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EmblemHealth VIP Gold Plus (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for EmblemHealth VIP Gold Plus (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 Plus (HMO) in 2025, please refer to our full plan details page.
EmblemHealth VIP Gold Plus (HMO) is a HMO plan offered by EmblemHealth, Inc. available for enrollment in 2025 to people living in NYC, LI, Middle Hudson Valley, 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 Plus (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 Plus (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 Plus (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $223.00. 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 Plus (HMO) plan has a $200 deductible for prescription drugs. After the deductible, your cost for drugs depends on the tier and where you get your prescriptions filled. For a 30-day supply, you can expect to pay a $10 copay for preferred generic drugs at a preferred pharmacy, while preferred mail order has no copay. Standard generic drugs have a $40 copay at a preferred pharmacy. Preferred brand drugs have a $95 copay, and non-preferred drugs have 29% coinsurance. Specialty tier drugs have no copay.
Additional Benefits
The EmblemHealth VIP Gold Plus (HMO) plan offers comprehensive coverage with a variety of benefits. It includes coverage for inpatient and outpatient hospital services, with varying copays. You'll also find coverage for primary care, preventive services, hearing, vision, and dental care. This plan also offers coverage for ambulance services, emergency services, home health, and skilled nursing facilities. The plan has no copay for primary care, and many other services, but has copays and coinsurance for other services.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you pay a $195 copay for days 1-10, and no copay for days 11-90; additional days are covered with no copay, while non-Medicare covered stays and upgrades are not covered. Inpatient Hospital Psychiatric has a $2036 copay, and additional days and non-Medicare covered stays are not covered.
Outpatient Services See details
Outpatient Services, including Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) 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 (ASC) Services have no copay, and Outpatient Blood Services have no cost sharing. Outpatient Substance Abuse Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. There is no information about the cost of this benefit in the provided snippet.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the EmblemHealth VIP Gold Plus (HMO) plan. Ground Ambulance Services have a $75 copay, while Air Ambulance Services have a 20% coinsurance, and Transportation Services are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Services, Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are covered. Emergency Services have a copay of $110, and no coinsurance. Worldwide Emergency Services have a maximum plan benefit coverage of $50,000.
Primary Care See details
The EmblemHealth VIP Gold Plus (HMO) plan covers primary care physician services, occupational therapy services, physician specialist services, podiatry services, physical therapy, speech-language pathology services, opioid treatment program services, and additional telehealth benefits with no copay and no coinsurance. Chiropractic services, mental health specialty services, and psychiatric services are partially covered, but routine chiropractic care, individual sessions for mental health specialty services, individual sessions for psychiatric services, and group sessions are not covered.
Preventive Services See details
Preventive services include coverage for Medicare-covered services with no copay, annual physical exams, health education, fitness benefits, enhanced disease management, kidney disease education services, 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 sessions of smoking cessation, telemonitoring services, home and bathroom safety devices, and counseling services are not covered.
Hearing Services See details
Hearing Services include coverage for hearing exams, routine hearing exams, fitting and evaluation for hearing aids, and prescription hearing aids. Routine hearing exams and fitting/evaluation for hearing aids are covered once per year, and prescription hearing aids are covered up to $3,000 every three years; however, inner ear, outer ear, and over-the-ear prescription hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
The EmblemHealth VIP Gold Plus (HMO) plan covers routine eye exams once per year, and offers eyewear coverage with a combined maximum benefit of $150 per year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames are covered, but upgrades are not covered.
Dental Services See details
Dental services are covered, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatments, and other preventive dental services. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with copays ranging from $0 to $150, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the EmblemHealth VIP Gold Plus (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered by the EmblemHealth VIP Gold Plus (HMO) plan, with Durable Medical Equipment (DME) subject to a 0-20% coinsurance and no copay, though DME for use outside the home is not covered. Prosthetics and Medical Supplies have no copay, but are subject to a 20% coinsurance for Medicare-covered items, while Diabetic Equipment is covered, but Diabetic Supplies and Therapeutic Shoes/Inserts are not.
Diagnostic and Radiological Services See details
The EmblemHealth VIP Gold Plus (HMO) plan covers diagnostic and radiological services, including diagnostic procedures/tests with a copay between $0 and $45 and lab services with no copay. Diagnostic radiological services, therapeutic radiological services, and outpatient X-ray services each have a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the EmblemHealth VIP Gold Plus (HMO) plan with no copay and no coinsurance, but prior authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are generally covered, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization is required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered under the EmblemHealth VIP Gold Plus (HMO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services are not covered by the EmblemHealth VIP Gold Plus (HMO) plan, 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. This plan does not require authorization or a referral for the services.
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