EmblemHealth VIP Essential (HMO)

This plan provides benefits Original Medicare does not cover, like comprehensive dental, hearing aids, vision, a SilverSneakers® membership, and acupuncture.

Depending on where you live, you will pay either $0 each month or a low set amount each month (a premium). You will pay $0 to see your primary care doctor and $45 to see specialists.

Available in the following counties: Suffolk

Monthly Plan Premium (Amount you pay for your insurance every month):

 

Your level of extra help Premium
0% $124.00
25% $116.20
50% $108.40
75% $100.70
100% $92.90

Plan Highlights

Benefit Summary

Primary care doctor visit  $0
Specialist doctor visit  $45
Preventive care (Services that keep you healthy) $0
Urgently needed services  $50
Emergency room $90
Inpatient hospital coverage $370 per day 1-5
Diagnostic services/labs/imaging $0 or 20% of the total cost*
Foot care   $40
Dental services (no annual dollar limit) Comprehensive and preventive.
Hearing aid $1,800 allowance every 3 years
Routine eyewear $150 allowance every year
24-Hour nurse hotline Yes

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.

The EmblemHealth formulary (list of covered drugs) is organized into five tiers (levels):

  WHAT YOU PAY
     Deductible (The amount you pay before your plan starts to pay) Initial Coverage $0-$3,655 Coverage Gap  Over $3,655; Catastrophic Over $5,100
Tier 1 Preferred Generic Drugs No Deductible $0 37% of the total cost The greater of 5% or $3.40
Tier 2 Generic Drugs No Deductible $16 37% of the total cost The greater of 5% or $3.40
Tier 3 Preferred Brand Drugs $250 deductible applies $42 25% of the total cost The greater of 5% or $8.50
Tier 4 Non-Preferred Drugs $250 deductible applies $95 37%/25% of the total cost

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

 

Tier 5 Specialty Drugs $250 deductible applies 28% of the total cost 37%/25% of the total cost

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

 



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. 

The SilverSneakers® fitness program is provided by Tivity Health, Inc., an independent company. © 2019. All rights reserved.

Last Updated 10/1/18

Y0026_127476 Accepted 10/1/18

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Last Updated 09/24/19

Y0026_127476 Accepted 10/1/18