NYCE PPO benefits at a glance

When will I get my new medical and hospital ID cards?

You will no longer have separate medical and hospital ID cards. Instead, you’ll have a single member ID card for all your medical needs with the same member ID number that you currently have. Your new member ID card, which will show you are a NYCE PPO member, should arrive before your coverage starts January 1, 2026. Please remember to only use your NYCE PPO member ID card after the plan’s coverage starts in January 2026. If you haven’t gotten your member ID card by the last week of December, please call Customer Service at 212-501-4444 (TTY: 711).

Will my dependents still have their own member ID card?

Yes, dependents will receive their own member ID cards.

How can I get a duplicate medical ID card?

You will be able to easily view or download your NYCE PPO member ID card on the member portal or mobile app beginning January 1, 2026. You can also call Customer Service at 212-501-4444 (TTY: 711) to ask for a duplicate medical card, or request one through the mobile app.

What will happen to my prescription drug coverage and ID card?

If you get prescription drugs through EmblemHealth, you will continue that coverage with the new prescription drug benefit manager, Prime Therapeutics. You will use your NYCE PPO member ID card for prescriptions. If you have prescription drug coverage through your union, you will continue using that ID card for your drug coverage. If you have more questions about drug benefits delivered through EmblemHealth, see the “Prescription drugs” section of this FAQ.

When should I stop using my current medical and hospital ID card(s)?

You should continue to use your GHI CBP and Anthem BlueCross and BlueShield plan member ID cards through December 31, 2025. After that, you’ll use the NYCE PPO member ID card.

Will I need to get referrals from my doctor to see specialists with this plan? 

No, NYCE PPO will not require referrals.

Do I call the same customer support phone number with the new plan?

Yes. NYCE PPO will keep the same phone number. Just call 212-501-4444 (TTY: 711) and our representatives will be there to support you as they always have.

Does NYCE PPO use artificial intelligence (AI) for prior authorizations?

All NYCE PPO prior authorizations will be made by qualified clinicians using clinical judgement, evidence-based guidelines, and established clinical policies. At no point will the critical decision-making involved in prior authorizations be done by anyone – or any tool – that is not a licensed health care professional.

Does NYCE PPO follow New York State mandates for health benefit coverage?

Yes, all NYCE PPO benefits either meet or exceed New York State mandates for health benefit coverage as of December 2025. Learn more about New York State’s mandates for health benefit coverage from the New York State Department of Financial Services.

Are fertility treatments still covered?

Yes, the NYCE PPO plan will continue to cover fertility treatments. Coverage is available for up to 3 cycles of in vitro fertilization per lifetime maximum.

Will WINFertility still manage fertility support?

Yes, WINFertility will continue to provide fertility care support services. For questions, please call 212-501-4444 (TTY: 711)

If I’m currently undergoing fertility treatments, will my existing prior authorizations carry over to the NYCE PPO plan?

Yes, your existing prior authorizations will carry over. You do not need to take any action if you are currently in treatment.

Will limitations on IVF reset with the new plan?

No, in vitro fertilization (IVF) limitations will remain set at three for a member’s lifetime, regardless of a member’s plan.

What is the NYCE PPO coverage for gender-affirming care?

Members are covered for gender-affirming care with in-network providers. This means that the member may be responsible for copays or coinsurance, depending on where the services are received. There is also a $2,000 benefit for travel and lodging available each calendar year if a member lives more than 75 miles away from a provider. The travel and lodging reimbursement form is located on the portal in the form center.

For out-of-network providers, the member must meet the deductible, and then the member will pay the difference between the plan allowance and the provider's fee. There is no travel and lodging benefit.

How do I find out if my doctor accepts NYCE PPO?

You can visit nyceppo.com or call Customer Service at 212-501-4444 (TTY: 711) to find out if your doctor is in NYCE PPO’s network.

Can I receive care from a UnitedHealthcare provider with my NYCE PPO plan?

With NYCE PPO, you’ll have access to care from an expanded EmblemHealth network of more than 78,000 world-class providers in New York City, Long Island, and the Hudson Valley (Dutchess, Orange, Putnam, Rockland, Ulster, and Westchester counties) – up from 64,000 in the current network. Outside of the downstate EmblemHealth coverage area, you’ll have access to UnitedHealthcare’s national Choice Plus network. You can choose from more than 1.6 million providers nationwide as part of your network. Please note that if you choose a UnitedHealthcare provider within the downstate EmblemHealth coverage area, they will only be considered in-network if they are also affiliated with EmblemHealth’s network. If not, they will be considered out-of-network, and you will use your out-of-network benefits for any visits.

