EmblemHealth VIP Part B Saver (HMO)

This plan provides $500 in annual savings toward your Part B premium. You will pay $0 each month for the plan — a “$0 premium.”  You will pay $25 to see your primary care doctor, and $50 to see specialists. 

This plan offers Optional Supplemental benefits, where you have the option to add SilverSneakers® fitness and/or comprehensive dental benefits at a low cost.

Available in: 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):

Plan Options Premium
EmblemHealth Part B Saver $0.00
EmblemHealth Part B Saver with Dental $11.50
EmblemHealth Part B Saver with SilverSneakers $15.00
EmblemHealth Part B Saver with Dental and SilverSneakers $26.50

Plan Highlights

Benefit Summary

Primary care doctor visit  $25
Specialist doctor visit  $50
Preventive care (Services that keep you healthy) $0
Urgently needed services  $50
Emergency room $90
Inpatient hospital coverage $495 per day 1-3; $0 for each additional day
Diagnostic services/labs/imaging $0 or 20% of the total cost *
Foot care   $40
Dental services (no annual dollar limit) Comprehensive optional supplemental benefit; Preventive Covered
Hearing aid $1,800 allowance every 3 years
Routine eyewear $240 allowance every year
24-Hour nurse hotline Yes

SilverSneakers®
Optional supplemental benefit
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):

    

DEDUCTIBLE

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

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 $0 37% of the total cost the greater of 5% or $3.40
Tier 2 Generic Drugs $415 deductible applies $18 37% of the total cost the greater of 5% or $3.40
Tier 3 Preferred Brand Drugs $415 deductible applies $45 25% of the total cost the greater or 5% or $8.50
Tier 4 Non-Preferred Drugs $415 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 $415 deductible applies 25% 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