2020 EmblemHealth VIP Passport (HMO) H5991-3-0 in NY from EmblemHealth | HealthPocket

EmblemHealth VIP Passport (HMO)

$32/mo

Benefits & Coverage

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderEmblemHealth
Plan IDH5991-3-0
Plan Year2020
CMS Rating
Plan TypeHMO
Annual Deductible$295.00
Out-of-Pocket Maximum6700

What To Know About This Plan
  • This plan has health and drug coverage

Why We Like This Plan
  • has both Health and Drug Coverage
  • has a copay of $0 for Tier 1 preferred generic drugs (30 day supply, preferred retail pharmacies)

Overview

Premium
Total monthly premium$32.00
Health plan premium$0.00
Drug plan premium$32.00
Standard Part B premium$135.50
Part B premium reductionNo
Deductible
Health plan deductible$0
Drug plan deductible$295.00
Estimated yearly costs
Estimated total yearly costs for care$4,338.00
Out-of-pocket max
Out-of-pocket max$6,700 In-network

Benefits & costs

Doctor services
Primary doctor visit$5 per visit
Specialist visit$35 per visit
Tests, labs, & imaging
Diagnostic tests & procedures$0-45
Lab services$0-15
Diagnostic radiology services (like MRI)20%
Outpatient x-rays$30
Emergency care$90 per visit (always covered)
Urgent care$30 per visit (always covered)
Hospital services
Inpatient hospital coverage$393 per day for days 1 through 5
$0 per day for days 6 through 90
Outpatient hospital coverage$375 per visit
Skilled nursing facility
Skilled nursing facility$0 per day for days 1 through 20
$178 per day for days 21 through 100
Preventive services
Preventive services$0 copay
Ambulance
Ground ambulance$295
Therapy services
Occupational therapy visit$35
Physical therapy & speech & language therapy visit$35
Mental health services
Outpatient group therapy with a psychiatrist$35
Outpatient individual therapy with a psychiatrist$35
Outpatient group therapy visit$35
Outpatient individual therapy visit$35
Opioid treatment services
Opioid treatment servicesCovered
Other services
Durable medical equipment (like wheelchairs & oxygen)20% per item
Prosthetics (like braces, artificial limbs)20% per item
Diabetes supplies$0 copay

Extra benefits & costs

Hearing
Hearing exam$35
Fitting/evaluation$0 copay
Hearing aids - All types$0 copay
Preventive dental
Oral exam$0 copay
Cleaning$0 copay
Fluoride treatment$0 copay
Dental x-rays$0 copay
Comprehensive dental
Non-routine servicesNot covered
Diagnostic servicesNot covered
Restorative services$0-125
Endodontics$0-20
Periodontics$0-150
Extractions$0-50
Prosthodontics, other oral/maxillofacial surgery, other services$0-150
Vision
Routine eye exam$20
Contact lenses$0 copay
Eyeglasses (frames & lenses)$0 copay
Eyeglass frames (only)$0 copay
Eyeglass lenses (only)$0 copay
UpgradesNot covered
More benefits
Fitness benefitLimited coverage
Over the counter drug benefitsNot covered
In-home support servicesNot covered
Home and bathroom safety devicesNot covered
Meals for short durationNot covered
Annual physical examsLimited coverage
TelehealthNot covered

Drug coverage & costs

Part B drugs
Chemotherapy drugs10-20%
Other Part B drugs10-20%

Coverage Area for EmblemHealth VIP Passport (HMO)

StateNew York
CountyKings

All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit


30 Day SupplyPreferred Retail Pharmacies Drug CostStandard Retail Pharmacies Drug CostPreferred Mail-Order Drug CostStandard Mail-Order Drug Cost
Tier 1: Preferred Generic$0 copay$4 copayNot offered$0 copay
Tier 2: Non-Preferred Generic$18 copay$20 copayNot offered$18 copay
Tier 3: Preferred Brand Name$45 copay$47 copayNot offered$45 copay
Tier 4: Non-Preferred Brand Name$95 copay$100 copayNot offered$95 copay
Tier 5: Specialty Tier27% coinsurance27% coinsuranceNot offered27% coinsurance
Tier 6: Select Care Drugs

