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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 2025, 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 Bronx, Kings, NY, Queens, Long Island, Westchester. This plan received an overall rating of 3.5 out of 5 stars in 2025.
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 $201.00. 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 $8850.00 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) plan has a $200 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For preferred generic drugs, you will pay a $10 copay at preferred pharmacies and no copay for mail order. Standard generic drugs have a $40 copay at preferred pharmacies. Preferred brand drugs have a $95 copay. Non-preferred drugs have a 29% coinsurance. Specialty tier drugs have no copay.
Additional Benefits
The EmblemHealth VIP Gold (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services have copays that vary by service. Other services, such as ambulance, emergency, primary care, hearing, vision, and dental services, are also covered with copays or coinsurance. This plan includes coverage for home health services, skilled nursing facilities, and home infusion bundled services. Some services, like dental and vision, have specific limits on coverage. It's important to note that some services require prior authorization, and certain services like cardiac rehabilitation and some other services are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For Inpatient Hospital-Acute, you'll pay a $290 copay for days 1-7, and no copay for days 8-90; for Inpatient Hospital Psychiatric, the copay is $2036 per admission or stay.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient hospital services have a copay between $0 and $295, observation services have a $295 copay, ambulatory surgical center services have no copay, and outpatient substance abuse services have a $25 copay for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered by the EmblemHealth VIP Gold (HMO) plan, but requires prior authorization. You will have a $25 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the EmblemHealth VIP Gold (HMO) plan. Ground ambulance services have a $100 copay, and air ambulance services have a 20% coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the EmblemHealth VIP Gold (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $110 copay, while Urgently Needed Services have a $35 copay. Worldwide Emergency Transportation and Worldwide Urgent Coverage also have a $110 copay.
Primary Care See details
The EmblemHealth VIP Gold (HMO) plan covers Primary Care Physician services, Chiropractic Services with a $10 copay, Occupational Therapy Services with a $25 copay, Physician Specialist Services with a $25 copay, Mental Health Specialty Services with a $25 copay, Podiatry Services with a $25 copay, Other Health Care Professional services with a $25 copay, Psychiatric Services with a $25 copay, Physical Therapy and Speech-Language Pathology Services with a $25 copay, Additional Telehealth Benefits with a $0-$25 copay, and Opioid Treatment Program Services with a $25 copay. Routine Chiropractic Care is not covered.
Preventive Services See details
The EmblemHealth VIP Gold (HMO) plan covers preventive services, including annual physical exams, health education, fitness benefits (memory fitness), enhanced disease management, remote access technologies, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs. However, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers, additional smoking cessation counseling, telemonitoring services, home and bathroom safety devices, and counseling services are not covered.
Hearing Services See details
Hearing services with the EmblemHealth VIP Gold (HMO) plan include hearing exams with a $25 copay, fitting/evaluation for hearing aids, and prescription hearing aids up to $2400 every three years. Prescription hearing aids are covered, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $25 copay. Eyewear is covered with a combined maximum plan benefit of $300 per year, and contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are also covered. Upgrades are not covered.
Dental Services See details
The EmblemHealth VIP Gold (HMO) plan covers a variety of dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery. Restorative services have a copay between $0 and $125, endodontics have a copay between $0 and $20, periodontics have a copay between $0 and $150, prosthodontics (removable) have a copay between $0 and $150, prosthodontics (fixed) have a copay between $0 and $150, and oral and maxillofacial surgery has a copay between $0 and $50. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with a coinsurance between 0% and 20%. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered under the EmblemHealth VIP Gold (HMO) plan. The coinsurance for these services is 20%.
Medical Equipment See details
Medical equipment is covered, including Durable Medical Equipment (DME) with a coinsurance of 10-20%, and Prosthetics/Medical Supplies with a coinsurance of 20% for Medicare-covered devices and supplies; however, Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures, tests, and lab services, are covered. Diagnostic Procedures/Tests have a copay between $0 and $45, while Lab Services have no copay. Diagnostic and Therapeutic Radiological Services have a coinsurance of at most 20%, and Outpatient X-Ray Services have a $25 copay and a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the EmblemHealth VIP Gold (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the EmblemHealth VIP Gold (HMO) plan. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the EmblemHealth VIP Gold (HMO) plan, but require prior authorization. You will have no copay for days 1-20, and a $214 copay for days 21-100.
Other Services See details
Other Services are not covered, including acupuncture, over-the-counter items, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services. No authorization or referral is required for any services.
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