Welcome to the Gold Standard

HIP HMO Preferred Plan Overview

Get to know these important basics about how to use and get the most out of your plan. Care received from out-of-network providers is generally not covered under this plan. You may have to pay for medical services if you go out-of-network.

In cases of emergency, care is covered regardless of the provider's network status, and you will have coverage at any hospital nationwide.

Refer to HIP policy form 155-23-LGTIERCERT (04/16).

    Care In-network cost when you select a preferred primary care doctor in our Prime Network In-network cost when you select a non-preferred primary care doctor in our Prime Network
Primary care doctor office visit $0 $10
Specialist office visit $0 $10
Lab/X-ray $0 $10
Routine physical exam $0 $0
Well-child care $0 $0
Outpatient physical therapy $0 $10
Outpatient mental health $0 $10
Urgent care $50 $50
Ambulatory surgery $50 $50
Ambulance $0 $0
Inpatient hospital care $100 $100
Anesthesia Included in hospital copay
$0 at Center of Excellence
Included in hospital copay
$0 at Center of Excellence
Emergency room $150 
(waived if admitted)
$150 
(waived if admitted)
Diagnostic testing $100 at hospital
$0 at other facilities
$100 at hospital
$0 at other facilities
High-tech radiology $100 at hospital
$0 at other facilities
$100 at hospital
$0 at other facilites
Infusion therapy $100 at hospital
$0 at other facilites
$100 at hospital
$0 at other facilities
Ambulatory surgery $150 at hospital
$50 at other facilities
$150 at hospital
$50 at other facilities

Optional Rider

City employees can add the following option rider benefit to their HIP HMO Preferred plan through a payroll deduction if the benefits are not already provided by their welfare fund:

  • Durable medical equipment and private duty nursing
  • Prescription drugs - $5 for generic drugs and $15 for brand drugs from network retail drug stores

Formulary copays are reduced by 50 percent when you use the Mail Order Pharmacy Service for home delivery.


Summary of Benefits and Coverage

Your Summary of Benefits and Coverage (SBC) summarizes what your plan covers and what (if any) cost-sharing responsibilities you have.

Provider Coverage

With our robust network of quality doctors, you can get care from many of the region’s leading doctors, clinicians and facilities, including hospitals and urgent care centers.


Drugs

Below is the list of drugs covered by the HMO Preferred plan for the City of New York. This drug list is also known as a formulary.

  • 2020 CNY HMO Preferred Plan Base Benefit Formulary

  • 2020 CNY HMO Preferred Plan Full Rx 2-Tier Formulary (Gold Rx Grandfathered Plan)

  • 2020 CNY HMO Preferred Plan Full Rx 3-Tier Formulary (Gold Rx Standard Plan)

Important Information

No cost virtual visits provide access to doctors by phone or video from the convenience of your own home.

Zoom – AdvantageCare Physicians (ACPNY) patients who have COVID-19 symptoms can speak with one of the practice’s medical providers through Zoom video conferencing. ACPNY patients should consider a virtual visit if they have experienced:

  • Fever (temperature > 100.4), cough, and shortness of breath combined with;
  • Close contact (within six feet) with someone known to have a Centers for Disease Control and Prevention (CDC)-confirmed/documented case of coronavirus or who has recently traveled to a CDC Level 2 or Level 3 country for any reason in the last 14 days. Visit the CDC website for the latest travel information.

To schedule a Zoom visit, contact ACPNY at 646-680-4227. You will need to answer some questions to assess your symptoms, risk, and need for a virtual visit. ACPNY will send you instructions on how to download the Zoom app before your visit.

Teladoc® – provides convenient, 24/7/365 access to doctors by phone or video. Within minutes, you can speak with a board-certified, state-licensed doctor. They can even send a prescription to your local pharmacy.

Talk to a doctor or get started today at member.teladoc.com/emblemhealth or call 800-835-2362. Services available in Spanish and Chinese.

 

Your plan covers services within our Prime Network. What that means is that you have to use health care providers and facilities within this network. A network is a group of health care professionals and facilities that arranges with EmblemHealth to provide covered services and products to members, like you.

The Prime Network is robust. There are more than 100,000 doctors across New York, New Jersey, and Connecticut to take care of you. Your plan includes providers in the QualCare and ConnectiCare networks, too. Services you get outside the Prime Network won’t be covered, unless it’s an emergency.

City employees can add the following in-network benefits to their HIP Prime HMO plan through a payroll deduction if the benefits are not already provided by their welfare fund:

  • Durable medical equipment and private duty nursing
  • Prescription drugs on the Premier Formulary (for $5 generic and $15 brand drugs from network retail drug stores). Formulary copays are reduced by 50 percent when utilizing the Mail Order Pharmacy Services for home delivery.

