EmblemHealth VIP Go (HMO-POS)

This plan provides in-network and out-of-network coverage for select services and does not require referrals. You will pay $10 to see your primary care doctor and $45 to see specialists in-network. 

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

 

Available in the following counties: Suffolk

 

MONTHLY PLAN PREMIUM (Amount you pay for your insurance every month)

 

Your level of extra help Premium
0% $140.00
25% $132.40
50% $124.70
75% $117.10
100% $109.50

Plan Highlights

Benefit Summary

Primary care doctor visit $10 In-Network / $30 Out-of-Network
Specialist doctor visit:  $45 In-Network/ $65 Out-of-Network
Preventive care: (Services that keep you healthy) $0
Urgently needed services: $50
Emergency room:  $90
Inpatient hospital coverage: $360 per day 1-5 In-Network /$565 per day 1-5 Out-of-Network
Diagnostic services/labs/imaging: $0 or 20%* In-Network / $0 or 20% Out-of-Network
Foot care: $40
Dental services (no annual dollar limit):  Comprehensive and preventive
Hearing aid:  $1,800 allowance every 3 years
Routine eyewear:  $240 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 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-$3,655

 

You Pay:

COVERAGE GAP 

Over $3,655

 

You Pay:

CATASTROPHIC 

Over $5,100

 

You Pay:

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

 

What drugs are covered in this plan?

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.

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