EmblemHealth VIP Gold (HMO)

This plans provides benefits Medicare does not cover, like comprehensive dental, hearing aids, vision, and a SilverSneakers® membership. You will pay $0 to see your primary care doctor and $25 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% (Full Premium) $265.50
25% $255.70
50% $245.80
75% $236.00
100% $226.20

Benefit Summary

Primary care doctor visit $0
Specialist doctor visit:  $25
Preventive care: (Services that keep you healthy) $0
Urgently needed services: $35
Emergency room:  $90
Inpatient hospital coverage: $290 per day 1-7, $0 for each additional day
Diagnostic services/labs/imaging: $0 or 20% of the cost.*
Foot care: $25
Dental services (no annual dollar limit):  Comprehensive and preventive
Hearing aid:  $2,400 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.

You will pay the below cost-sharing when you use preferred pharmacies. You pay more when you use standard pharmacies. You may pay less if you get extra help.

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

    

DEDUCTIBLEinfo

 

You Pay:

INITIAL COVERAGE

$0-$3,605

You Pay:

COVERAGE GAP 

Over $3,605

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 $10 37% of the total cost The greater of 5% or $3.40
Tier 3 Preferred Brand Drugs $200 deductible applies $40 25% of the total cost The greater of 5% or $8.50
Tier 4 Non-Preferred Drugs $200 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 $200 deductible applies 29% 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. 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