New York City
Oce of Labor Relations
Health Benets Program
Employee Benets Program
Summary Program
Description (SPD)
1 | Page
TABLE OF CONTENTS
Table of Contents ....................................................................................................................................................................................... 1
The City of New York’s Health Benefits Program ....................................................................................................................................... 4
Introduction ........................................................................................................................................................................................... 4
Employee Self-Service ........................................................................................................................................................................... 4
How to Use Self-Service for Health Benefits? ................................................................................................................................... 4
Section I – Employee Health Benefits ........................................................................................................................................................ 5
Eligibility ................................................................................................................................................................................................ 6
Health Plan Coverage for Employees .................................................................................................................................................... 6
Enrollment ............................................................................................................................................................................................. 6
How to Enroll For Health Benefits .................................................................................................................................................... 6
Health Plan Premiums ....................................................................................................................................................................... 7
Optional Riders ................................................................................................................................................................................. 7
Incorrect Deductions from your Paycheck .................................................................................................................................... 7
Waiver of Health Benefits .................................................................................................................................................................. 8
Effective Dates of Coverage ................................................................................................................................................................... 8
For Employees ................................................................................................................................................................................... 8
For Eligible Dependents .................................................................................................................................................................... 8
Changes in Family Status - Adding or Dropping Dependents ................................................................................................................ 8
Annual Fall Transfer Period ................................................................................................................................................................... 8
Pre-Tax Benefits Program ..................................................................................................................................................................... 9
Leave of Absence Coverage ................................................................................................................................................................. 10
Family and Medical Leave Act (FMLA) ............................................................................................................................................. 10
Special Leave of Absence Coverage (SLOAC) .................................................................................................................................. 10
Transfer from One City Agency to Another ......................................................................................................................................... 10
Change of Union or Welfare Fund Membership ................................................................................................................................. 10
Termination and Reinstatement.......................................................................................................................................................... 10
Options Available When City Coverage Terminates ............................................................................................................................. 11
Line of Duty Survivor Coverage Under NYC Administrative Code Section 12.126 .............................................................................. 12
Special Continuation of Coverage Under NYS Chapter Law 436 ......................................................................................................... 12
Provisions for Medicare-Eligible Employees - Age 65 and over .......................................................................................................... 12
Retiring Employees who are Medicare Eligible ................................................................................................................................... 13
Section II – Retiree Health Benefits ......................................................................................................................................................... 14
Enrollment Eligibility for City Health Benefits As a Retiree ................................................................................................................. 15
Effective Dates of Coverage ................................................................................................................................................................. 17
2 | Page
For Retirees ..................................................................................................................................................................................... 17
For Eligible Dependents .................................................................................................................................................................. 17
Health Plan Premiums ......................................................................................................................................................................... 17
Changes in Enrollment Status .............................................................................................................................................................. 18
Changes in Family Status - Adding or Dropping Dependents.......................................................................................................... 18
Health Benefit Changes ................................................................................................................................................................... 18
Termination and Reinstatement.......................................................................................................................................................... 19
Options Available When City Coverage Terminates ............................................................................................................................ 19
Special Continuation of Coverage under NYS Chapter Law 436 .......................................................................................................... 19
City Coverage for Medicare-Eligible Retirees ...................................................................................................................................... 19
Medicare & Medicare Part B Reimbursement .................................................................................................................................... 20
Retiring Employees Aged 65 or older Who Waived City Health Benefits ............................................................................................ 21
Section III - COBRA ................................................................................................................................................................................... 21
COBRA Eligibility .................................................................................................................................................................................. 21
COBRA Periods of Continuation for Dependents ................................................................................................................................ 22
COBRA Notification Responsibilities ................................................................................................................................................... 22
Election of COBRA Continuation ......................................................................................................................................................... 23
Transferring Health Plans While Enrolled Under COBRA..................................................................................................................... 23
SECTION IV – Disability Benefits .............................................................................................................................................................. 23
