Over $3,935 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 | $250 | $42 |
25% of the cost | $9.20 or 5% of the cost |
| Tier 4 Non-Preferred Drugs | $250 | $95 | 25% of the cost |
$3.70, $9.20 or 5% of the cost
|
| Tier 5 Specialty Drugs | $250 | 28% of the cost | 25% of the cost |
$3.70, $9.20 or 5% of the cost
|
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.
Out-of-network/non-contracted providers are under no obligation to treat EmblemHealth members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
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
