EmblemHealth VIP Reserve (HMO)
H5991 - 009 - 0
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EmblemHealth VIP Reserve (HMO) is a Medicare Advantage (Part C) Plan by EmblemHealth Medicare HMO.
This page features plan details for 2022 EmblemHealth VIP Reserve (HMO) H5991 – 009 – 0 available in Bronx, Kings, New York, Queens.
IMPORTANT: This page features the 2022 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.
Locations
EmblemHealth VIP Reserve (HMO) is offered in the following locations.
Plan Overview
EmblemHealth VIP Reserve (HMO) offers the following coverage and cost-sharing.
| Insurer: | EmblemHealth Medicare HMO |
| Health Plan Deductible: | $0 |
| MOOP: | $7,550.00 |
| Drugs Covered: | Yes |
Please Note:
- This plan does not charge an annual deductible for all drugs. The $325.00 annual deductible only applies to drugs on certain tiers.
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Premium Breakdown
EmblemHealth VIP Reserve (HMO) has a monthly premium of $0. 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 |
|---|---|---|---|---|
| $170.10 | $0.00 | $0.00 | $0.00 | $170.10 |
- 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 Reserve (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $325.00 |
| Initial Coverage Limit: | $4,275.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | No |
| 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 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Initial Coverage Phase
After you pay your $325.00 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 $4,275.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,275.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
30 Day
90 Day
30 Day
90 Day
| Drug Type | Cost Share |
|---|---|
| Generic drugs | 25% |
| Brand-name drugs | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Tier | Cost |
|---|---|
| Generic | $4.15 copay or 5% (whichever costs more) |
| Brand-name | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
EmblemHealth VIP Reserve (HMO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | Not covered |
| Endodontics: | $0-20 copay (limits may apply) (authorization required) |
| Extractions: | $0-50 copay (limits may apply) (authorization required) |
| Non-routine services: | Not covered |
| Periodontics: | $0-150 copay (limits may apply) (authorization required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | $0-150 copay (limits may apply) (authorization required) |
| Restorative services: | $0-125 copay (limits may apply) (authorization required) |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) |
| Dental x-ray(s): | $0 copay (limits may apply) |
| Fluoride treatment: | $0 copay (limits may apply) |
| Oral exam: | $0 copay (limits may apply) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | 20% coinsurance (authorization required) |
| Diagnostic tests and procedures: | $0-50 copay (authorization required) |
| Lab services: | $0-15 copay (authorization required) |
| Outpatient x-rays: | $40 copay (authorization required) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | $25 copay per visit |
Emergency care/Urgent care
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $65 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | $40 copay |
| Routine foot care: | $40 copay (limits may apply) |
Ground ambulance
| $440 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | $10 copay (limits may apply) |
| Hearing aids: | $0 copay (limits may apply) |
| Hearing exam: | $25 copay |
Hospital coverage (inpatient)
| $492 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required) |
Hospital coverage (outpatient)
| $475 copay per visit (authorization required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $7,550 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 10-20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 10-20% coinsurance (authorization required) |
| Other Part B drugs: | 10-20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $1,871 per stay (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | $40 copay (authorization required) |
| Outpatient group therapy visit: | $40 copay (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | $40 copay (authorization required) |
| Outpatient individual therapy visit: | $40 copay (authorization required) |
Optional supplemental benefits
| No |
Preventive care
| $0 copay |
Rehabilitation services
| Occupational therapy visit: | $40 copay (authorization required) |
| Physical therapy and speech and language therapy visit: | $40 copay (authorization required) |
Skilled Nursing Facility
| $0 per day for days 1 through 20 $188 per day for days 21 through 100 (authorization required) |
Transportation
| Not covered |
Vision
| Contact lenses: | $0 copay (limits may apply) |
| Eyeglass frames: | $0 copay (limits may apply) |
| Eyeglass lenses: | $0 copay (limits may apply) |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) |
| Other: | Not covered |
| Routine eye exam: | $10 copay (limits may apply) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered |
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