SECTION V - Coordination of Benefits (COB) ............................................................................................................................................. 23
Section VI - Transgender Inclusive Health Benefits Coverage ................................................................................................................. 24
What’s Covered, Other Services? (Affirmatively covering transgender-related services, as with other services.) ............................ 24
Section VII - In-Vitro Fertilization (IVF) and Fertility Preservation ........................................................................................................... 24
In-Vitro Fertilization (IVF) and Fertility Preservation Health Benefits Coverage for Employees and Non-Medicare Retirees and
Their Dependents ............................................................................................................................................................................ 24
Who is Eligible For IVF Coverage? ....................................................................................................................................................... 24
What’s Covered, Other Services? ........................................................................................................................................................ 25
SECTION VIII – Antiretroviral Pre-Exposure Prophylaxiz (“PrEP”), Effective July 1, 2020 ........................................................................ 25
Antiretroviral Pre-Exposure PROPHYLAXIz (“PrEP”) Health Benefits Coverage to Reduce the Risk of Contracting Human
Immunodeficiency Virus (“HIV) Infection for Employees and Non-Medicare Retirees and Their Dependents, Effective July 1,
2020 ................................................................................................................................................................................................ 25
Who is Eligible for PrEP Coverage? ...................................................................................................................................................... 25
What’s Covered, Other Services? ........................................................................................................................................................ 26
SECTION IX – Summary of Health Plans ................................................................................................................................................... 26
Choosing a Health Plan ........................................................................................................................................................................ 27
Glossary of Important Terms ............................................................................................................................................................... 28
Health Plans & PICA Program for Employees and non-Medicare Retirees .............................................................................................. 30
Aetna EPO ............................................................................................................................................................................................ 31
3 | Page
Anthem EPO ........................................................................................................................................................................................ 33
Anthem Blue Access Gated EPO .......................................................................................................................................................... 36
Cigna .................................................................................................................................................................................................... 38
DC 37 Med-Team ................................................................................................................................................................................. 40
GHI-Comprehensive Benefits Plan/Anthem Blue Cross and Blue Shield Hospital Plan (GHI-CBP) ...................................................... 43
GHI HMO .............................................................................................................................................................................................. 48
HIP HMO Preferred .............................................................................................................................................................................. 50
HIP Prime POS ...................................................................................................................................................................................... 53
MetroPlusHealth Gold ......................................................................................................................................................................... 56
Vytra Health Plans ............................................................................................................................................................................... 58
PICA Program ....................................................................................................................................................................................... 61
Health Plans for Medicare-Eligible Retirees and Their Medicare-Eligible Dependents ........................................................................... 64
Important Information about Health Plan Enrollment and Disenrollment ..................................................................................... 64
Medicare Supplemental Plans ........................................................................................................................................................ 65
Medicare HMOs & Medicare Advantage Plans ............................................................................................................................... 65
Medicare Coordination of Benefit Plans ......................................................................................................................................... 65
DC 37 Med-Team Senior Care ............................................................................................................................................................. 66
Anthem Medicare-Related Coverage .................................................................................................................................................. 67
GHI/ANTHEM Senior Care ................................................................................................................................................................... 68
Aetna Medicare Advantage PPO ESA Plan (PPO) ................................................................................................................................. 69
Elderplan .............................................................................................................................................................................................. 71
Anthem Medicare Preferred (PPO) ..................................................................................................................................................... 72
VIP® Premier (HMO) Medicare (formerly HIP VIP Medicare) .............................................................................................................. 73
UnitedHealthCare Group Medicare Advantage Plan ........................................................................................................................... 74
AvMed Medicare Choice HMO ............................................................................................................................................................ 75
BlueCross BlueShield of Florida Health Options - Medicare & More (Florida Residents) ................................................................... 76
Cigna Medicare (Arizona Only) ............................................................................................................................................................ 77
Humana Gold Plus ............................................................................................................................................................................... 78
GHI HMO Medicare Senior Supplement .............................................................................................................................................. 79
SECTION X – The City of New York’s Employee Assistance Programs ..................................................................................................... 80
SECTION XI – The Employee Blood Program ............................................................................................................................................ 81
Current as of July 2024
4 | Page
THE CITY OF NEW YORK’S HEALTH BENEFITS PROGRAM
INTRODUCTION
Through collective bargaining agreements, the City of New York and the Municipal Unions have cooperated in choosing health plans
and designing the benefits for the City’s Health Benefits
Program. These benefits are intended to provide you with the fullest
possible protection that can be purchased with the available funding.
This Summary Program Description (SPD) provides you with information about your benefits under the New York City Health
Benefits Program.
EMPLOYEE SELF-SERVICE
HOW TO USE SELF-SERVICE FOR HEALTH BENEFITS?
Employee Self-Service (ESS) is an online tool that employees use to enroll or make changes to their personal, health benefits, pay,
tax and deduction information.