60 Day SupplyPreferred Retail Pharmacies Drug CostStandard Retail Pharmacies Drug CostPreferred Mail-Order Drug CostStandard Mail-Order Drug Cost
Tier 1: Preferred Generic$0 copay$8 copayNot offered$0 copay
Tier 2: Non-Preferred Generic$36 copay$40 copayNot offered$36 copay
Tier 3: Preferred Brand Name$90 copay$94 copayNot offered$90 copay
Tier 4: Non-Preferred Brand Name$190 copay$200 copayNot offered$190 copay
Tier 5: Specialty Tier
Tier 6: Select Care Drugs
90 Day SupplyPreferred Retail Pharmacies Drug CostStandard Retail Pharmacies Drug CostPreferred Mail-Order Drug CostStandard Mail-Order Drug Cost
Tier 1: Preferred Generic$0 copay$12 copayNot offered$0 copay
Tier 2: Non-Preferred Generic$54 copay$60 copayNot offered$45 copay
Tier 3: Preferred Brand Name$135 copay$141 copayNot offered$135 copay
Tier 4: Non-Preferred Brand Name$285 copay$300 copayNot offered$285 copay
Tier 5: Specialty Tier
Tier 6: Select Care Drugs

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Colorectal cancer screening
Annual flu vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Adult BMI assessment

Managing Chronic Conditions

Special needs plan care management
Care for older adults – medication review
Care for older adults – functional status assessment
Care for older adults – Pain assessment
Osteoporosis management in women who had a fracture
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Rheumatoid arthritis management
Reducing the risk of falling
Improving bladder controlNot Rated
Medication reconciliation post-discharge
Plan all-cause readmissions
Statin Therapy for Patients with Cardiovascular Disease

Member Experience with Health Plan

Getting needed careNot Rated
Getting appointments and care quickly
Customer serviceNot Rated
Rating of health care qualityNot Rated
Rating of health plan
Care CoordinationNot Rated

Member Complaints, and Changes in Health Plan's Performance

Complaints about the health plan
Members choosing to leave the health plan
Health plan quality improvement

Health Plan Customer Service

Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability - Medical

Drug Plan Customer Service

Call center – foreign language interpreter and TTY availability
Appeals auto-forward
Appeals upheldNot Rated

Member Complaints, and Changes in Drug Plan's Performance

Complaints about the drug plan
Members choosing to leave the drug plan
Drug plan quality improvement

Member Experience with Drug Plan

Rating of drug plan
Getting needed prescription drugsNot Rated

Drug Pricing and Patient Safety

MPF Price Accuracy
Medication adherence for diabetes medications
Medication adherence for hypertension - RAS antagonists
Medication adherence for cholesterol - Statins
MTM program completion rate for CMR
Statin use in persons with diabetes - SUPD

Physicians that accept EmblemHealth VIP Passport (HMO) for New York

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Steven, Liverpool
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Stephanie, Blomquist
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Mireille, Moise
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Mathieu, Francois
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Enayatollah, Hariri
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Bayomy, Moustafa
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Clifford, Civil
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Meghna, Kanakia
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Daphney, Maylor
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Charles, Medwynter
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Hope, Garner
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Jerry, Uduevbo
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Akua, Boah
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Louis, Vital
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Haydn, Briggs
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Mitzi, Reid
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Family Care Center
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Prudence, Osei-tutu
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Steven, Horowitz
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Gerald, Valme
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Marie, Conde
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Steven Liverpool, M.D.
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  • Phone Number
    (718) 282-1570
  • Office Locations
    322 Linden Blvd
    Brooklyn, NY 11226
322 Linden Blvd Brooklyn NY, 11226
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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Health Insurance Innovations, Inc. family of companies (NASDAQ: HIIQ).

Medicare Plans Found

 

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Health Insurance Innovations, Inc. family of companies (NASDAQ: HIIQ).