EmblemHealth VIP Gold Plus (HMO)

You will pay $0 for many medical services, such as when you see your primary care doctor or specialists or get urgently needed services.

You will also get benefits Medicare does not cover, like comprehensive dental, hearing aids, vision, and a SilverSneakers® membership.


Available in the following counties: Bronx, Dutchess, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Sullivan, Ulster and Westchester


 Provider Network: VIP Bold


Your level of Extra Help Premium
0% $302.00
25% $291.40
50% $280.90
75% $270.30
100% $259.70

Plan Highlights

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 (Services that keep you healthy): $0
Urgently needed services: $0
Emergency room: $90
Inpatient hospital coverage: $195 per day 1-10, $0 each additional day
Lab Services: $0 or $15
X-rays:  $0 or 20% of the cost
Type of Care Copay
Foot care: $0
Dental services (no annual dollar limit): Comprehensive and preventive
Hearing Aids: $3,000 every 3 years
Routine eyewear: $150 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 s 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


You Pay


Over $3,885

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 $10 25% of the cost $3.70 or 5% of the cost
Tier 3 Preferred Brand Drugs $200 $40 25% of the cost $9.20 or 5% of the cost 
Tier 4 Non-Preferred Drugs $200 $95 25% of the cost $3.70, $9.20 or 5% of the cost 
Tier 5 Specialty Drugs $200 29% 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.


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Last Update 10/01/2020

Y0026_ 200570  Accepted 9/29/20