For NYCAPS Central agencies, employees should use Employee Self Service (ESS) to enroll in or make changes to their health
benefits. For assistance in using ESS, employees should contact their HR department or NYCAPS Central directly. Employees in need
of a password for ESS should contact NYCAPS at (212) 487-0500 or email their request to [email protected]c.gov
.
If you are an employee of one of the following NYCAPS agencies, however, you must contact either your HR or Benefits/Payroll
Office directly to enroll in or make changes to their health benefits:
• Police Department
• Fire Department
• Department of Sanitation
• Department of Education (contact HR Connect at (718) 935-4000)
• District Attorney Offices
• Department of Investigation
• New York City Housing Authority
Employees of non-NYCAPS agencies must contact either their HR or Benefits/Payroll Office directly to enroll in or make changes to
their health benefits:
• NYC Health + Hospitals (contact Shared Services at (646) 458-5634)
• New York City School Construction Authority
• Cultural Institutions
• Libraries
• CUNY Senior Colleges
5 | Page
SECTION I – EMPLOYEE HEALTH BENEFITS
YOUR RESPONSIBILITIES
It is important that you know how your health plan works and what is required of you. Here are some important things that you
need to remember:
• Contact your agency health benefits or payroll office to add new dependents (newborn, adoption, marriage) within 30
days after the event;
• Notify your agency when you change your address;
• Review your payroll check to ensure appropriate premiums are deducted;
• Know your rights and responsibilities under COBRA continuation coverage.
IF YOU NEED ASSISTANCE
Contact your agency health benefits or payroll office or NYCAPS Central at (212) 487-0500. Department of Education employees can
contact HR Connect at (718) 935-4000, and H + H employees can contact Shared Services at (646) 458-5634.
• For questions concerning eligibility and enrollment, including changes in family status other than domestic partnership
issues
• For questions regarding deductions for health benefits
• For Transfer Period information
• To obtain information and an application for COBRA benefits
• To change your address
• If health coverage has been terminated for you and/or your dependents
Employees with access to Employee Self Service (ESS) through CityShare can check their coverage status and make changes.
WHEN SHOULD I CONTACT MY HEALTH PLAN?
• If you have questions regarding covered services
• To obtain written information about covered services
• For information about the status of pending claims or claim disputes
• For claim allowances (How much will a plan pay towards a claim?)
• For health plan service areas
When writing to a health plan, include your name and address, certificate number, date(s) of service, and claim number(s), if
applicable. Some plans also allow inquiries through their web sites. (Refer to your health plan identification card or plan booklet for
telephone numbers.)
WHEN SHOULD I CONTACT MY UNION/WELFARE FUND?
When you are adding/dropping dependents from your union/welfare fund coverage and for information about:
• Prescription drug coverage (if applicable)
• Vision benefits
• Dental benefits
• Life Insurance (if applicable)
WHEN SHOULD I, AS AN ACTIVE EMPLOYEE, CONTACT THE HEALTH BENEFITS PROGRAM?
• To add or drop a domestic partner
• To register to attend a Transition to Retiree Health Benefits seminar prior to retiring. Visit the Health Benefits Program
at nyc.gov/hbp to register and view available seminar dates and times.
6 | Page
ELIGIBILITY
To be eligible for participation in the City Health Benefits Program, employees must
meet all of the following criteria:
1. You work for the City of New York or one of the following Participating Employers: New York City Department of Education,
City University of New York, NYC Health + Hospitals, New York City Housing Authority, New York City School Construction
Authority, New York Public Library, Queensborough Public Library, Brooklyn Public Library and certain Cultural Institutions.
2. You work -- on a regular schedule -- at least 20 hours per week; and
3. Your appointment is expected to last for more than six months.
Dependents are eligible if their relationship to the eligible participant is one of the following:
1. A legally married spouse, but never an ex-spouse.
2. A domestic partner at least 18 years of age, living together with the participant in a current continuous relationship. More
details concerning eligibility and tax consequences are available from your agency or the Office of Labor Relations Domestic
Partnership Liaison Unit at 212-306-7605 or online at nyc.gov/hbp.
3. Children under age 26 (whether married or unmarried):
a) natural children;
b) children for whom a court has accepted a consent to adopt and for the support of whom an employee has entered into
an agreement;
c) children required to be covered under a qualified medical child support order until the court order expires, at which
time the child may continue to be eligible for coverage under (a) or (b) above;
d) children for whom a court of law has named the employee as legal guardian;
e) any other child who lives with an employee in a regular parent/child relationship and is the employee’s tax dependent.
