2019 EmblemHealth Affinity Medicare Passport Essentials NYC (HMO) | EmblemHealth

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EmblemHealth Affinity Medicare Passport Essentials NYC (HMO)

This plan does not require referrals. You will pay $0 each month for the plan — a $0 premium. With this plan, you will pay $10 to see your primary care doctor and $40 to see specialists in-network. 

You will also get benefits Original Medicare does not cover, like preventive dental, hearing aids allowance, vision, a SilverSneakers® membership, and acupuncture.

 

Available in the following counties: Bronx, Kings, New York, Queens, Richmond

 

Your level of extra help Premium
0% (Full Premium) $0.00
25% $0.00
50% $0.00
75% $0.00
100% $0.00

Plan Highlights

Benefits Summary

Primary care doctor visit $10
Specialist doctor visit:  $40
Preventive care (Services that keep you healthy):  $0
Urgently needed services: $30
Emergency room:  $90
Inpatient hospital coverage: $310 per day 1-6. $0 per each additional day
Lab services: $15
Foot care: $40
Dental services (no annual dollar limit):  Preventive
Hearing aid:  $350 allowance every year
Routine eyewear:  $100 allowance every year
SilverSneakers® Yes
Prescription drug:  Yes

Medicare Pharmacy

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

 

You Pay:

INITIAL COVERAGE

$0-$3,820

You Pay:

COVERAGE GAP 

Over $3,820

You Pay:

CATASTROPHIC 

Over $5,100

You Pay:

Tier 1 Preferred Generic Drugs No Deductible $1 37% of the total cost The greater of 5% or $3.40
Tier 2 Generic Drugs No Deductible $12 37% of the total cost The greater of 5% or $3.40
Tier 3 Preferred Brand Drugs $295 deductible applies $47 25% of the total cost The greater of 5% or $8.50
Tier 4 Non-Preferred Drugs $295 deductible applies $100 37%/25% of the total cost

The greater of 5% or $3.40 for generic or $8.50 for brand

 

Tier 5 Specialty Drugs $295 deductible applies 27% of the total cost 37%/25% of the total cost

The greater of 5% or $3.40 for generic or $8.50 for brand

 

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.



HIP Health Plan of New York (HIP) is an HMO plan with a Medicare contract. Enrollment in HIP depends on contract renewal. HIP is an EmblemHealth company. This information is not a complete description of benefits. Call 877-344-7364/TTY: 711 for more information. Out-of-network/non-contracted providers are under no obligation to treat EmblemHealth members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

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Last Updated 09/24/19

Y0026_127476 Accepted 10/1/18