EmblemHealth VIP Gold Plus (HMO)
H3330 - 038 - 0
(3 / 5)
EmblemHealth VIP Gold Plus (HMO) is a Medicare Advantage (Part C) Plan by EmblemHealth.
This page features plan details for 2024 EmblemHealth VIP Gold Plus (HMO) H3330 – 038 – 0 available in New York City, Long Island, Hudson Valley.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
EmblemHealth VIP Gold Plus (HMO) is offered in the following locations.
Plan Overview
EmblemHealth VIP Gold Plus (HMO) offers the following coverage and cost-sharing.
| Insurer: | EmblemHealth |
| Health Plan Deductible: | $0.00 |
| MOOP: | $8,850 In-network |
| Drugs Covered: | Yes |
Please Note:
- This plan does not charge an annual deductible for all drugs. The $200.00 annual deductible only applies to drugs on certain tiers.
Ready to sign up for EmblemHealth VIP Gold Plus (HMO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
8am – 11pm EST. 7 days a week
Premium Breakdown
EmblemHealth VIP Gold Plus (HMO) has a monthly premium of $241.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $174.70 | $151.50 | $89.50 | $0.00 | $415.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
EmblemHealth VIP Gold Plus (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $200.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Enhanced Alternative |
| Additional Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.
The table below shows how the LIS impacts the Part D premium of this plan.
| Part D | LIS Full |
|---|---|
| $89.50 | $ |
NOTE: The Inflation Reduction Act of 2022 has expanded full subsidy eligibility under the LIS program to individuals with incomes up to 150% of the Federal Poverty Level. People who qualify for Extra Help generally will pay no more than $4.50 for each generic drug and $11.20 for each brand-name drug.
Initial Coverage Phase
After you pay your $200.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $2.00 copay | $7.00 copay | $0.00 copay | $7.00 copay |
| 2 (Generic) | $10.00 copay | $20.00 copay | $0.00 copay | $20.00 copay |
| 3 (Preferred Brand) | $40.00 copay | $47.00 copay | $40.00 copay | $47.00 copay |
| 4 (Non-Preferred Drug) | $95.00 copay | $100.00 copay | $95.00 copay | $100.00 copay |
| 5 (Specialty Tier) | 29% | 29% | 29% | 29% |
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $6.00 copay | $21.00 copay | $0.00 copay | $21.00 copay |
| 2 (Generic) | $30.00 copay | $60.00 copay | $0.00 copay | $60.00 copay |
| 3 (Preferred Brand) | $120.00 copay | $141.00 copay | $120.00 copay | $141.00 copay |
| 4 (Non-Preferred Drug) | $285.00 copay | $300.00 copay | $285.00 copay | $300.00 copay |
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00, you will pay no more than the amounts below for any drug tier until you reach $8,000.00.
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
| Generic drugs | ||||
| Brand-name drugs |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
| Generic drugs | ||||
| Brand-name drugs |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.
Additional Benefits
EmblemHealth VIP Gold Plus (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $8,850 In-network |
| No |
| In-network | No |
| $295 copay per visit (Authorization is required.) (Referral is not required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $0 copay (Authorization is not required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $0 copay (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0-45 copay (Authorization is required.) (Referral is not required.) |
| Lab services | $0-15 copay (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| Outpatient x-rays | 0-20% coinsurance (Authorization is required.) (Referral is not required.) |
| Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Restorative services | $0-125 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Endodontics | $0-20 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Periodontics | $0-150 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Extractions | $0-50 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0-150 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| Occupational therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| $75 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $0 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 10-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | $0 copay (Authorization is not required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| $195 per day for days 1 through 10 $0 per day for days 11 through 90 (Authorization is required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $0 copay (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $0 copay (Authorization is required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $0 copay (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| Outpatient individual therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $203 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
Ready to sign up for EmblemHealth VIP Gold Plus (HMO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
8am – 11pm EST. 7 days a week
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