HIP HMO Preferred Plan Overview | EmblemHealth

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HIP HMO Preferred Plan Overview

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

You also have access to telemedicine through Teladoc®.

Refer to HIP policy form 155-23-LGTIERCERT(12/18).

    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
Telemedicine* $10 $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)
(waived if admitted)
Diagnostic testing $100 at hospital
$0 at other facilities
$100 at hospital
$10 at other facilities
High-tech radiology $100 at hospital
$0 at other facilities
$100 at hospital
$10 at other facilities
Infusion therapy $100 at hospital
$0 at other facilites
$100 at hospital
$10 at other facilities
Ambulatory surgery $150 at hospital
$50 at other facilities
$150 at hospital
$50 at other facilities

*Telemedicine provided through Teladoc®.

Optional Rider

City employees can add the following option riders 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


Summary of Benefits and Coverage

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


Certificate of Coverage

Your Certificate of Coverage describes the benefits available under the group contract.

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.



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. To find your plan’s formulary, simply locate the letter identifiers in the “Formulary” section on the front of your member ID card, which will match one of the options found in parenthesis below.

  • 2024 CNY HMO Preferred Plan Base Benefit Formulary (HMOB)

  • 2024 CNY HMO Preferred Plan Full Rx 3-Tier Formulary (Gold Rx Standard Plan) (HMO3T)

  • 2024 CNY HMO Preferred Plan Full Rx 2-Tier Formulary (Gold Rx Grandfathered Plan) (HMO2T)

HIP HMO Preferred Plan Overview | EmblemHealth

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

AdvantageCare Physicians (ACPNY) offers virtual visits as a convenient way to continue to care for the whole you, right from the comfort of your own home. Whether you are unable to get to the office or just prefer to stay home, our providers and teams are ready to care for you.


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, BronxDocs, an affiliate of ACPNY, SOMOS, 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 October 1, 2022 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.