2024 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | EmblemHealth VIP Gold Plus (HMO) | ||||
Location: | Queens, New York Click to see other locations | ||||
Plan ID: | H3330 - 038 - 0 Click to see other plans | ||||
Member Services: | 1-877-344-7364 TTY users 711 | ||||
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 Plus (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $241.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $200 (Tier 1, 2 and 6 excluded from the Deductible.) | ||||
Annual Rx Initial Coverage Limit (ICL): | $5,030 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $8,850 | ||||
Additional Rx Gap Coverage? | Yes, some additional gap coverage. | ||||
Total Number of Formulary Drugs: | 3,590 drugs | Browse the EmblemHealth VIP Gold Plus (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 | 879 | 756 | 785 | 764 |
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 Queens, New York: | 87 members | ||||
Number of Members enrolled in this plan in (H3330 - 038): | 677 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 Premium Details — | |||||
The Monthly Premium is Split as Follows: ❔ | Total Premium | Part C Premium | Part D Basic Premium | Part D Supplemental Premium | |
$241.00 | $151.50 | $89.50 | $0.00 | ||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | $40.80 | ||||
Total Monthly Premium with LIS (Parts C & D): | $192.30 |
— Plan Health Benefits — | |||||
** Base Plan ** | |||||
Premium | |||||
• Total monthly premium: $241.00 | |||||
• Health plan premium: $151.50 | |||||
• Drug plan premium: $89.50 | |||||
• You must continue to pay your Part B premium. | |||||
• Part B premium reduction: No | |||||
Deductible | |||||
• Health plan deductible: $0 | |||||
• Other health plan deductibles: In-network: No | |||||
• Drug plan deductible: $200.00 annual deductible | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $8,850 In-network | |||||
Optional supplemental benefits | |||||
• No | |||||
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? | |||||
• In-network: No | |||||
Doctor visits | |||||
• Primary: $0 copay | |||||
• Specialist: $0 copay | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures: $0-45 copay (authorization required) | |||||
• Lab services: $0-15 copay (authorization required) | |||||
• Diagnostic radiology services (e.g., MRI): 20% coinsurance (authorization required) | |||||
• Outpatient x-rays: 0-20% coinsurance (authorization required) | |||||
Emergency care/Urgent care | |||||
• Emergency: $100 copay per visit (always covered) | |||||
• Urgent care: $0 copay | |||||
Inpatient hospital coverage | |||||
• $195 per day for days 1 through 10 $0 per day for days 11 through 90 (authorization required) | |||||
Outpatient hospital coverage | |||||
• $295 copay per visit (authorization required) | |||||
Skilled Nursing Facility | |||||
• $0 per day for days 1 through 20 $203 per day for days 21 through 100 (authorization required) | |||||
Preventive care | |||||
• $0 copay | |||||
Ground ambulance | |||||
• $75 copay | |||||
Rehabilitation services | |||||
• Occupational therapy visit: $0 copay (authorization required) | |||||
• Physical therapy and speech and language therapy visit: $0 copay (authorization required) | |||||
Mental health services | |||||
• Inpatient hospital - psychiatric: $0 copay (authorization required) | |||||
• Outpatient group therapy visit with a psychiatrist: $0 copay (authorization required) | |||||
• Outpatient individual therapy visit with a psychiatrist: $0 copay (authorization required) | |||||
• Outpatient group therapy visit: $0 copay (authorization required) | |||||
• Outpatient individual therapy visit: $0 copay (authorization required) | |||||
Medical equipment/supplies | |||||
• 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) | |||||
• Diabetes supplies: $0 copay | |||||
Hearing | |||||
• Hearing exam: $0 copay | |||||
• Fitting/evaluation: $0 copay (limits apply) | |||||
• Hearing aids: $0 copay (limits apply) | |||||
Preventive dental | |||||
• Oral exam: $0 copay (limits apply) | |||||
• Cleaning: $0 copay (limits apply) | |||||
• Fluoride treatment: $0 copay (limits apply) | |||||
• Dental x-ray(s): $0 copay (limits apply) | |||||
Comprehensive dental | |||||
• Non-routine services: Not covered | |||||
• Diagnostic services: Not covered | |||||
• Restorative services: $0-125 copay (limits apply, authorization required) | |||||
• Endodontics: $0-20 copay (limits apply, authorization required) | |||||
• Periodontics: $0-150 copay (limits apply, authorization required) | |||||
• Extractions: $0-50 copay (limits apply, authorization required) | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: $0-150 copay (limits apply, authorization required) | |||||
Vision | |||||
• Routine eye exam: $0 copay (limits apply) | |||||
• Other: Not covered | |||||
• Contact lenses: $0 copay (limits apply) | |||||
• Eyeglasses (frames and lenses): $0 copay (limits apply) | |||||
• Eyeglass frames: $0 copay (limits apply) | |||||
• Eyeglass lenses: $0 copay (limits apply) | |||||
• Upgrades: Not covered | |||||
Medically-approved non-opioid pain management services | |||||
• Chiropractic services: Not covered | |||||
• Acupuncture: Not covered | |||||
• Therapeutic Massage: Not covered | |||||
• Alternative Therapies: Not covered | |||||
More benefits | |||||
• Over-the-counter drug benefits: Not covered | |||||
• Meals for short duration: Not covered | |||||
• Annual physical exams: Some coverage | |||||
• Telehealth: Some coverage | |||||
• WorldWide emergency transportation: Some coverage | |||||
• WorldWide emergency coverage: Some coverage | |||||
• WorldWide emergency urgent care: Some coverage | |||||
• Fitness Benefit: Some coverage | |||||
• In-Home Support Services: Not covered | |||||
• Bathroom Safety Devices: Not covered | |||||
• Health Education: Some coverage | |||||
• In-Home Safety Assessment: Not covered | |||||
• Personal Emergency Response System (PERS): Not covered | |||||
• Medical Nutrition Therapy (MNT): Not covered | |||||
• Post discharge In-Home Medication Reconciliation: Not covered | |||||
• Re-admission Prevention: Not covered | |||||
• Wigs for Hair Loss Related to Chemotherapy: Not covered | |||||
• Weight Management Programs: Not covered | |||||
• Adult Day Health Services: Not covered | |||||
• Nutritional/Dietary Benefit: Not covered | |||||
• Home-Based Palliative Care: Not covered | |||||
• Support for Caregivers of Enrollees: Not covered | |||||
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered | |||||
• Enhanced Disease Management: Some coverage | |||||
• Telemonitoring Services: Not covered | |||||
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage | |||||
• Counseling Services: Not covered | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered | |||||
Transportation | |||||
• Not covered | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment: $0 copay | |||||
• Routine foot care: $0 copay (limits apply) | |||||
Medicare Part B drugs | |||||
• Part B Insulin drugs: $35 copay (authorization required) | |||||
• Chemotherapy: 0-20% coinsurance (authorization required) | |||||
• Other Part B drugs: 0-20% coinsurance (authorization required) |