2023 EmblemHealth VIP Gold Plus (HMO) | EmblemHealth

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EmblemHealth VIP Gold Plus (HMO)

You will pay $0 for many medical services, such as when you see your primary care doctor or specialists or get urgently needed services.

You will also get benefits Medicare does not cover, like comprehensive dental, hearing aid allowance, eyewear allowance, and a SilverSneakers® membership.

 

Available in the following counties: Bronx, Dutchess, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk, Sullivan, Ulster, and Westchester

 

 Provider Network: VIP Bold

 

Your level of Extra Help Premium
0% $254.00
25% $244.30
50% $234.50
75% $224.80
100% $215.10

Benefit Summary

Type of Care Copay
Primary care doctor visit: $0
Specialist doctor visit: $0
Preventive care (services that keep you healthy): $0
Urgently needed services: $0
Emergency room: $95
Inpatient hospital coverage: $195 per day 1-10, $0 each additional day
Lab services: $0 or $15
X-rays:  $0 or 20% of the cost
Type of Care Copay
Foot care: $0
Dental services (no annual dollar limit): Comprehensive and preventive
Hearing aids: $3,000 every 3 years
Routine eyewear: $150 every year
24-Hour Nurse Line: 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-$4,355 – 30 Day Supply

You Pay

COVERAGE GAP
Over $4,355

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 $10 25% of the cost 5% or $4.15
Tier 3 Preferred Brand Drugs* $200 $40 25% of the cost 5% or $10.35
Tier 4 Non-Preferred Drugs $200 $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 $200 29% 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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