EmblemHealth VIP Passport (HMO)

EmblemHealth VIP Passport (HMO) H5991-003 Plan Details
3 out of 5 stars

EmblemHealth VIP Passport (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by EmblemHealth, Inc..
Plan ID: H5991-003.

$34.40
Monthly Premium

EmblemHealth VIP Passport (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by EmblemHealth, Inc..
Plan ID: H5991-003.

EmblemHealth VIP Passport (HMO) H5991-003 Plan Details
3 out of 5 stars

EmblemHealth VIP Passport (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by EmblemHealth, Inc..
Plan ID: H5991-003.

$34.40
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $350
Out of Pocket Max In-Network: $7550
Out-of-Network: N/A
Initial Coverage Limit $4300
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $5.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $40.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$393.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care $65.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $90.00
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 1 days

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $90.00 (Ground Transportation Only)
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $295.00

Air Ambulance:
Coinsurance for Air Ambulance Services 20%

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

Health Care Services and Medical Supplies

EmblemHealth VIP Passport (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $20.00
Prior Authorization Required for Chiropractic Services
Prior authorization required
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 10% to 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $45.00
Copayment for Medicare-covered Lab Services $0.00 to $15.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Coinsurance for Medicare-covered Diagnostic Radiological Services 20%
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $30.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $1871.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $35.00
Copayment for Medicare-covered Group Sessions $35.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $375.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $375.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $175.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $35.00
Copayment for Medicare-covered Group Sessions $35.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $35.00
Copayment for Routine Foot Care $35.00
  • Maximum 4 visits every year
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 1 visit every six months
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 1 visit every six months
Copayment for Fluoride Treatment $0.00
  • Maximum 1 visit every six months
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Copayment for Restorative Services $0.00 to $125.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Endodontics $0.00 to $20.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Periodontics $0.00 to $150.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Extractions $0.00 to $50.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00 to $150.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Prior Authorization Required for Comprehensive Dental
Prior authorization required

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $40.00
Copayment for Routine Eye Exams $20.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
  • Maximum 1 Pair every year
Copayment for Eyeglasses (lenses and frames) $0.00
  • Maximum 1 Pair every year
Copayment for Eyeglass Lenses $0.00
  • Maximum 1 Pair every year
Copayment for Eyeglass Frames $0.00
  • Maximum 1 Pair every year
Maximum Plan Benefit of $500.00 every year for all Non-Medicare covered eyewear

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $40.00
Copayment for Routine Hearing Exams $20.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $0.00
Maximum Plan Benefit of $350.00 every year both ears combined

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The EmblemHealth VIP Passport (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $350 (excludes Tiers 1, 2 and 3) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $350 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Preferred retail $2.00
    • Standard retail $7.00
    • Preferred mail order $0.00
    • Standard mail order $7.00
    Generic
    • Preferred retail $15.00
    • Standard retail $20.00
    • Preferred mail order $0.00
    • Standard mail order $20.00
    Preferred Brand
    • Preferred retail $42.00
    • Standard retail $47.00
    • Preferred mail order $42.00
    • Standard mail order $47.00
    Annual Drug Deductible $350 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Preferred retail $4.00
    • Standard retail $14.00
    • Preferred mail order $0.00
    • Standard mail order $14.00
    Generic
    • Preferred retail $30.00
    • Standard retail $40.00
    • Preferred mail order $0.00
    • Standard mail order $40.00
    Preferred Brand
    • Preferred retail $84.00
    • Standard retail $94.00
    • Preferred mail order $84.00
    • Standard mail order $94.00
    Annual Drug Deductible $350 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Preferred retail $6.00
    • Standard retail $21.00
    • Preferred mail order $0.00
    • Standard mail order $21.00
    Generic
    • Preferred retail $45.00
    • Standard retail $60.00
    • Preferred mail order $0.00
    • Standard mail order $60.00
    Preferred Brand
    • Preferred retail $126.00
    • Standard retail $141.00
    • Preferred mail order $126.00
    • Standard mail order $141.00