2022 EmblemHealth VIP Passport NYC (HMO) | EmblemHealth

Switch to:

EmblemHealth VIP Passport NYC (HMO)

You will pay $42.30 each month for the plan. With this plan, you will pay $15 to see your primary care doctor and $34.90 to see specialists in-network. You will also get benefits Medicare does not cover, like preventive dental, hearing aid allowance, eyewear allowance, and a SilverSneakers® membership.


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


Provider Network: VIP Bold


Your level of Extra Help Premium
0% $34.90
25% $26.20
50% $17.40
75% $8.70
100% $0

Plan Highlights

If you have questions, please call 800-859-4880 (TTY: 711) daily from 8 am to 8 pm.

Benefit Summary

Type of Care Copay
Primary care doctor visit: $15
Specialist doctor visit: $50
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 annual 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 $4,300

You Pay
Over $7,050

You Pay
Tier 1 Preferred Generic Drugs No Deductible $2 25% of the cost $3.95 or 5% of the cost
Tier 2 Generic Drugs No Deductible $15 25% of the cost $3.95 or 5% of the cost
Tier 3 Preferred Brand Drugs No Deductible $42 25% of the cost $9.85 or 5% of the cost 
Tier 4 Non-Preferred Drugs $350 $95 25% of the cost $3.95, $9.85 or 5% of the cost 
Tier 5 Specialty  Drugs $350 27% of the cost 25% of the cost $3.95, $9.85 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 and 2 generics are available through preferred 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 Provider & Pharmacy Directories

Health Insurance Plan of Greater New York (HIP) is an HMO/HMO D-SNP plan with a Medicare contract and a contract with the New York State Department of Health. Enrollment in HIP depends on contract renewal. HIP is an EmblemHealth company.

SilverSneakers and the SilverSneakers shoe logotype are registered trademarks of Tivity Health, Inc. © 2021 Tivity Health, Inc. All rights reserved. All rights reserved. Teladoc and related marks are trademarks of Teladoc Health, Inc. and are used by EmblemHealth with 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 10/01/2021

Y0026_ 201700