EmblemHealth VIP Gold (HMO)

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.

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:

Drug Coverage

The EmblemHealth VIP Gold (HMO) plan features an annual drug deductible of $200. Members enjoy no copay for Tier 1 preferred generic and Tier 6 select care drugs at standard pharmacies and through mail order. For Tier 2 generic medications, standard retail and mail order options require a $10 to $30 copay depending on the supply length, while preferred mail order services offer these generics with no copay. Brand-name and specialty medications are subject to 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% coinsurance through preferred mail order. Tier 4 non-preferred drugs carry a 25% to 28% coinsurance, while Tier 5 specialty drugs require 29% coinsurance for a one-month supply.

Additional Benefits

The EmblemHealth VIP Gold (HMO) plan provides comprehensive coverage for essential medical needs, featuring no copays for primary care doctor visits, home health services, and preventive care. For hospital care, inpatient acute stays require a $290 daily copay for days 1 through 7 and no copay thereafter, while outpatient hospital services carry a copay ranging from no copay to $295. Emergency room visits require a $115 copay, which is waived if you are admitted, while ground ambulance services carry a $100 copay. Specialty services like specialist visits, routine hearing exams, and routine eye exams are covered with a $25 copay and no coinsurance. The plan also includes helpful allowances, such as no copay for preventive dental care, up to $300 annually for eyewear, and up to $2,400 every three years for prescription hearing aids. Additionally, skilled nursing facility stays require no copay for the first 20 days, and durable medical equipment is covered with no copay and 0% to 20% coinsurance.