NYCE PPO benefits at a glance

Do my dependents have their own member ID card?

Yes, dependents have their own member ID cards.

How can I get a duplicate medical ID card?

You can easily view or download your NYCE PPO member ID card on the member portal or mobile app. 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.

Is prescription drug information listed on my ID card?

If you get prescription drugs through EmblemHealth, your coverage continues with the new prescription drug benefit manager, Prime Therapeutics. Use your NYCE PPO member ID card for prescriptions. If you have prescription drug coverage through your union, 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.

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

No, NYCE PPO does not require referrals.

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

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

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

All NYCE PPO prior authorizations are made by qualified clinicians using clinical judgement, evidence-based guidelines, and established clinical policies. At no point is the critical decision-making involved in prior authorizations 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 covered?

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

Does WINFertility manage fertility support?

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

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

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

Do limitations on IVF reset with the new plan?

No, in vitro fertilization (IVF) limitations remain set at 3 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 pays the difference between the plan allowance and the provider's fee. There is no travel and lodging benefit.

What is the impact of the nursing strike on NYCE PPO?

There is currently a nursing strike at Mount Sinai, Montefiore Einstein Medical Center, and NewYork-Presbyterian. NYCE PPO is temporarily waiving required specific facility related authorizations to help ensure members get care in a timely fashion. This helps ensure members who may need certain care can get that care without delay. It also means that members who need to move to a skilled nursing facility (nursing home) or would benefit from home care can be transferred quickly and efficiently while hospitals are short-staffed.

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 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 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, thay are only considered in-network if they are also affiliated with EmblemHealth's network. If not, thare are considered out-of-network, and you would 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 downstate 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 would typically pay less out of pocket than the current plan when you see out-of-network doctors because NYCE PPO pays out-of-network doctors the Medicare allowed amount, which is generally more than the current plan pays.

Where can my providers direct questions?

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.

Do 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 do I submit a claim for out-of-network service?

There are two ways to submit a claim for an out-of-network service:
1) The out-of-network provider can submit the claim directly to NYCE PPO for processing.
Or
2) You can submit a claim from an out-of-network provider in one of the following ways:

Electronically:
• Secure NYCE PPO member portal: Sign in and select Claims and EOBs, then Submit a claim.
• Mobile app: Sign in and scroll to the bottom of the home page, then select Claims Submission.

Paper: Fill out this form and submit by mail or fax.

What about mental/behavioral health services?

The UnitedHealthcare behavioral health network replaces Carelon Behavioral Health (formerly Beacon Health Options). With NYCE PPO, you have access to 39,000 providers in New York State, an increase from 12,000 in the current network. Mental/behavioral health providers also increase nationally, from 31,000 to 418,000. Through NYCE PPO, you have in-person and virtual care options, including access to 22 specialty mental and behavioral health provider organizations, up from the 7 offered in the current plan. Examples include:

• Charlie Health for teens and adults who need mental health, substance use disorder, or eating disorder-specific care.
• Hazelden Betty Ford for virtual/digital therapy for substance use disorders.
• InStrider Health for virtual/digital therapy for pediatric anxiety and obsessive-compulsive disorders (OCD).
• Talkspace for virtual/digital therapy via texting, video, or chat with licensed therapists

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

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

If you have prescription drug coverage through your union, that coverage continues for your drug benefit. All members are covered for Affordable Care Act (ACA)/New York State mandated drugs (such as diabetic medication) through NYCE PPO. For these drugs, there is a new pharmacy benefits manager, Prime Therapeutics, effective January 1, 2026. This replaced Express Scripts. If you have a prescription drug plan not provided by EmblemHealth, this change does not impact you.

Watch this video to learn how you can use the Prime Therapeutics member portal, PrimeCentral™, to easily access and make the most of your 2026 pharmacy benefits. 

What is Prime Therapeutics?

Starting January 1, 2026, Prime Therapeutics is EmblemHealth's new pharmacy benefits manager. EmblemHealth and Prime Therapeutics work together to make sure members get the medicines they need to feel better and live well. (Note: Prime Therapeutics is not related to Amazon Prime.)

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

Yes, NYCE PPO covers 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 — does that continue?

