EmblemHealth VIP Gold Plus (HMO)

This plan provides $0 for many medical services, such as when you see your primary care doctor, specialists, or get urgently needed services.

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

 

Available in the following counties: Bronx, Kings, New York, Queens, Nassau, Richmond, Suffolk, Orange, Rockland, Weschester, Dutchess, Putnam, Sullivan, Ulster

 

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

 

Your level of extra help Premium
0% (Full Premium) $298.00
25% $288.20
50% $278.30
75% $268.50
100% $258.70

Benefit Summary

Primary care doctor visit: $0
Specialist doctor visit: $0
Preventive care: (Services that keep you healthy) $0
Urgently needed services: $0
Emergency room: $90
Inpatient hospital coverage: $195 per day 1-10. $0 for each additional day
Diagnostic services/labs/imaging:  $0 or 20% of the cost*
Foot care: $0
Dental services (no annual dollar limit): Comprehensive and preventive
Hearing aid: $3,000 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.

 

    

DEDUCTIBLE
(The amount you pay before your plan starts to pay)

 

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 or 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

 

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. 

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