3

3 out of 5 stars* for plan year 2024

Plan ID: H5991-003

What You Need to Know:

  • EmblemHealth VIP Passport (HMO) is a Medicare Advantage Health Maintenance Organization Local HMO plan.
  • It must provide all of the same hospital and medical benefits as Medicare Part A and Part B, however, costs may be different.
  • It has additional benefits not included in Medicare Part A and Part B, including prescription drug coverage.
  • The plan's monthly premium is $42, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is $295 (Tier 1 and 2 excluded from the Deductible.).
  • The plan includes an out-of-pocket maximum of $7,550 per year (in-network).
  • EmblemHealth VIP Passport (HMO) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is $295 (Tier 1 and 2 excluded from the Deductible.).
  • This plan's Part D Initial Coverage Limit is $42.

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$42

Monthly Premium

Medicare Plan Features
Monthly Premium: $42.30
Part C Premium: $0.40
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$42.30 $0.40 $41.90 $0 $41.90 $295.0 1.0
Gap Coverage: No
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local HMO
Similar Plan: H5991-006
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: No additional gap coverage, only the Donut Hole Discount
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $7,550
Annual Deductible: $295 (Tier 1 and 2 excluded from the Deductible.)
Annual Initial Coverage Limit ICL: $3,980
Number of Members enrolled in this plan in Ulster, New York: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
22 members 3 out of 5 Stars. 3 out of 5 Stars. 3 out of 5 Stars.
Plan Offers Mail Order: Yes
Plan Health Benefits
Total # of Formulary Drugs: 3,480 drugs
Number of Members Enrolled in this Plan in Ulster, New York: NULL
Number of Drugs Per Tier: NULL
Preferred Pharmacy Cost Sharing During Initial Coverage Phase: NULL
Special Needs Plan SNP Eligibility Requirement: NULL
Monthly Premium Split as Follows:
Part C Premium Part D Base Premium Part D Supplemental Premium Total Premium
$0.40 $41.90 $0.00 $42.30
Monthly Premium with Extra Help Low Income Subsidy:
LIS100 Subsidy Total Monthly Premium with LIS Parts CD LIS25 Subsidy Monthly PartD Premium with LIS LIS25 Subsidy Total Monthly Premium with LIS Parts CD LIS50 Monthly PartD Premium with LIS LIS50 Subsidy Total Monthly Premium with LIS Parts CD LIS75 Monthly PartD Premium with LIS LIS75 Subsidy Total Monthly Premium with LIS Parts CD
$0.40 $31.40 $31.80 $20.90 $21.30 $10.50 $10.90
Formulary Drug Details:
Tier 1 # of Drugs per Tier Tier 1 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 2 # of Drugs per Tier Tier 2 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 3 # of Drugs per Tier Tier 3 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 4 # of Drugs per Tier Tier 4 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 5 # of Drugs per Tier Tier 6 Preferred Pharmacy Cost Sharing (initial coverage phase)
320 $2.00 1799 $15.00 287 $42.00 400 $95.00 674 27%

Other Medicare Advantage Plans in Ulster, New York

Plan Name Type Premium MOOP Rx Deduct. Rating
UnitedHealthcare Medicare Advantage Patriot (Regional PPO (2023)Regional PPO *$6,700$-
5
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MVP Medicare WellSelect Plus with Part D (PPO) (2023)Local PPO$6,500$0
4
MVP Medicare WellSelect with Part D (PPO) (2023)Local PPO$7,550$325
4
MVP Medicare Patriot Plan with Part D (PPO) (2023)Local PPO$7,550$250
4
UnitedHealthcare Medicare Advantage Choice Plan 4 (Region (2023)Regional PPO$6,700$150
5
UnitedHealthcare Medicare Advantage Choice Plan 1 (Region (2023)Regional PPO$6,700$300
5
Aetna Medicare Elite Plan (PPO) (2023)Local PPO$7,550$100
5
WellCare Patriot (HMO) (2023)Local HMO *$6,700$-
5
WellCare Value (HMO) (2023)Local HMO$6,700$0
5
Fidelis Medicare Advantage Flex (HMO-POS) (2023)Local HMO$7,550$445
New plan - not yet rated.
EmblemHealth VIP Gold Plus (HMO) (2023)Local HMO$7,550$200
2
Aetna Medicare Credit Plan (PPO) (2023)Local PPO$7,550$250
5
Fidelis Medicare $0 Premium (HMO) (2023)Local HMO$7,550$0
New plan - not yet rated.
EmblemHealth VIP Rx Saver (HMO) (2023)Local HMO$7,550$395
2
Empire MediBlue Select (HMO) (2023)Local HMO$6,400$200
4
MVP Medicare Secure Plus with Part D (HMO-POS) (2023)Local HMO$7,550$0
4
MVP SmartFund (MSA) (2023)MSA *$-$-
4
EmblemHealth VIP Part B Saver (HMO) (2023)Local HMO$7,550$445
2
WellCare Absolute (PPO) (2023)Local PPO$7,550$150
5
MVP Medicare Secure with Part D (HMO-POS) (2023)Local HMO$7,550$150
4
EmblemHealth VIP Go (HMO-POS) (2023)Local HMO$7,550$250
2
Aetna Medicare Eagle Plan (PPO) (2023)Local PPO *$7,550$-
5
Aetna Medicare Premier Plan (PPO) (2023)Local PPO$7,550$200
5
WellCare Today's Options Advantage Plus 750B (PPO) (2023)Local PPO$6,700$0
5
AARP Medicare Advantage (HMO) (2023)Local HMO$6,700$395
5
MVP Medicare Preferred Gold without Part D (HMO-POS) (2023)Local HMO *$7,550$-
4
Aetna Medicare Value Plan (HMO) (2023)Local HMO$7,550$250
5
EmblemHealth VIP Gold (HMO) (2023)Local HMO$7,550$200
2
MVP Medicare Preferred Gold with Part D (HMO-POS) (2023)Local HMO$5,800$0
4
EmblemHealth VIP Essential (HMO) (2023)Local HMO$7,550$295
2
EmblemHealth VIP Value (HMO) (2023)Local HMO$7,550$295
2
Medicare Advantage Plans by EmblemHealth Medicare HMO
EmblemHealth VIP Gold Plus (HMO) (2023)Local HMO$7,550$200
2
EmblemHealth VIP Rx Saver (HMO) (2023)Local HMO$7,550$395
2
EmblemHealth VIP Part B Saver (HMO) (2023)Local HMO$7,550$445
2
EmblemHealth VIP Go (HMO-POS) (2023)Local HMO$7,550$250
2
EmblemHealth VIP Gold (HMO) (2023)Local HMO$7,550$200
2
EmblemHealth VIP Essential (HMO) (2023)Local HMO$7,550$295
2
EmblemHealth VIP Value (HMO) (2023)Local HMO$7,550$295
2

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