A child is the employee’s tax dependent if the employee claims the child on his/her income tax return as a dependent.
Coverage will terminate for children (other than eligible disabled children) at
the end of the month in which the child
reaches age 26.
Exception: Unmarried, disabled children age 26 and older, who cannot support themselves, are eligible for continued
coverage if the following criteria are met:
1. the disability occurred before the age at which the dependent coverage would otherwise terminate, and
2. the proof of disability was approved by the health plan at least 31 days before the date the dependent reached age 26.
The eligibility for such dependents only applies to current employees whose disabled dependent children reach the age
limitation while covered by a City health plan. New employees with disabled dependent children, already over the age
limitation, may not include such children as dependents on their City health plan coverage. In
addition, employees may
not add disabled dependent children to their health plan coverage, if the child is already over age 26.
HEALTH PLAN COVERAGE FOR EMPLOYEES HIRED ON OR AFTER JULY 1, 2023
City of New York employees, and employees of Participating Employers, hired on or after July 1, 2023, and their eligible dependents,
may enroll into any health plan for which they are eligible.
Employees may participate in any Annual Fall Transfer Period. (See Annual Fall Transfer Period section below for details.)
ENROLLMENT
HOW TO ENROLL FOR HEALTH BENEFITS
• For instructions on how to enroll, you must contact your agency health benefits or payroll office. Employees of a NYCAPS
Centralized agency must log into ESS. Department of Education employees should contact HR Connect at (718) 935-4000 and
H + H employees should contact Shared Services at (646) 458-5634. Your enrollment request must be submitted within 30 days
of your appointment date (for exceptions, see Effective Dates of Coverage section). If you do not submit your request on time,
the start of your coverage will be delayed and you may be subject to loss of benefits.
7 | Page
• New employees, employees enrolling for the first time or current employees requesting to add dependents are required to
provide acceptable documentation to support the eligibility status of all persons to be covered on their City health plan
coverage.
a. If you are including a spouse on your coverage, and you have been married for more than one year, you must submit a
Government issued Marriage Certificate AND Federal Tax Returns from the last two years, (only send the first page of
each tax return which shows your spouse) OR Proof of Joint Ownership issued within the last six months (with both
names) such as a mortgage statement, lease agreement, utility bills, bank statement, credit card statements and
property tax statements.
b. If you are including a domestic partner on your coverage, and you have been registered for more than one year, you
must submit a Government issued Certificate of Domestic Partnership AND Proof of Joint Ownership issued within the
last six months (with both names) such as a mortgage statement, lease agreement, utility bills, bank statement, credit
card statements and property tax statements.
At retirement you must file a Health Benefits Application with your payroll or personnel office prior to retirement to continue your
coverage into retirement.
Note - DOUBLE CITY Coverage Prohibited
No person can be covered by two City health contracts at the same time. In other words, no person can be covered as both an
employee/retiree and a dependent of another City employee/retiree at the same time.
Eligible dependent children must be enrolled as dependents under one City contract.
If either a spouse or a domestic partner, or eligible dependent, is enrolled as a dependent of the other, the spouse/domestic
partner/eligible dependent may pick up coverage in their own name if the other’s contract is terminated.
HEALTH PLAN PREMIUMS
There is no cost for basic coverage under some of the health plans offered through the City Health Benefits Program, but others
require a payroll deduction. Payroll deductions for health coverage are made on a pre-tax basis (See Medical Spending
Conversion). Enrollees may purchase additional benefits through Optional Riders. Please refer to the Employee Health Plan Rate
Chart available on the Health Benefits Website.
OPTIONAL RIDERS
All health plans, except DC 37 Med-Team, have an Optional Rider consisting of benefits that
are not part of the basic plan, such as
prescription drug coverage. You may select Optional Rider coverage when you enroll and pay for it through payroll deductions. Each
rider is a package and you may not select individual benefits from the rider.
Many employees get additional health benefits through their welfare funds. If your welfare fund is providing benefits similar to
some (or all) of the benefits in your plan’s Optional Rider, those specific benefits will be provided only by your welfare fund and will
not be available through your health plan Optional Rider. Payroll deductions will be adjusted accordingly.
If the Optional Rider consists only of a prescription drug plan, and your union welfare fund provides prescription drug benefits,
payroll deductions will not be adjusted automatically to account for union welfare fund benefits if you select the optional rider. You
will then pay for drug benefits through the rider and have those benefits from the rider in addition to your welfare fund.
