EmblemHealth VIP Gold Plus (HMO)

EmblemHealth VIP Gold Plus (HMO) is a HMO plan offered by EmblemHealth, Inc. available for enrollment in 2025 to people living in NYC, LI, Mid- Hudson Valley, Westchester. This plan received an overall rating of 4 out of 5 stars in 2026.

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.

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 Plus (HMO) prescription drug plan features an annual drug deductible of $200. You will enjoy no copay for Tier 1 preferred generic drugs and Tier 6 select care drugs across standard pharmacy and mail order options. For Tier 2 generic drugs, there is no copay for preferred mail order, while standard pharmacy and mail order options range from a $10 copay for a one-month supply to a $30 copay for a three-month supply. For higher-tier medications, the plan utilizes coinsurance rather than flat copays. Tier 3 preferred brand drugs carry a 25% coinsurance at standard pharmacies and standard mail order, which decreases to 22% when using preferred mail order. Tier 4 non-preferred drugs require 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 Plus (HMO) plan offers comprehensive coverage for everyday medical needs, featuring no copays and no coinsurance for primary care visits, specialist consultations, and annual physical exams. Routine dental, vision, and hearing exams are also covered with no copays, and members receive a $150 annual eyewear allowance and up to $3,000 for hearing aids every three years. Comprehensive dental care is highly accessible with no coinsurance and copays ranging from no copay up to $150. For emergency and hospital care, members pay a $115 copay for emergency room visits and a $195 daily copay for the first 10 days of an inpatient hospital stay, with no copay thereafter. Ground ambulance rides carry a $75 copay, while skilled nursing facility stays are covered with no copay for the first 20 days. Diagnostic services, outpatient procedures, and durable medical equipment are covered with minimal cost-sharing, featuring no copays for lab tests and coinsurance up to 20% for medical equipment.