Retail Pharmacy

To use the retail pharmacy service, present your ID card at any participating pharmacy nationwide. Most major drug store chains (e.g., Walgreens, Duane Reade, CVS, Rite Aid, Target and Walmart) are part of your plan. The retail pharmacy should be used when filling a prescription for short-term (a 30-day supply or less) medications.

Find a pharmacy.

Set Up Home Delivery and Refills

Using Express Scripts, Inc. (ESI), our home-delivery pharmacy, you can have your approved long-term medications (maintenance drugs) mailed right to your home.

Examples of maintenance drugs are medications used for high cholesterol, high blood pressure, allergies and heartburn. There is no difference between drugs delivered by ESI and those you pick up at your walk-in pharmacy.

Click the button below to find out more about the benefits of home delivery and how to enroll in the service.

One of the first things to do is to pick a primary care physician. The relationship with your primary care doctor is one of the most important you’ll have.

This is the doctor who gives you your everyday care. They help take care of your overall health. They provide preventive care and help treat conditions before they become serious. When you see doctors and health care professionals within the Prime Network, you will be covered and pay less.

Certain doctors in the Prime Network are preferred doctors. You can see a preferred doctor in the network for a lower copay than other doctors. Doctors at AdvantageCare Physicians, Montefiore, HealthCare Partners, St. Barnabas, and Middletown Medical are preferred.

If you pick a preferred primary care doctor from our Prime Network, you’ll have a $0 copay for most services, including if you are referred to a specialist in the network. A copay is the set dollar amount you pay for health services each time you use them.

Click the button below to go to the Find a Doctor tool and search results by the Preferred Provider indicator. Preferred doctors are marked, so they are easy to find.

We also have non-preferred doctors in the Prime Network. A non-preferred doctor is one who is in our network, but is not a preferred doctor.

If you pick a non-preferred primary care doctor, you’ll have a $10 copay for most services, including seeing a specialist. Your choice of primary care doctor determines your copay for many services.

At AdvantageCare Physicians, you’ll experience a level of quality care and service you won’t find anywhere else. As an AdvantageCare Physicians patient, you’ll be surrounded by a Care Team focused on helping you achieve and maintain your best health. The high-quality, team-based, coordinated care focuses on patient needs. The team partners with patients in their pursuit of better health through primary and specialty care, urgent care, and on-site services such as laboratory and radiology.

Choose AdvantageCare Physicians and you will benefit from the following advantages:

  • Convenient hours, same day appointments, and treatment of your overall well-being.
  • Quality physicians affiliated with most of the area’s leading hospitals.
  • Medical offices that have achieved Level 3 status for Patient-Centered Medical Homes from the National Committee for Quality Assurance (NCQA) – the highest recognition possible.

There are more than 37 medical offices right in your neighborhood, with locations throughout Brooklyn, Manhattan, Queens, Staten Island and Long Island. All AdvantageCare Physicians doctors and specialists are preferred providers in the Prime Network, so you do not have to worry about out-of-network costs.

You'll need a referral to see specialists

With this plan, you need a written or electronic referral from your primary care doctor before receiving specialist care. A referral is permission from your primary doctor to see a specialist. Specialists are doctors such as allergists or dermatologists who provide services other than primary care. Your primary care doctor will take care of the referral for you.

Some specialists do not need referrals. You do not need a referral for the following specialist services:

  • Chiropractic care.
  • Outpatient mental health services, like therapists.
  • OB-GYN care.
  • Diabetes-related eye exams from an ophthalmologist.

You'll need prior approval for some services

In some circumstances, you have to get approval before you receive certain services. This is known as prior approval. Examples of these services include: inpatient nonemergency procedures, outpatient surgery, home health care, hospice care, and outpatient physical, occupational, and speech therapies.

You'll need to use Quest Diagnostics for lab work

Be sure to remind your doctor to use Quest Diagnostics when lab testing is needed. For details about these services, you can call our Gold Line. You can also go to questdiagnostics.com, or call Quest Diagnostics directly at 888-277-8772 to schedule an appointment.

Health care assistance

We know this is a lot of information, and we want to make sure that you understand and know the basics about your plan. Your Gold Line agent is available to walk you through your plan details and benefits. Call 833‑CNY‑GOLD (833-269-4653) (TTY: 711) Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 1 p.m. Have your new Gold member ID card ready when you call.

City of New York employees and employees of Participating Employers and their eligible dependents hired on or after July 1, 2019 will only be eligible to enroll in the EmblemHealth HIP HMO Preferred Plan and must remain in the HIP HMO Preferred Plan for the first year (365 days) of employment.

An employee who needs to request an exemption from the required enrollment in the HIP HMO Preferred Plan can do so by submitting an Opt-Out Request Form.

To view HIP HMO Preferred Plan's service area, click here.

Important Information

Your safety and health are our top priority. Stay up to date on coronavirus (COVID-19) here.