If there is a payroll deduction for your plan’s basic coverage, or if you apply for an Optional Rider, your paycheck should reflect
the deduction within two pay periods after submitting a request.
Please refer to the Summary of Health Plans section for information regarding the optional riders available to you.
INCORRECT DEDUCTIONS FROM YOUR PAYCHECK
Please review your payroll health deduction carefully to be sure the amount is correct. If the deduction is incorrect, you must
contact your agency health benefits or payroll office or NYCAPS Central at (212) 487-0500 (Department of Education employees
should contact HR Connect at (718) 935-4000) within 30 days. Adjustments will be made accordingly. Otherwise, the deduction will
be deemed as accurate.
8 | Page
WAIVER OF HEALTH BENEFITS
Every employee or retiree eligible for City health benefits must either enroll for coverage or waive membership by contacting their
agency health benefits or payroll office: NYCAPS Central at (212) 487-0500, Department of Education HR Connect at (718) 935-4000
or H + H Shared Services at (646) 458-5634. Those who waive or cancel City health plan coverage and subsequently wish to enroll or
reinstate benefits will not have coverage until the beginning of the first
payroll period 90 days after the submission of their request,
unless the participant has lost other coverage.
EFFECTIVE DATES OF COVERAGE
Coverage becomes effective according to the following:
FOR EMPLOYEES
1) For employees appointed from Civil Service lists, Exempt employees, and those Non-Competitive employees for whom
there is an experience or education requirement, coverage begins on your appointment date, provided your Health
Benefits enrollment request for has been received by your agency personnel or payroll office within 30 days of that date.
2) For Provisional employees, Temporary employees, and those Non-Competitive employees for whom there is no experience
or education requirement for employment, coverage begins on the ninety-first day of continuous employment, provided
that your Health Benefits enrollment request has been submitted within that period.
Note: Special Enrollment Qualifying Event for Employees who are victims of domestic violence or gender-based violence: Employees
who are victims of domestic violence or gender-based violence who separate from a household member due to an incident or
incidents of domestic or gender-based violence shall be allowed to enroll for City health benefits or make reasonable changes in
their current City health benefits at any time during the calendar year. The effective date of enrollment or benefit change will be the
first day of the month following the processing of the health benefits application.
FOR ELIGIBLE DEPENDENTS
Coverage for eligible dependents will begin on the day that you become covered. Dependents acquired after you submit request for
Health Benefits will be covered from the date of marriage, domestic partnership, birth or adoption; provided that you submit the
required notification and documentation within 30 days of
the event (see Changes in Family Status section).
For enrollment information and instructions, access ESS or contact your agency health benefits or payroll office.
CHANGES IN FAMILY STATUS - ADDING OR DROPPING DEPENDENTS
Employees should report all changes in family status either through ESS or by contacting their agency health benefits or payroll
office within 30 days after the event. Changes should also be reported by the employee to their union/welfare fund.
Changes include adding a dependent due to marriage, domestic partnership, birth or adoption of a child, and to
drop dependents
due to death, divorce, termination of domestic partnership, or a child reaching an ineligible age. If a covered dependent loses
eligibility, that person may obtain benefits through the COBRA Continuation of Benefits
provisions.
For NYCAPS Central agencies, employees should enter their family status change directly in Employee Self Service (ESS). NYCAPS
Central will mail the employee the necessary paperwork, including a request for any required documentation, if applicable.
ANNUAL FALL TRANSFER PERIOD
A Health Benefits Transfer Period is held once each year for coverage effective January 1
st
of the following year. During this period,
you may transfer from your current health plan to any other plan for which you are eligible, or you may add or drop Optional Rider
coverage in your current plan. If you previously waived health insurance coverage, you may elect coverage during this period.
9 | Page
If you did not select the Optional Rider when you first enrolled, you may add these additional benefits only during a Transfer Period.
You may also add the Optional Rider at retirement.
Procedures for Employee Health Plan Transfers — In order to transfer from one plan to another or to add Optional Rider coverage,
and to obtain the effective date of the change, you must submit your request through ESS or contact your agency health benefits or
payroll office during the Annual Transfer Period. Once the transfer request is submitted the change is irrevocable.
