EmblemHealth VIP Passport NYC (HMO)

You will pay $42.30 each month for the plan. With this plan, you will pay $10 to see your primary care doctor and $40 to see specialists in-network. You will also get benefits Medicare does not cover, like preventive dental, hearing aids, vision, and a SilverSneakers® membership.


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


Provider Network: VIP Bold


Your level of Extra Help Premium
0% $42.30
25% $32.10
50% $21.90
75% $11.70
100% $1.50

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: $10
Specialist doctor visit: $40
Preventive care(Services that keep you healthy): $0
Urgently needed services: $30
Emergency room: $90
Inpatient hospital coverage: $393 per day 1-5, $0 each additional day
Lab Services: $0 or $15
X-rays: $30
Type of Care Copay
Foot care: $40
Acupuncture: $10 per visit (20 visits per year)
Dental services (no annaul benefit limit):

Comprehensive and preventive.

Hearing Aids: $350 every year
Routine eyewear: $500 every year
SilverSneakers®: Yes
Teladoc: $45
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.

(The amount you pay before your plan starts to pay)
You Pay
You Pay
Over $3,980
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 $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