Are the same downstate 13-county hospitals currently in the GHI CBP/Anthem BlueCross and BlueShield plan covered by NYCE PPO?

With NYCE PPO, you still have access to the same EmblemHealth providers you see today – more than 78,000 premier providers and all hospitals in the 13 downstate New York counties. This includes these highly utilized hospitals and health systems:

• Hospital for Special Surgery 
• Memorial Sloan Kettering Cancer Center 
• Montefiore Health System
• Mount Sinai Health System
• New York Presbyterian Health Care System
• New York City Health and Hospitals (H+H) Corporation
• Northwell Health
• NYU Langone Health System

View the full list of hospitals

What providers and hospitals are part of the NYCE PPO network in New Jersey?

In New Jersey, NYCE PPO plan members will have access to care from:
• 82 hospitals.
• 486 urgent care centers.
• More than 53,000 doctors and health care professionals.
• More than 15,000 mental health providers.

This includes but is not limited to large health systems such as:
• RWJ Barnabas.
• Hackensack Meridian Health.
• Atlantic Health System.
• Summit Medical Group.
• Valley Hospital.

Does NYCE PPO have providers in Puerto Rico?

NYCE PPO members traveling to or living in Puerto Rico have in-network coverage through the MAPFRE network of health care professionals. Look for the MAPFRE logo and contact information on the back of your member ID card. You must bring your member ID card when visiting a MAPFRE provider.

How do I find a durable medical equipment (DME) provider?

Using the “find a provider” tool, search under the Hospital/Facility tile.

What if my doctor is not in NYCE PPO’s network?

Your doctor can join EmblemHealth’s or UnitedHealthcare’s network. If your doctor cannot join the network, please see the “Transitioning care” section of this FAQ. You can also continue seeing this doctor using NYCE PPO’s out-of-network benefit, which generally costs more than seeing in-network providers. 

If I see an out-of-network doctor, what can I expect to pay?

Like the current plan, NYCE PPO has a deductible for out-of-network doctors. However, you will typically pay less out of pocket than the current plan when you see out-of-network doctors because NYCE PPO will pay out-of-network doctors the Medicare allowed amount, which is generally more than the current plan pays.

Where can my providers direct questions?

Prior to January 1, 2026, providers can visit emblemhealth.com/nyceppo and uhcprovider.com/ny or call 212-501-4444 (TTY: 711) with any questions. Providers can also reach out to their relationship manager.

Will I need a primary care provider (PCP)? 

No, a PCP is not required with this plan. However, choosing a PCP can save you time, reduce stress, and help you get the most out of your health benefits. Having a PCP means having someone who knows you — and your health — personally. Your PCP is your go-to for everyday care, preventive checkups, and managing ongoing conditions. They help you stay healthy, catch issues early, and coordinate care if you ever need to see a specialist.

What is a preferred provider?

Preferred providers are a selection of doctors, health care professionals, and facilities through which NYCE PPO members will likely pay less or even $0 for certain health care services.

Preferred providers are only available in the downstate New York coverage area of New York City, Long Island, and the Hudson Valley (Dutchess, Orange, Putnam, Rockland, Ulster, and Westchester counties). They include AdvantageCare Physicians New York and New York City Health + Hospitals locations, as well as Memorial Sloan Kettering Cancer Center facilities and Hospital for Special Surgery facilities. See the NYCE PPO Summary Plan Document, or SPD, for more details on preferred providers.

Please note: A doctor, health care professional, or facility is only considered a preferred provider when offering treatment within the downstate coverage area. If you visit a preferred provider with locations outside the downstate coverage area, the provider would not be preferred.

How does coverage for applied behavioral analysis (ABA) therapy work? Does NYCE PPO follow New York State mandates?

Yes, all NYCE PPO benefits either meet or exceed New York State mandates as of December 2025. ABA therapy usually requires prior authorization through the UnitedHealthcare behavioral health network. There is no limit on the number of visits. Learn more about New York State’s ABA mandate from the Department of Financial Services website

I get my prescription drug coverage through my union. How does prescription drug coverage work?

