2021 EmblemHealth VIP Rx Saver (HMO)

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2021 EmblemHealth VIP Rx Saver (HMO) | EmblemHealth

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EmblemHealth VIP Rx Saver (HMO)

You will pay $5 to see your primary care doctor and $35 to see specialists. This plan does not have an annual deductible on Tier 1, Tier 2, and Tier 3 drugs. In addition, you will get benefits Medicare does not cover, like comprehensive dental, hearing aids, vision, and a SilverSneakers^® membership.

Available in the following counties: Bronx, Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster and Westchester

Provider Network: VIP Bold

Your level of Extra Help	Premium
0%	$49.00
25%	$38.40
50%	$27.90
75%	$17.30
100%	$6.70

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Plan Highlights

No referrals required
$0 Tier 1 preferred generics are available through mail order
SilverSneakers® fitness program
Healthy Living PATH Program 24 Hour Health Information Line

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

Benefit Summary

Type of Care	Copay
Primary care doctor visit (Services that keep you healthy):	$5
Specialist doctor visit:	$35
Preventive care:	$0
Urgently needed services:	$50
Emergency room:	$90
Inpatient hospital coverage:	$350 per day 1-5, $0 each additional day
Lab Services:	$0 or $15
X-rays:	$40

Type of Care	Copay
Foot care:	$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.

	DEDUCTIBLE (The amount you pay before your plan starts to pay) You Pay	INITIAL COVERAGE $0-$4,080 You Pay	COVERAGE GAP Over $4,080 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	No Deductible	$42	25% of the cost	$9.20 or 5% of the cost
Tier 4 Non-Preferred Drugs	$395	$95	25% of the cost	$3.70, $9.20 or 5% of the cost
Tier 5 Specialty Drugs	$395	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. $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.

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

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.

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Last Updated 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.