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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 $175.00. 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) plan features a $200 drug deductible and offers competitive cost-sharing rates on prescription drugs. Beneficiaries enjoy no copay for Tier 1 (Preferred Generic) and Tier 6 (Select Care) medications across standard pharmacies and mail order services. Tier 2 (Generic) medications also have no copay when filled through preferred mail order, or a standard pharmacy copay starting at $10 for a one-month supply. For higher-tier medications, costs are based on coinsurance rather than flat copays. Tier 3 (Preferred Brand) drugs require a 25% coinsurance at standard pharmacies and standard mail order, which drops to 22% through preferred mail order. Tier 4 (Non-Preferred) drugs carry a 25% to 28% coinsurance, while Tier 5 (Specialty) drugs require a 29% coinsurance for a one-month supply.
Additional Benefits
The EmblemHealth VIP Gold (HMO) plan offers robust coverage for core medical needs, featuring no copays for primary care visits and preventive services. For specialized care, members pay a $25 copay for specialist visits, physical therapy, and mental health services, while emergency room visits carry a $115 copay. Inpatient hospital stays require a $290 daily copay for the first seven days, with no copay for days eight and beyond. Additional benefits include no-copay preventive dental care, while comprehensive dental services feature copays ranging from $0 to $150. Routine vision and hearing exams require a $25 copay, with generous coverage allowances of up to $300 annually for eyewear and $2,400 every three years for prescription hearing aids. Skilled nursing facility stays are also covered with no copay for the first 20 days.
Inpatient Hospital See details
EmblemHealth VIP Gold (HMO) covers inpatient acute hospital stays with no coinsurance and a $290 daily copay for days 1 through 7, with no copay for days 8 and beyond, though upgrades and non-Medicare-covered stays are not covered. Inpatient psychiatric care is also covered with no coinsurance and a $2,080 copay per stay, but additional psychiatric days and non-Medicare-covered stays are not covered.
Outpatient Services See details
EmblemHealth VIP Gold (HMO) covers outpatient services with no coinsurance, offering ambulatory surgical center and blood services with no copay. Outpatient hospital services have a copay of $0 to $295 (including a $295 copay per stay for observation services), while outpatient substance abuse sessions require a $25 copay.
Partial Hospitalization See details
Partial hospitalization services are covered under the EmblemHealth VIP Gold (HMO) plan with a $25 copay and no coinsurance. Prior authorization is required to receive this benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by EmblemHealth VIP Gold (HMO), with ground ambulance services requiring a $100 copay and no coinsurance, and air ambulance services requiring a 20% coinsurance and no copay, subject to prior authorization. Although some transportation services are covered, trips to plan-approved health-related locations and any health-related locations are not covered.
Emergency Services See details
EmblemHealth VIP Gold (HMO) covers emergency services with a $115 copay and no coinsurance, which is waived if you are admitted to the hospital within one day. Urgently needed services require a $35 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered up to a $50,000 maximum with no copay or coinsurance.
Primary Care See details
EmblemHealth VIP Gold (HMO) covers primary care physician visits with no copay and no coinsurance, while specialist visits, physical therapy, and mental health services require a $25 copay and no coinsurance. Telehealth benefits are offered with a $0 to $25 copay and no coinsurance, but routine and other chiropractic services are not covered.
Preventive Services See details
EmblemHealth VIP Gold (HMO) preventive services are partially covered with no copay and no coinsurance for covered services, including annual physical exams, kidney disease education, and glaucoma screenings. Several additional preventive benefits are not covered, such as in-home safety assessments, personal emergency response systems, medical nutrition therapy, and weight management programs.
Hearing Services See details
Hearing services are covered by EmblemHealth VIP Gold (HMO), which offers annual routine hearing exams and fitting evaluations for a $25 copay and no coinsurance. Prescription hearing aids are partially covered with no copay and no coinsurance up to a $2,400 maximum every three years, but OTC hearing aids and inner ear, outer ear, and over-the-ear prescription models are not covered.
Vision Services See details
EmblemHealth VIP Gold (HMO) covers one routine eye exam per year with 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, but upgrades are not covered.
Dental Services See details
EmblemHealth VIP Gold (HMO) partially covers dental services, providing preventive care like cleanings and exams with no copay and no coinsurance. Comprehensive services, which may require prior authorization, have copays ranging from $0 to $150 and no coinsurance, though 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 and no coinsurance, subject to prior authorization. Associated Medicare Part B chemotherapy and other drugs carry no copay and 0% to 20% coinsurance, while Part B insulin drugs require a $35 copay and no coinsurance.
Dialysis Services See details
Dialysis Services are covered by EmblemHealth VIP Gold (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
EmblemHealth VIP Gold (HMO) covers medical equipment with no copays, featuring a 0% to 20% coinsurance for durable medical equipment and a 20% coinsurance for prosthetics and medical supplies. Diabetic equipment is covered with no copay or coinsurance, but the benefit is only partially covered because diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
EmblemHealth VIP Gold (HMO) covers diagnostic and radiological services with prior authorization required. Diagnostic tests and procedures have a $0 to $45 copay with no coinsurance, lab services have no copay or coinsurance, and radiological services range from no coinsurance for diagnostic imaging to a 20% minimum coinsurance for therapeutic services and outpatient X-rays, which also carry a $25 copay.
Home Health Services See details
Home Health Services are covered under the EmblemHealth VIP Gold (HMO) plan 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) plan with no coinsurance and prior authorization required. While some services are covered, standard cardiac rehabilitation (with a $25 copay), intensive cardiac rehabilitation ($25 copay), pulmonary rehabilitation ($15 copay), and SET for PAD services ($20 copay) are not covered.
Skilled Nursing Facility (SNF) See details
EmblemHealth VIP Gold (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
EmblemHealth VIP Gold (HMO) offers coverage for other services, meaning some services are covered, but acupuncture, over-the-counter (OTC) items, and meal benefits are not covered.
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