Plan Options
Considering EmblemHealth?
Please contact your broker or EmblemHealth sales at
1-877-411-3625
Pharmacy
Drug Lookup
See covered drugs in our formulary.
Find a Pharmacy.
Download Formulary
For plans that contain pharmacy coverage. Check the applicable benefits design or the certificate of insurance for more information.
PPO (2 - 50)
Plan Overview
Choice
We respect that different people have different needs. That's why we offer a choice of affordable, quality plans with extensive benefits that provide real value:
EmblemHealth PPOoffers:
Hospital, medical and prescription drug coverage
Benefits for most covered services out-of-network
Several cost-saving options available
Outstanding provider choice from any in- or out-of network provider, with no referrals to specialists needed. 1
Affordability
No copay for children for office visits or diagnostic tests performed in-network.
All other members receive most covered in-network medical and hospital services for just the cost of a copayment. 1
No copay for generic drugs when members use network pharmacies.
Quality
Quality doctors. Our network includes more than half the "Top Docs" from New York Magazine's list, and virtually every acute care hospital in the region--great hospitals like Memorial Sloan-Kettering, Montefiore Medical Center, Lenox Hill Hospital, North Shore- Long Island Jewish Health System, and Albany Medical Center. Health and Wellness Programs. We help members stay healthy with*:
Timely reminders about flu shots and diagnostic testing, such as mammograms and prostate exams.
Quit-smoking programs.
A Nurse Advice Line that members may call 24/7 to speak with a Registered Nurse.
Discounts on health-related services such as weight-loss programs, laser vision, and acupuncture. 2
Confidential, professional counseling, education, and referral services through our 24/7 toll-free Employee Assistance Program (EAP) hotline.
Access to Care
Our National network provides access regionally to more than 106,000 doctors at more than 172,000 locations in New York, New Jersey, and Connecticut and to more than one million practitioners nationwide.
Ease
Less paperworkWith EmblemHealth PPO and InBalance PPO, there are generally no claim forms to file for services received in-network.
24/7 customer service.Provider listings, eligibility, claims status, benefits, and more are all available at www.emblemhealth.com or by calling our automated phone system.
Respect
At EmblemHealth, we understand the things that matter to members about their health care coverage-including respect for their time, intelligence, and money.
Plan Details
[ Back to Top]
| Services | in-network | out-of-network |
|---|---|---|
| Office Visits | Office Copayment | Deductible & Coinsurance |
| Office visits and diagnostic copay for dependent children/students | $0 | Deductible & Coinsurance |
| Annual Physical Check-up | Covered in Full | Deductible & Coinsurance |
| Preventive Mammography, Pap Smear, Prostate Screening | Covered in Full | Deductible & Coinsurance |
| Well-Baby and Well-Child Care | Covered in Full | Deductible & Coinsurance |
| Inpatient Hospital Services | Hospital Copayment May Apply | Deductible & Coinsurance |
| Skilled Nursing Facility Care | Covered in Full | Deductible & Coinsurance |
| Hospice Care - Inpatient and Outpatient | Covered in Full | Covered In-Network Only |
| Ambulatory Surgery Facility | Facility Copayment May Apply | Deductible & Coinsurance |
| Home Health Care | Covered in Full | Deductible & Coinsurance |
| Chiropractic Care | Office Copayment | Deductible & Coinsurance |
| Diagnostic Lab and Radiology | ||
| Facility | Diagnostic Copayment | Deductible & Coinsurance |
| Office | Diagnostic Copayment | Deductible & Coinsurance |
| Emergency Room Facility | ER Facility Copayment | ER Facility Copayment |
| Inpatient Mental Health Care | Hospital Copayment May Apply | Deductible & Coinsurance |
| Outpatient Mental Health Care | Office Copayment | Deductible & Coinsurance |
| Inpatient Chemical Dependency Care | Hospital Copayment May Apply | Deductible & Coinsurance |
| Outpatient Chemical Dependency Care | Covered in Full | Deductible & Coinsurance |
| Vision Exam, Frames and Lenses for Children | $10 Copayment , $20 Copayment | Covered In-Network Only |
| Prescription Drugs | Prescription Drug Copayment | Covered In-Network Only |
1 Some services are subject to precertification.
2 EmblemHealth cannot ensure that a particular vendor will remain in the program. The services available under these programs are not covered services underwritten by Group Health Incorporated ("GHI") as part of the EmblemHealth PPO.
* Availability of health and wellness programs may vary based on the EmblemHealth product selected.
Please note: If members choose non-network providers, their out-of-pocket costs will increase.
The EmblemHealth PPO program is underwritten by Group Health Inc. ("GHI"). Coverage
is subject to all terms, conditions, limitations, and exclusions set forth in the contract and certificate of insurance.
Refer to GHI policy form numbers PLH-SGC-976-2 et al.
Press |
Privacy/Security Policies |
Legal |
Glossary |
Site Map |
News & Media |
Careers |
Conversion Information
