2023 EmblemHealth VIP Essential (HMO) | EmblemHealth

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EmblemHealth VIP Essential (HMO)

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

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: $600 every 2 years
24-Hour Nurse Line: Yes
Teladoc®: $45
SilverSneakers®: Yes
Prescription drugs: 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

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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