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EmblemHealth VIP Gold (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for EmblemHealth VIP Gold (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on EmblemHealth VIP Gold (HMO) in 2026, please refer to our full plan details page.
EmblemHealth VIP Gold (HMO) is a HMO plan offered by EmblemHealth, Inc. available for enrollment in 2025 to people living in Brooklyn, Long Island, Westchester. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that EmblemHealth VIP Gold (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about EmblemHealth VIP Gold (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For EmblemHealth VIP Gold (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $114.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $200.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $9250.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The EmblemHealth VIP Gold (HMO) prescription drug coverage includes an annual drug deductible of $200. Plan members enjoy no copay for Tier 1 preferred generic drugs and Tier 6 select care drugs across standard retail and mail order options. Tier 2 generic drugs also feature no copay when filled through preferred mail order, or a low $10 copay for a one-month supply at standard pharmacies. For higher-tier medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brands require a 25% coinsurance at standard pharmacies, which is reduced to 22% for preferred mail orders. Tier 4 non-preferred drugs have a 28% coinsurance at standard pharmacies and 25% through preferred mail order, while Tier 5 specialty drugs require a 29% coinsurance for a one-month supply.
Additional Benefits
EmblemHealth VIP Gold (HMO) provides robust healthcare coverage with no copay or coinsurance for primary care visits, annual physicals, and preventive screenings. Specialist consultations, urgent care, and outpatient services are highly accessible, typically requiring low flat copayments like $25 for specialists. For inpatient hospital stays, members pay a $290 daily copay for the first seven days, after which there is no copay. Supplemental benefits include routine dental care with no copay, alongside routine vision and hearing exams for a $25 copay. This plan also features generous allowances with no copay for prescription hearing aids up to $2,400 every three years and eyewear up to $300 annually. Furthermore, members pay no copay for home health services and the first 20 days of skilled nursing facility care.
Inpatient Hospital See details
EmblemHealth VIP Gold (HMO) covers inpatient hospital services with no coinsurance, requiring a $290 daily copay for days 1 to 7 (no copay for days 8 and beyond) for acute stays, and a $2,080 copay per admission for psychiatric stays. Prior authorization is required, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
EmblemHealth VIP Gold (HMO) covers outpatient hospital services with a $0 to $295 copay and no coinsurance, and observation services with a $295 copay per stay and no coinsurance. Ambulatory surgical center and outpatient blood services have no copay and no coinsurance, while outpatient substance abuse sessions require a $25 copay and no coinsurance.
Partial Hospitalization See details
EmblemHealth VIP Gold (HMO) covers partial hospitalization services with a $25.00 copay and no coinsurance. Prior authorization is required to receive these covered services.
Ambulance and Transportation Services See details
EmblemHealth VIP Gold (HMO) covers ground ambulance services with a $100 copay and no coinsurance, and air ambulance services with a 20% coinsurance and no copay, both requiring prior authorization. Transportation services are not covered, meaning trips to plan-approved or any health-related locations are excluded.
Emergency Services See details
EmblemHealth VIP Gold (HMO) covers emergency services with a $115 copay and no coinsurance, with the copay waived if you are admitted to the hospital within one day. Urgently needed services are covered with a $35 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered up to $50,000 with no copay and no coinsurance.
Primary Care See details
EmblemHealth VIP Gold (HMO) offers primary care physician services with no copay and no coinsurance, and telehealth benefits with a $0 to $25 copay and no coinsurance. Specialist visits, physical, occupational, speech therapy, podiatry, mental health, psychiatric, and opioid treatment services feature a $25 copay and no coinsurance, while chiropractic services are not covered.
Preventive Services See details
Preventive services are covered by EmblemHealth VIP Gold (HMO) with no copay and no coinsurance for annual physical exams, kidney disease education, and various screenings. Additional preventive services are partially covered with no copay and no coinsurance, excluding in-home safety assessments, PERS, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, additional smoking cessation, telemonitoring, home/bathroom safety, and counseling.
Hearing Services See details
EmblemHealth VIP Gold (HMO) covers annual routine hearing exams and evaluations with a $25 copay and no coinsurance. Prescription hearing aids are covered with no copay and no coinsurance up to a $2,400 maximum every three years, though OTC hearing aids and inner-ear, outer-ear, or over-the-ear prescription models are not covered.
Vision Services See details
EmblemHealth VIP Gold (HMO) vision services are partially covered, featuring one routine eye exam per year for a $25 copay and no coinsurance, though other eye exam services are not covered. Eyewear is covered with no copay and no coinsurance up to a $300 annual maximum for contacts and eyeglasses, but upgrades are not covered.
Dental Services See details
Dental services are partially covered by EmblemHealth VIP Gold (HMO), offering preventive care with no copay and no coinsurance, and comprehensive services with copays ranging from $0 to $150 and no coinsurance. Prior authorization is required for comprehensive care, and maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by EmblemHealth VIP Gold (HMO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy and other drugs require a 0% to 20% coinsurance, while Part B insulin is covered with a $35 copay and no coinsurance.
Dialysis Services See details
EmblemHealth VIP Gold (HMO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
EmblemHealth VIP Gold (HMO) covers durable medical equipment and prosthetics with no copay and coinsurance ranging from no coinsurance to 20%, with prior authorization required. Diabetic equipment is covered with no copay and no coinsurance, although diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by EmblemHealth VIP Gold (HMO) and require prior authorization. Diagnostic tests have no coinsurance and a $0 to $45 copay, lab services have no copay or coinsurance, and radiological services require a 20% minimum coinsurance for therapeutic and X-ray services (with a $25 copay for X-rays) and a copay with no coinsurance for diagnostic radiology.
Home Health Services See details
EmblemHealth VIP Gold (HMO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the EmblemHealth VIP Gold (HMO) with no coinsurance and require prior authorization, though some services are covered while standard cardiac, intensive cardiac, pulmonary, and SET for PAD services are not covered. Copays for these excluded rehabilitation services range from $15 to $25.
Skilled Nursing Facility (SNF) See details
EmblemHealth VIP Gold (HMO) covers Skilled Nursing Facility (SNF) care with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the standard Medicare limit are not covered.
Other Services See details
EmblemHealth VIP Gold (HMO) offers an other services benefit where some services are covered, but acupuncture, over-the-counter (OTC) items, and meal benefits are not covered.
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