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).

   护理关系 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 美元 10 美元
Specialist office visit 0 美元 10 美元
Lab/X-ray 0 美元 10 美元
Routine physical exam 0 美元 0 美元
Well-child care 0 美元 0 美元
物理疗法 0 美元 10 美元
Outpatient mental health 0 美元 10 美元
紧急护理 50 美元 50 美元
Ambulatory surgery 50 美元 50 美元
Ambulance 0 美元 0 美元
Inpatient hospital care 100 美元 100 美元
Anesthesia Included in hospital copay Included in hospital copay
急诊室 150 美元 
(waived if admitted)
150 美元 
(waived if admitted)

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.


福利和承保范围一览表

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

  • HIP HMO Preferred Base

  • HIP HMO Preferred with DME and PDN

  • HIP HMO Preferred with Rx

  • 2019 Benefits Brochure

Provider Coverage

凭借我们强大的优质医生网络,您可以从该地区许多领先的医生、临床医生和设施(包括医院和紧急护理中心)获得治疗。


Drugs

Below is the list of drugs covered by the HMO Preferred plan for the City of New York. 该药物清单也称为药物名册。

  • CNY HMO Preferred Plan Base Benefit Formulary

  • CNY HMO Preferred Plan Full Rx Formulary

  • Large Group Formulary

Important Information

Get Industry-Leading Care at Our Centers of Excellence

Have peace of mind with access to industry-leading hospitals for cancer care and orthopedics through our Centers of Excellence.

Everyone deserves to be treated with compassion. And members with serious injuries or illnesses related to cancer or orthopedics and musculoskeletal conditions will have access to our industry-leading hospital partners, Memorial Sloan Kettering Cancer Center and Hospital for Special Surgery (HSS).

We chose these Centers of Excellence partners after a competitive evaluation process because they are as committed as we are to meeting the needs of City workers. These top hospitals and doctors are nationally recognized for their high-quality, patient-focused care and best-in-class research, training, and technology standards. They have many convenient locations throughout Manhattan, Long Island, Westchester, and New Jersey.

Other Centers of Excellence, beyond cancer and orthopedics, may be available in the near future. Your health is our priority. And high-quality care has never been more affordable.

To learn more about the Hospital for Special Surgery (HSS), click here

To learn more about the Memorial Sloan Kettering Cancer Center (MSKCC), click here

 

 

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.

查找药房.

设置送货上门和续配药

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. ESI 提供的药物与您在走进药房购买的药物没有区别。

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.

在卓护医疗中心,您将体验到在其他任何地方都找不到的高品质护理和服务。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 2019年7月1日 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.