You will pay 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: Suffolk
Provider Network: VIP Bold
| Your level of Extra Help | Premium |
|---|---|
| 0% | $32.00 |
| 25% | $24.00 |
| 50% | $16.00 |
| 75% | $8.00 |
| 100% | $0 |
If you have questions, please call 800-859-4880 (TTY: 711) daily from 8 am to 8 pm.
| 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: | $600 every 2 years |
| 24-Hour Nurse Line: | Yes |
| Teladoc®: | $45 |
| SilverSneakers®: | Yes |
| Prescription drugs: | Yes |
| 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 |
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.
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.
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Last Update 10/01/2022
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