Yes, that continues. However, there is a new pharmacy benefits manager, Prime Therapeutics, effective January 1, 2026.

Watch this video to learn how you can use the Prime Therapeutics member portal, 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 continues 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?

Your personalized pharmacy information is available in your NYCE PPO member portal, as well as the mobile app. After signing in, select Pharmacy from the purple navigation bar, then select Visit the pharmacy to sign in to Prime Therapeutics member portal, PrimeCentral™. You can find general NYCE PPO pharmacy documents, including the drug list (or formulary) here. If you need to see your 2025 EmblemHealth pharmacy coverage with Express Scripts after 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.

My access is not working to the PrimeCentral™ member portal - what do I do?

If you are trying to access PrimeCentral™ and are not able to get into the system, please contact PrimeCentral™ technical support at: 866-394-0513 (TTY: 711). Please note: benefit-specific questions should be directed to Customer Service at: 212-501-4444 (TTY: 711).

Why does the PrimeCentral™ website or app only show a 30-day supply in the medications search?

You can sign in to your profile to understand more specific details about your coverage and costs beyond just a 30-day supply. If you have not yet signed in to your profile, the website has limited features and is only intended to show if a medicine is covered (on the formulary) and the tier.

Who is Levrx and why do they appear in my PrimeCentral™ portal or communications?

The Prime Therapeutics member portal, PrimeCentral™, is powered by Levrx, a technology company. You may see their name or logo on some materials or communications.

Do 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, have been 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 remains in place through the date noted in your notice of approval. The authorization was 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.

As a patient, do I need to do anything to get prior authorization?

Generally no. The prior authorization process is usually between your doctor, pharmacy, and health plan. Your doctor will answer questions or submit information so we can review the request. If your medicine needs prior authorization, you can see details on the PrimeCentral™ member portal: go to Menu in the upper right corner, select Member Resources, then select Resource Type, and choose Prior Authorizations from the list. Note: while the prior authorization process is typically between the pharmacy and your doctor, if your medicine now needs prior authorization, it is a good idea to reach out to your doctor.

I have refills for my medicone left. How do I get them filled?

• Retail pharmacy: There's no need to get a new script. Simply bring your new member ID card to your network pharmacy. They can use the new information to fill your prescription. If you received a letter about your retail pharmacy being out of our network, you can find a new one here. Your new pharmacy can have your prescriptions transferred.
  
  
• Mail order: Convenient home delivery is available. You can use Amazon Pharmacy to get your drugs delivered to your door. We have already transferred your available prescription refills from Express Scripts mail order for you.

If I get prescription drug coverage through EmblemHealth, are my drugs 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.

How do I request a formulary exception?

If your medicine is not on the formulary and your doctor believes there are no appropriate covered alternatives, your doctor may request an exception to our formulary. Your doctor can submit a Coverage Exception request with a statement by phone, fax, mail, or the provider portal:

Phone: 866-799-7919 (TTY: 711).
Fax: 855-212-8100
Mail:    Prime Therapeutics LLC
             2900 Ames Crossing Road, Suite 200
             Eagan, MN  55121

Provider portal: covermymeds.com or covermymeds.health

If I get my prescription drug coverage through EmblemHealth, can I 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 continues to provide your specialty medicines (that are not covered by the PICA program) with no changes.

If I get prescription drug coverage through EmblemHealth, can I 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?

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; 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?

All NYCE PPO members 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 elegible refills have been 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 drug plan copay, your rider benefits, or Amazon’s MedsYourWay discount pricing.

Where do I tell my doctor to send my prescriptions?

Your doctor can send your prescription to the retail pharmacy of your choice. If your doctor is ordering a mail order supply, they can send the prescription to Amazon Pharmacy (fax: 512-884-5981).

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).

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

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

I’m currently in treatment or scheduled for surgery when this plan begins. How does it work moving to NYCE PPO?

There are 2 things to keep in mind:

1. Prior authorizations approved before January 1, 2026 were transferred to NYCE PPO so your care could continue without interruption. Foar all future services requiring prior authorization, doctors can submit prior authorization requests at nyceppo.com
   
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.