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2023 EmblemHealth VIP Essential (HMO) | EmblemHealth

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EmblemHealth VIP Essential (HMO)

Depending on where you live, you will pay either $0 each month or a low set amount each month (a premium). You will pay $0 to see your primary care doctor and $45 to see specialists.

 

This plan provides benefits Original Medicare does not cover, like comprehensive dental, hearing aid allowance, eyewear allowance, and a SilverSneakers® membership.

 

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

 

Provider Network: VIP Bold

 

Your level of Extra Help Premium
0% $65.00
25% $55.30
50% $45.50
75% $35.80
100% $26.10

Quick Links

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:  $0
Specialist doctor visit: $45
Preventive care (services that keep you healthy): $0
Urgently needed services: $60
Emergency room: $95
Inpatient hospital coverage: $492 per day 1-4, $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: $900 every 3 years
Routine eyewear: $200 every year
24-Hour Nurse Line: Yes
Teladoc®: $45
SilverSneakers®: Yes
Prescription drug: Yes

Drug Coverage

     DEDUCTIBLE
(The amount you pay before your plan starts to pay)

You Pay		 INITIAL COVERAGE
$0-$4,480– 30-Day Supply 

You Pay		 COVERAGE GAP
Over $4,480

You Pay		 CATASTROPHIC
Over $7,400


You Pay
Tier 1 Preferred Generic Drugs $0 $2 25% of the cost 5% or $4.15
Tier 2 Generic Drugs $0 $15 25% of the cost 5% or $4.15
Tier 3 Preferred Brand Drugs* $325 $42 25% of the cost 5% or $10.35
Tier 4 Non-Preferred Drugs $325 $95 25% of the cost

5% or $4.15 for generic/ preferred multisource drugs

5% or $10.35 for all other drugs
Tier 5 Specialty  Drugs $325 27% of the cost 25% of the cost

5% or $4.15 for generic/preferred multisource drugs

5% or $10.35 for all other drugs

Tier 6 Select Care Drugs

$0

$0

$0

5% or $4.15

*You pay no deductible and $0 for most covered Part D vaccines, and no more than $35 for a one-month supply of covered insulin.

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, 2, and 6 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. © 2022 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 10/01/2022

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2023 EmblemHealth VIP Essential (HMO) | EmblemHealth

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© 2020 EmblemHealth. All Rights Reserved.

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.

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