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 and Westchester
Provider Network: VIP Bold
| Your level of Extra Help | Premium |
|---|---|
| No Extra Help | $219.00 |
| Extra Help | $170.30 |
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: | $100 |
| 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®: | $0 |
| 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) |
INITIAL COVERAGE $0-$5,030 – 30 Day Supply |
COVERAGE GAP Over $5,030 |
CATASTROPHIC Over $8,000 |
||
|---|---|---|---|---|---|
| You Pay | Preferred | Standard | You Pay | You Pay | |
| Tier 1 Preferred Generic | $0 | $2 | $7 | 25% | $0 |
| Tier 2 Generic | $0 | $10 | $20 | 25% | $0 |
| Tier 3 Preferred Brand | $200 | $40 | $47 | 25% | $0 |
| Tier 4 Non-Preferred Drugs | $200 | $95 | $100 | 25% | $0 |
| Tier 5 Specialty | $200 | 29% | 29% | 25% | $0 |
| Tier 6 Select Care Drugs | $0 | $0 | $0 | $0 | $0 |
You pay no deductible and no more than $35 for one-month supply of covered insulins and $0 for most adult Part D vaccines, including shingles, tetanus, and travel vaccines.
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 Therapy Management program, how to get help paying for Part D drugs through the Extra Help program (as known as Low-Income Subsidy), and much more.
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 plan with a Medicare contract. Enrollment in HIP depends on contract renewal. HIP is an EmblemHealth company.
SilverSneakers is a registered trademark of Tivity Health, Inc. © 2023 Tivity Health, Inc. 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 10/15/2023
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