2024 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | EmblemHealth VIP Gold (HMO) | ||||
Location: | Nassau, New York Click to see other locations | ||||
Plan ID: | H3330 - 021 - 0 Click to see other plans | ||||
Member Services: | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the EmblemHealth VIP Gold (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $112.00 | ||||
Annual Deductible: | $200 | ||||
Annual Initial Coverage Limit (ICL): | $5,030 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $8,850 | ||||
Additional Gap Coverage? | Yes, some additional gap coverage. | ||||
Total Number of Formulary Drugs: | 3,528 drugs | Browse the EmblemHealth VIP Gold (HMO) Formulary | |||
This plan has 6 drug tiers. See cost-sharing for all pharmacies and tiers. | |||||
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $2.00 | $10.00 | $40.00 | $95.00 | 29% |
• Number of Drugs per Tier: | 254 | 878 | 737 | 789 | 726 |
Plan Offers Mail Order? | Yes | ||||
Medicare Plan Pharmacy Numbers: | BIN: 400023 PCN: 0020050403 See BIN/PCNs for all plans | ||||
Number of Members enrolled in this plan in Nassau, New York: | 1,855 members | ||||
Number of Members enrolled in this plan in (H3330 - 021): | 6,784 members | ||||
Plan’s Summary Star Rating: | 3 out of 5 Stars. | ||||
• Customer Service Rating: | 2 out of 5 Stars. | ||||
• Member Experience Rating: | 2 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 3 out of 5 Stars. |
— Plan Health Benefits — |