You will pay $0 to see your primary care doctor and $25 to see specialists. 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: Suffolk
Provider Network: VIP Bold
| Your level of Extra Help | Premium |
|---|---|
| 0% | $237.00 |
| 25% | $227.30 |
| 50% | $217.50 |
| 75% | $207.80 |
| 100% | $198.10 |
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: | $25 |
| Preventive care (services that keep you healthy): | $0 |
| Urgently needed services: | $35 |
| Emergency room: | $95 |
| Inpatient hospital coverage: | $290 per day 1-7, $0 each additional day |
| Lab services: | $0 or $15 |
| X-rays: | $25 or 20% of the cost |
| Type of Care | Copay |
|---|---|
| Foot care: | $25 |
| Dental services (no annual dollar limit): | Comprehensive and preventive |
| Hearing aids: | $2,400 every 3 years |
| Routine eyewear: | $300 every year |
| 24-Hour Nurse Line: | Yes |
| Teladoc®: | $45 |
| SilverSneakers®: | Yes |
| Prescription drugs: | Yes |
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 s 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 |
$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.
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
Y0026_203227_M