If you have prescription drug coverage through your union, you will continue using that coverage for your drug benefit. All members will continue to be covered for Affordable Care Act (ACA)/New York State mandated drugs (such as diabetic medication) through NYCE PPO. For these drugs, there will be a new pharmacy benefits manager, Prime Therapeutics. This will replace Express Scripts. If you have a prescription drug plan not provided by EmblemHealth, this change will not impact you. You will receive more information about Prime Therapeutics, including retail and home delivery options, in the near future.

Watch this video to learn how you can use PrimeCentral to easily access and make the most of their 2026 pharmacy benefits. 

Will NYCE PPO continue to cover Affordable Care Act (ACA)/New York State mandated drugs (such as medicine for diabetes)?

Yes, NYCE PPO will continue to cover Affordable Care Act (ACA)/New York State mandated drugs (such as medicine for diabetes) as of December 2025. Please refer to the NYCE PPO formulary documents for more information.

I currently use PICA to cover certain specialty drugs. Is anything changing? 

No, your PICA drug coverage with Express Scripts^® (ESI) is remaining the same. 

I get prescription drug coverage through EmblemHealth — will that continue?

You will continue getting prescription drugs through EmblemHealth. However, there will be a new pharmacy benefits manager, Prime Therapeutics. You will receive more information about Prime Therapeutics, including retail and home delivery options, in the near future. 

Watch this video to learn how you can use PrimeCentral to easily access and make the most of your 2026 pharmacy benefits.

I get prescription drug coverage through my union — is anything changing?

NYCE PPO does not change anything about your prescription drug coverage through your union. It will continue to be managed through your union. Just like now, those who do not have coverage through their welfare fund can purchase the optional prescription drug rider. For more information on the cost of the optional prescription drug rider, visit the Office of Labor Relations.

Where can I find my pharmacy benefits?

You can find general NYCE PPO pharmacy documents, including the drug list (or formulary) here. Your new personalized pharmacy information is also available in your NYCE PPO member portal. After signing in, select Pharmacy from the purple navigation bar, then select Visit the pharmacy to sign in to Prime Therapeutics. If you need to see your 2025 EmblemHealth pharmacy coverage with Express Scripts, on Jan. 1, 2026, continue to sign in using your Express Scripts username and password at express-scripts.com/login. If you receive medicine through PICA, you will continue to sign in at Express Scripts using your PICA member ID. This does not apply to the pharmacy benefits you receive through your union.

Will I need to get new prescriptions with this plan?

No, if you get your prescription drug coverage through EmblemHealth, any active prescriptions, including mail order, will be transferred to Prime Therapeutics as long as the pharmacy you use remains in-network.

Do I need to get a new prior authorization for my previously approved medicine?

No, you do not, as long as you have an active prior authorization. Your existing prior authorization will remain in place through the date noted in your notice of approval. The authorization will be automatically transferred from Express Scripts to Prime Therapeutics on Jan. 1, 2026, where it will stay active through the approval date. Please continue to take your medicine as your doctor prescribed.

If I get prescription drug coverage through EmblemHealth, will my drugs be covered under my 2026 plan?

Every year, we review our formulary (drug list) to update the drugs your plan will cover. Your formulary may change at any time. If we change coverage for any medicine you are taking, you will receive a letter from Prime Therapeutics. If the medicine you are currently taking will now require an authorization, the letter will provide alternatives and instructions to share with your doctor. If the medicine that you are currently taking will no longer be covered, alternative medicines will be provided in the letter. If you have an existing authorization for a covered drug, the authorization will remain in effect under your 2026 prescription benefit and no further action is required.

If I get my prescription drug coverage through EmblemHealth, will I be able to obtain my specialty medicines from Accredo Specialty Pharmacy?   

Prime Therapeutics has a large network of more than 60,000 participating pharmacies to provide you access to the medicines that you need. Accredo Specialty Pharmacy participates in Prime Therapeutics pharmacy networks. Accredo will continue to provide your specialty medicines (that are not covered by the PICA program) with no changes.

If I get prescription drug coverage through EmblemHealth, will I be able to obtain a 90-day supply of maintenance medicines from a retail pharmacy and/or through home delivery?

