EmblemHealth VIP Go (HMO-POS)

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: 800-859-4880 daily from
8 am to 8 pm.

Benefit Summary

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

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.



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

You Pay:



You Pay:


Over $3,935

You Pay:


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


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.

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

Y0026_ 200570  Accepted 9/29/20