EmblemHealth VIP Rx Saver (HMO)

This plan does not have an annual deductible on Tier 1, Tier 2, and Tier 3 drugs. You will pay $5 to see your primary care doctor and $35 to see specialists. 

In addition, 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

 

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

 

Your level of extra help Premium
0% (Full Premium) $55.00
25% $45.20
50% $35.30
75% $25.50
100% $15.70

Benefit Summary

Primary care doctor visit $5
Specialist doctor visit $35.00
Preventive care (Services that keep you healthy) $0
Urgently needed services $50
Emergency room $90
Inpatient hospital coverage $275 per day 1-7. $0 for each additional day
Diagnostic services/labs/imaging

$0 or 20% of the cost.* 

 

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 medications 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 medications 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-$3,595

You Pay

COVERAGE GAP 

Over $3,595

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 No Deductible $42 25% of the total cost The greater of 5% or $8.50
Tier 4 Non-Preferred Drugs $395 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 $395 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

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 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.

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.

Y0026_127476 Accepted 10/1/18

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Last Updated 09/24/19

Y0026_127476 Accepted 10/1/18