Yes. Prime Therapeutics has a large network of more than 60,000 participating pharmacies to provide you access to the medicines that you need, as well as more retail pharmacy options so that you can obtain a 90-day supply of your maintenance medicines. If you use Walgreens for your 90-day supply of maintenance medications, you may continue to do so. If your current pharmacy is not in Prime Therapeutic’s network, you will receive a letter letting you know how you can find a new pharmacy to meet your needs. Just ask your pharmacy to transfer your prescription to any participating network pharmacy that you choose that provides a 90-day supply of your maintenance medicines (Find a pharmacy near you).

Which pharmacies can fill 90-day prescriptions?

Today, current plan members can fill 90-day prescriptions only at Walgreens and with Express Scripts Mail Order Pharmacy. Beginning Jan. 1, 2026, NYCE PPO members will no longer be able to use Express Scripts Mail Order. Here are the NYCE PPO mail order and retail options:
• Mail order 90-day prescriptions are filled through Amazon Pharmacy.
• Retail 90-day prescriptions are filled at: Walgreens; Wal-Mart; Costco; Rite-Aid; Sam’s Club; Stop & Shop Pharmacy; Wegmans Food Markets, Inc.; New York Cancer & Blood Specialists; Genoa Healthcare, LLC; Hannaford Food and Drug; Hannaford Supermarket & Pharmacy; Kinney Drugs; Price Chopper Pharmacy; Quick Rx; Tops Pharmacy; and others. Find a pharmacy near you.

How do I sign up for Amazon Pharmacy?

Starting Jan. 1, 2026, all NYCE PPO members will have access to prescription medicine from Amazon Pharmacy home delivery (and you don’t need an Amazon Prime membership). It's easy to get started; go to amazon.com/emblemhealth and sign up! If you have an active prescription, you will receive – or may have already received – more information about Amazon Pharmacy in the mail. Any of your current home delivery prescriptions with eligible refills will automatically be transferred to Amazon Pharmacy. For new prescriptions, ask your doctor to e-prescribe directly to Amazon Pharmacy. With Amazon Pharmacy, you can expect:
• Easy online sign-up.
• Free home delivery in five days or less.
• 24/7 help from a pharmacist; you can also talk or chat with a customer care representative to ask general questions.
• Clear pricing and easy, automatic refills (optional).
• The ability to manage your medicine and order history online. You can purchase your prescription drugs using either your insurance copay, your rider benefits, or Amazon’s MedsYourWay discount pricing.

Are GLP-1s covered by NYCE PPO?

GLP-1 medicines may be covered for diabetes (subject to prior authorization) under NYCE PPO’s medical benefit. For additional information and requirements, you can call Customer Service at 212-501-4444 (TTY: 711)

Will I need to get new prior authorizations with this plan? 

No. Your GHI CBP and Anthem BlueCross and BlueShield plan’s prior authorizations will all be transferred to NYCE PPO for you.

I’m currently in treatment or scheduled for surgery when this plan begins. How will it work moving to the new plan?

There are 2 things to keep in mind:

1. Prior authorization: We’ll make sure your prior authorization information is transferred smoothly so your care continues without interruption. For services starting January 1, 2026, doctors can begin submitting prior authorization requests for this plan on December 1, 2025.
2. Are your doctor and facility in-network? Given the expanded network, in the rare instance when a current in-network provider is not contracted with the NYCE PPO plan, you may qualify for transition of care coverage if you are under active treatment for certain medical conditions – for example, if you are in the second or third trimester of pregnancy. Transition of care coverage allows you to continue seeing that doctor for up to 90 days from January 1, 2026, while you transition to an in-network doctor or facility. (If you are pregnant, you may continue care through delivery and any post-partum services directly related to the delivery.) You will be able to submit a request starting December 1, 2025, and if approved, your provider will be treated as in-network during the transition period. It is important to remember to submit this request before your first 2026 doctor visit. We will review your clinical needs to help ensure your care continues smoothly. To check if your doctor is in-network, visit the medical provider search at nyceppo.com. Mental/behavioral health services work the same way. 

To start a transition of care request, please review, complete and submit the Transition of Care form. If you need help, call Customer Service at 212-501-4444 (TTY: 711). You will need to provide all the required information when calling.

I have an appointment with a doctor after January 1, 2026. Do I need to do anything?

You will be able to keep appointments with your currently contracted/in-network EmblemHealth providers in New York City, Long Island, and the Hudson Valley (Dutchess, Orange, Putnam, Rockland, Ulster, and Westchester counties). In-network providers have a contract to deliver services to members of this health plan. For providers outside this area, you can always visit nyceppo.com to confirm your provider is in-network.