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EmblemHealth VIP Rx Saver (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for EmblemHealth VIP Rx Saver (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on EmblemHealth VIP Rx Saver (HMO) in 2025, please refer to our full plan details page.
EmblemHealth VIP Rx Saver (HMO) is a HMO plan offered by EmblemHealth, Inc. available for enrollment in 2025 to people living in Capital Region. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that EmblemHealth VIP Rx Saver (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 Rx Saver (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 Rx Saver (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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 $395.00 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 $6000.00 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 Rx Saver (HMO) plan has a $395.00 deductible for prescription drugs. After meeting the deductible, you'll pay a copay for your prescriptions depending on the drug tier and pharmacy. For example, preferred generic drugs have a $15 copay at preferred pharmacies, and preferred mail order has no copay. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered Part D drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The EmblemHealth VIP Rx Saver (HMO) plan offers a range of benefits, including inpatient and outpatient hospital services, with varying copays for each. Emergency, urgent, and worldwide emergency services are covered, with a copay for emergency and urgent care. The plan also covers primary care, specialist visits, mental health services, and various therapies with copays, as well as preventive, hearing, vision, and dental services with specific coverage limits and copays. This plan also includes coverage for ambulance services, home health, and skilled nursing facilities, with copays or coinsurance depending on the service. Other benefits include home infusion, dialysis, medical equipment, and diagnostic services, each with specific cost-sharing arrangements. Additionally, the plan provides an allowance for over-the-counter items and nicotine replacement therapy.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you pay a $325 copay for days 1-4 and no copay for days 5-90; for Inpatient Hospital Psychiatric, you pay a $2036 copay. Additional days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, and Additional Days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a copay between $0 and $150, observation services with a $150 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services are covered, with individual and group sessions each having a copay of $40. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the EmblemHealth VIP Rx Saver (HMO) plan, but requires prior authorization. The copay for this benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the EmblemHealth VIP Rx Saver (HMO) plan. Ground ambulance services have a $250 copay, while 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 by the EmblemHealth VIP Rx Saver (HMO) plan. Emergency Services have a $110 copay and no coinsurance, while Urgently Needed Services have a $45 copay and no coinsurance. Worldwide Emergency Services have a maximum plan benefit coverage of $50,000.
Primary Care See details
The EmblemHealth VIP Rx Saver (HMO) plan covers primary care physician services, chiropractic services with a $10 copay, occupational therapy with a $25 copay, and physician specialist services with a $25 copay. Mental health specialty services and psychiatric services each have a $40 copay for individual and group sessions. Podiatry services and other health care professional services each have a $25 copay, and physical therapy and speech-language pathology services have a $25 copay. Additional telehealth benefits have a copay ranging from $0-$40, and opioid treatment program services have a $40 copay.
Preventive Services See details
The EmblemHealth VIP Rx Saver (HMO) plan covers various preventive services, including annual physical exams, health education, and fitness benefits. However, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and several other services are not covered.
Hearing Services See details
Hearing services include coverage for routine hearing exams, fitting/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 (all types) are covered up to $3,000 every three years, with two visits every three years. Prescription hearing aids - inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
The EmblemHealth VIP Rx Saver (HMO) plan covers vision services, including routine eye exams once per year, and eyewear with a combined maximum benefit of $750 per year for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames, but does not cover upgrades.
Dental Services See details
Dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, and orthodontic services are covered. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with varying copays. 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. Other Medicare Part B drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the EmblemHealth VIP Rx Saver (HMO) plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, though Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies are covered with 20% coinsurance, but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests have a copay between $0 and $45, and Lab Services have no copay. Diagnostic Radiological Services have a copay up to $50, Therapeutic Radiological Services have a coinsurance of at least 20%, and Outpatient X-Ray Services have a $25 copay and a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the EmblemHealth VIP Rx Saver (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 covered, but specific services including Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services are not covered. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the EmblemHealth VIP Rx Saver (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
The EmblemHealth VIP Rx Saver (HMO) plan covers Over-the-Counter (OTC) items with a maximum benefit of $70.00 every month, including Nicotine Replacement Therapy (NRT) and Naloxone coverage. Other services such as acupuncture, meal benefits, and additional services are not covered.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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