VIP Premier HMO Medicare | EmblemHealth

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VIP Premier HMO Medicare

The VIP® Premier (HMO) Medicare plan is a great fit for Medicare-eligible retirees. It offers quality coverage with low out-of-pocket costs, with $0 copays for most services and $0 deductions. With this plan, you choose a regular doctor who will manage and oversee your care, including administering referrals to network specialists and arranging for hospital stays.

Enrollment: 800-447-6929, 8 am to 8 pm, seven days a week

Customer Service: 877-344-7364, 8 am to 8 pm, seven days a week.

Plan Details

VIP Premier (HMO) Medicare plan helps Medicare-eligible retirees meet their medical needs. You get:

  • Coverage for in-network services
  • A primary care physician (PCP) to partner in your health
  • $0 copays for most services
  • Value-added wellness and disease management programs
  • A Part D prescription drug benefit that meets the needs of Medicare-eligible retirees
  • A no cost fitness benefit with access to 15,000+ fitness locations nationwide

Your in-network costs:

  • PCP office visit: $0 copay
  • Specialist office visit: $30 copay
  • Diagnostic lab/X-ray: $0 copay
  • Routine physical exam: $0 copay
  • Outpatient mental health: $5 copay
  • Ambulatory surgery: $0
  • Ambulance: $50 copay
  • Inpatient care: $250 copay Days 1-7, $0 copay Days 8-90
  • Anesthesia: $0
  • Emergency room: $100 copay (waived if admitted)
  • Routine hearing exam: $15 copay
  • Routine vision exam: $15 copay
  • Prescription Drugs: copays apply – see table below
  • Skilled nursing facility, non custodial: $0 copay Days 1-20, $164 copay Days 21-100
  • Home health care, non custodial: $0 copay
  • Private duty nursing: $0 copay
  • Durable medical equipment: 20% coinsurance

In order to sign up for the VIP Premier (HMO) Medicare plan, you must:

  • Have Medicare Parts A and B
  • Continue to pay your Medicare Part B premium and remain enrolled in Part A
  • Live in the plan’s Medicare-approved service area, which includes New York City (the Bronx, Brooklyn, Manhattan, Queens and Staten Island), Nassau, Suffolk, Rockland, Orange, and Westchester counties.

HIP Health Plan of New York (HIP) is a Medicare Advantage organization with a Medicare contract. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments and restrictions may apply.

The information in this section is intended to provide general information and highlights regarding the VIP Prime (HMO) Medicare plan. It does not provide a complete benefit description. VIP Prime (HMO) Medicare plan coverage is subject to all terms, conditions and limitations contained in the certificate of insurance. Refer to HIP policy form H3330-122519.

Pharmacy Benefits

The VIP Premier (HMO) Medicare High-Option plan includes an in-network prescription drug benefit. This benefit covers drugs that are prescribed by your network doctor. They can be filled at one of our network pharmacies or through our network home delivery service.

If you are a City of New York retiree, and do not get prescription drug coverage through your Union Welfare Fund, you must buy a rider. This makes sure that you can get prescription drug benefits you need with no annual limit. If you do not receive prescription drug coverage through your welfare fund, we will enroll you in this high-option plan.

You may have to pay a portion of the cost for these medicines. This may include a: Copay – the amount you pay for drugs; Deductible – the amount you pay for drugs before EmblemHealth starts to pay each year; Coinsurance – The percentage you pay for drugs after your deductible when EmblemHealth begins to pay.

Tier 1 (Preferred generic drugs): $10 copay per 30-day supply

Tier 2 (Preferred brand drugs): $15 copay per 30-day supply

Tier 3 (Non preferred generic and brand drugs): $100 copay per 30-day supply

Tier 4 (Specialty drugs): 25% coinsurance per 30-day supply

Home Delivery (Preferred Drugs)

Tier 1 (Preferred generic drugs): $5 copay per 30-day supply

Tier 2 (Preferred brand drugs): $7.50 copay per 30-day supply

Tier 3 (Non preferred generic and brand drugs): $50 copay per 30-day supply

Tier 4 (Specialty drugs): 25% coinsurance per 30-day supply

Benefit Limits

The member pays copays and coinsurance as listed above for drug costs between $0 and $2,960. After reaching $2,960, the member is covered for generic and brand drugs, until the member qualifies for catastrophic coverage.


Catastrophic coverage is when a member reaches $3,700 of true out-of-pocket (TrOOP) costs for the calendar year. The member will then pay either a $3.30 copay for generic ($8.25 copay for brand drugs), or a 5% coinsurance, whichever is the greater amount.


Plan Documents

Provider Coverage

With our robust network of quality doctors, you can get care from many of the region’s leading doctors, clinicians and facilities, including hospitals and urgent care centers.

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The Right Care, Right in Your Neighborhood

AdvantageCare Physicians are the newest addition to the EmblemHealth family and are now one of the largest primary and specialty care practices in New York City. With 37 locations throughout New York City and Long Island, you can find a convenient location near home or work.