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EmblemHealth VIP Gold (HMO)

H3330 - 021 - 5

(3.5 / 5)

EmblemHealth VIP Gold (HMO) is a Medicare Advantage Plan by EmblemHealth.

This page features plan details for 2025 EmblemHealth VIP Gold (HMO) H3330 – 021 – 5 available in Bronx, Kings, NY, Queens, Long Island, Westchester.

Locations

EmblemHealth VIP Gold (HMO) is offered in the following locations.

Kings County, New York

New York

Click to see more locations

Plan Overview

EmblemHealth VIP Gold (HMO) offers the following coverage and cost-sharing.

Insurer:	EmblemHealth
Health Plan Deductible:	$0
MOOP:	$8,850 In-network
Drugs Covered:	Yes

Ready to sign up for EmblemHealth VIP Gold (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

EmblemHealth VIP Gold (HMO) has a monthly premium of $54.00. 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
$185.00	$29.50	$24.50	$	$

Please Note:

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 (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$200.00
Drug Out-Of-Pocket maximum:	$2,000.00
Drug Benefit Type:	Enhanced Alternative

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
$24.50	$0.00

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 $2,000.00. 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		$7.00 Copay
2) Generic	$10.00 Copay	$20.00 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	29.00% Coinsurance	29.00% Coinsurance	29.00% Coinsurance	29.00% Coinsurance
6) Select Care Drugs

60 Day

Tier	Pref. Pharm	Std. Pharm	Pref. Mail	Std. Mail
1) Preferred Generic	$4.00 Copay	$14.00 Copay		$14.00 Copay
2) Generic	$20.00 Copay	$40.00 Copay		$40.00 Copay
3) Preferred Brand	$80.00 Copay	$94.00 Copay	$80.00 Copay	$94.00 Copay
4) Non-Preferred Drug	$190.00 Copay	$200.00 Copay	$190.00 Copay	$200.00 Copay
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		$21.00 Copay
2) Generic	$30.00 Copay	$60.00 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

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, 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 (HMO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

- In-Network: No

Comprehensive Dental

Adjunctive General Services
- In-Network: No Coins – No Co pay (Limits Apply, Authorization Required)
Endodontics
- In-Network: No Coins – 0.00-20.00 Copay (Authorization Required)
Oral and Maxillofacial Surgery
- In-Network: No Coins – 0.00-50.00 Copay (Authorization Required)
Periodontics
- In-Network: No Coins – 0.00-150.00 Copay (Authorization Required)
Prosthodontics, fixed
- In-Network: No Coins – 0.00-150.00 Copay (Authorization Required)
Prosthodontics, removable
- In-Network: No Coins – 0.00-150.00 Copay (Authorization Required)
Restorative Services
- In-Network: No Coins – 0.00-125.00 Copay (Authorization Required)

Diagnostic and Preventive Dental

Dental X-Rays
- In-Network: No Coins – No Copay
Fluoride Treatment
- In-Network: No Coins – No Copay
Oral Exams
- In-Network: No Coins – No Copay
Other Diagnostic Dental Services
- In-Network: No Coins – No Copay (Limits Apply)
Other Preventive Dental Services
- In-Network: No Coins – No Copay
Prophylaxis (cleaning)
- In-Network: No Coins – No Copay

Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures
- $0-45 copay (Authorization Required)
Diagnostic radiology services (e.g., MRI)
- 0-20% coinsurance (Authorization Required)
Lab services
- $0-15 copay (Authorization Required)
Outpatient x-rays
- $25 copay or 20% coinsurance (Authorization Required)

Doctor visits

Specialist
- $25 copay per visit
Primary
- $0 copay

Emergency care/Urgent care

Emergency
- $110 copay per visit (always covered)
Urgent care
- $35 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment
- $25 copay
Routine foot care
- $25 copay (Limits Apply)

Ground ambulance

- $100 copay

Health plan deductible

- $0

Hearing

Hearing aids
- $0 copay (Limits Apply)
Hearing aids OTC
- Not covered
Medicare-Covered Hearing Exam
- $25 copay
Fitting/evaluation
- $0 copay (Limits Apply)

Inpatient hospital coverage

- $290 per day for days 1 through 7
  $0 per day for days 8 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

- $8,850 In-network

Medical equipment/supplies

Durable medical equipment (e.g., wheelchairs, oxygen)
- 10-20% coinsurance per item (Authorization Required)
Diabetes supplies
- $0 copay
Prosthetics (e.g., braces, artificial limbs)
- 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

Chemotherapy
- 0-20% coinsurance (Authorization Required)
Other Part B drugs
- 0-20% coinsurance (Authorization Required)

Mental health services

Outpatient group therapy visit
- $25 copay (Authorization Required)
Outpatient individual therapy visit
- $25 copay (Authorization Required)
Inpatient hospital – psychiatric
- $2,036 per stay (Authorization Required)
Outpatient individual therapy visit with a psychiatrist
- $25 copay (Authorization Required)
Outpatient group therapy visit with a psychiatrist
- $25 copay (Authorization Required)

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- $0-295 copay per visit (Authorization Required)

Preventive care

- $0 copay

Rehabilitation services

Physical therapy and speech and language therapy visit
- $25 copay
Occupational therapy visit
- $25 copay

Skilled Nursing Facility

- $0 per day for days 1 through 20
  $214 per day for days 21 through 100 (Authorization Required)

Transportation

- Not covered

Vision

Eyeglass frames
- $0 copay (Limits Apply)
Eyeglass lenses
- $0 copay (Limits Apply)
Upgrades
- Not covered
Eyeglasses (frames and lenses)
- $0 copay (Limits Apply)
Contact lenses
- $0 copay (Limits Apply)
Other
- Not covered
Routine eye exam
- $0 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

- Covered