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) Group Medicare plan includes Medicare Part D prescription drug coverage that you can use at our national network of pharmacies that includes 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. If you do not receive prescription drug coverage through your welfare fund, we will enroll you in this group Medicare Advantage Prescription Drug plan. This makes sure that you can get the prescription drug benefits you need.

When you get your prescriptions, you may have to pay a portion of the cost. This may include a copay (the flat amount you pay for drugs) or coinsurance (the percentage of the cost you pay for the drugs).

Retail Pharmacy (30 day supply)

Tier 1 (Preferred Generic): $10 copay

Tier 2 (Preferred Brand): $15 copay ($0 most vaccines)

Tier 3 (Non- Preferred): $100 copay

Tier 4 (Specialty): 25% coinsurance

Tier 5 (Select Care Drugs) $0 copay

Home Delivery (Mail Order Pharmacy) (30-day supply)

Tier 1 (Preferred Generic): $5 copay

Tier 2 (Preferred Brand): $7.50 copay ($0 most vaccines)

Tier 3 (Non-Preferred ): $50 copay

Tier 4 (Specialty): 25% coinsurance

Tier 5 (Select Care Drugs) $0 copay

Part D Benefit stages

You will pay the copays and coinsurance amounts listed above until your drug costs reach the catastrophic limit of $7,400. Once you reach $7,400, you will pay the greater of 5% coinsurance or $4.15 copay for generic drugs and $10.35 copay for brand and other multi-source drugs.


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.

A partner in wellness

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.