2021 EmblemHealth VIP Rx (PDP)

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2021 EmblemHealth VIP Rx (PDP) | EmblemHealth

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EmblemHealth VIP Rx (PDP)

With EmblemHealth VIP Rx (PDP), you get $2 preferred generic drugs at preferred pharmacies nation-wide. You pay small a premium of $49.30 per month.

Your level of Extra Help	Premium
0%	$49.30
25%	$38.70
50%	$28.20
75%	$17.60
100%	$7.00

Quick Links

If you have questions, please call: 800-447-9169 daily from
8 am to 8 pm.

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
Tier 1 Preferred Generic Drugs	$445	$2	25% of the cost	$3.70 or 5% of the cost
Tier 2 Generic Drugs	$445	$12	25% of the cost	$3.70 or 5% of the cost
Tier 3 Preferred Brand Drugs	$445	$40	25% of the cost	$9.20 or 5% of the cost
Tier 4 Non-Preferred Drugs	$445	33% of the cost	25% of the cost	$3.70, $9.20 or 5% of the cost
Tier 5 Specialty Drugs	$445	25% 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.

Our plan groups each drug into one of five “tiers” (levels). You will need to use the formulary (list of covered drugs) to find what tier a drug is on.

Four Stages of Drug Coverage

Deductible
The deductible is the amount you pay before your plan starts to pay. This deductible is for retail and home delivery. There is a $445 deductible for Tier 4 (Non-Preferred), and Tier 5 (Specialty) drugs.

Initial Coverage
After you’ve reached the deductible, you’ll enter the initial coverage phase.
In this phase, you and the plan share the costs of some of the covered drugs until your total drug costs including deductible reach $4,130. The total drug costs paid by both you and our Part D plan will help you reach the coverage gap.

Coverage Gap
The coverage gap (also called the “donut hole”) starts after the total yearly drug costs (along with what our plan has paid and what you have paid) reach $4,130. While in the coverage gap in 2021, you’ll pay 25% of the price for brand-name drugs and 25% of the price for generic drugs. You enter the catastrophic coverage phase once your yearly true out-of-pocket costs (TrOOP) reach $6,550. The costs you paid, and the manufacturer discount payment for brand-name drugs count 70% toward your true out-of-pocket costs and help you get out of the coverage gap. Not everyone will reach the coverage gap.

Catastrophic Coverage
After your yearly out-of-pocket drug costs reach $6,550, your cost sharing will be the larger amount of $3.70 or 5% for generic or preferred multi-source drugs, and $9.20 or 5% for all other drugs.

Set up Home Delivery and Refills
Have your prescriptions and refills delivered directly to your home through Express Scripts, Inc. (ESI), our home-delivery pharmacy.

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.

Calculate Drug Costs

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

Medicare HMO and HMO-POS Provider & HMO Pharmacy Directories

View Provider and Pharmacy Directories

Group Health Incorporated (GHI) is a standalone PDP with a Medicare contract. Enrollment in GHI depends on contract renewal. GHI 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.