NYCE PPO benefits at a glance

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) from 8 a.m. to 6 p.m. Eastern Standard Time, Monday through Friday, 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.

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.

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

You can visit nyceppo.com or call EmblemHealth Customer Service at 212-501-4444 (TTY: 711) from 8 a.m. to 6 p.m. Eastern Standard Time, Monday through Friday, to find out if your doctor is in NYCE PPO’s network.

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 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 866-447-9717 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 doctors, health care professionals and facilities that are available only in the EmblemHealth coverage area of New York City, Long Island, and the Hudson Valley (Dutchess, Orange, Putnam, Rockland, Ulster and Westchester counties). These include AdvantageCare Physicians New York and New York City Health + Hospitals locations. By using preferred providers, NYCE PPO members will likely pay lower to $0 costs for health care services.

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. ABA therapy usually requires prior authorization through UnitedHealthcare behavioral health network. There is no limit on visits.

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. You will receive more information about Prime Therapeutics, including retail and home delivery options, in the near future.

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. 

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.

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.

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. You will be able to continue to get your specialty medicines with no disruption.

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?

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. (A link to Prime Therapeutics’ pharmacy network will soon be available for you to search.) 

If you prefer the convenience of home delivery, Amazon Pharmacy is new to Prime Therapeutic’s network of pharmacies. For NYCE PPO members, all eligible medicine refills obtained through Express Scripts home delivery pharmacy will be transferred to Amazon Pharmacy.  As long as you have refills still available, your prescription will be automatically transferred and there is nothing for you to do.  

More information about Amazon Pharmacy will be provided to you in the near future.

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 two 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 provider medical search at nyceppo.com. Mental/behavioral health services work the same way. 

You can also call EmblemHealth Customer Service at 212-501-4444 (TTY: 711) starting December 1, 2025, to speak with a nurse about any transition of care needs. We will update these FAQs to share more guidance as we get closer to your coverage start date.

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.