Required Documentation for Dependent Changes — If you are including a spouse on your coverage, and you have been married
for more than one year, you must submit a Government issued Marriage Certificate AND Federal Tax Returns from the last two
years, (only send the first page of each tax return which shows your spouse) OR Proof of Joint Ownership issued within the last six
months (with both names) such as a mortgage statement, lease agreement, utility bills, bank statement, credit card statements and
property tax statements. If you are including a domestic partner on your coverage, and you have been registered for more than one
year, you must submit a Government issued Certificate of Domestic Partnership AND Proof of Joint Ownership issued within the last
six months (with both names) such as a mortgage statement, lease agreement, utility bills, bank statement, credit card statements
and property tax statements.
PRE-TAX BENEFITS PROGRAM
The City of New York Employee Benefits Program provides two programs, the Medical Spending Conversion (MSC) and the Health
Care Flexible Spending Account (HCFSA), that offer participants the opportunity to use pre-tax funds to increase take-home pay.
These programs are administered through the Flexible Spending Accounts (FSA) Program. Please contact the Flexible Spending
Accounts Program Administrative Office at (212) 306-7760 for additional information or online at www.nyc.gov/fsa.
MEDICAL SPENDING CONVERSION
1. Premium Conversion Program
All employees who have payroll deductions for health benefits are automatically enrolled in the MSC Premium Conversion
Program. The Premium Conversion Program allows for premiums of
health plan deductions on a pre-tax basis, thus
reducing the amount of gross salary on which federal income and Social Security (FICA) taxes are calculated. Employees
may decline enrollment in the Premium Conversion Program when they first become eligible for health plan coverage or
during the FSA
Open Enrollment Period, which is in the fall of each calendar year. To do so, employees must
complete an
MSC Premium Conversion Program Form and the Health Benefits Application and submit them for approval to their
personnel office.
2. Health Benefits Buy-Out Waiver (Employees Only)
The MSC Health Benefits Buy-Out Waiver Program entitles all eligible employees to receive a cash incentive payment for
waiving their City health benefits if non-City group health coverage is available to them (e.g., a spouse’s/domestic partner’s
plan, coverage from another employer). Annual incentive payments, which are taxable income, are $500 for those waiving
individual coverage and $1,000 for those waiving family coverage. Incentive payments will be made in June and December
of the Plan Year and will be included in the employee’s regular paycheck. This amount will be prorated for any period less
than six months by the number of days the employee is participating in the MSC Health Benefits Buy-Out Waiver Program.
To do so, employees must
complete an MSC Health Benefits Buy-Out Waiver Program Form and the Health Benefits
Application and submit them for approval to their personnel office.
Eligible employees who have waived health benefits coverage may enroll for coverage subject to
the waiting period.
Reinstatement of Coverage is only possible within 30 days of a Qualifying Event or during the Open Enrollment Period. Such
enrollment will be on a pre-tax basis (unless enrollment in the Premium Conversion Program is declined).
HEALTH CARE FLEXIBLE SPENDING ACCOUNT (HCFSA)
The Health Care Flexible Spending Account (HCFSA) Program is designed to help employees pay for necessary out-of-pocket
medical, dental, vision, and hearing aid expenses not covered by insurance. HCFSA is funded through pre-tax payroll deductions,
thereby effectively reducing the employee’s taxable income.
10 | Page
LEAVE OF ABSENCE COVERAGE
FAMILY AND MEDICAL LEAVE ACT (FMLA)
The Federal Family and Medical Leave Act of
1993 (“FMLA”) entitles eligible City employees to 12 weeks of family leave in a 12-
month period to care for a dependent child or covered family member, and/or for the serious illness of the employee.
Employees using this leave may be able to continue their City health coverage through the FMLA provisions. Contact your payroll
or personnel office for
details.
SPECIAL LEAVE OF ABSENCE COVERAGE (SLOAC)
SLOAC may provide continued City health coverage for specified periods of time to certain employees who are on authorized leave
without pay as a result of temporary disability, illness, or ordered military duty or who are receiving Workers’ Compensation. Contact
your payroll or personnel office for details.
TRANSFER FROM ONE CITY AGENCY TO ANOTHER
If you leave the employment of one City agency and you are covered under the City’s Health Benefits Program, and subsequently
become employed by another City agency and you are eligible to enroll for health coverage, your coverage will become effective on
your appointment date at the new agency, provided that no more than 90 days have elapsed since your coverage terminated at the
first agency. You must remain in the same health plan unless you experience certain qualifying events. Contact your agency health
benefits or payroll office or NYCAPS Central at (212) 487-0500 (Department of Education employees should contact HR Connect at
(718) 935-4000 and H + H employees should contact Shared Services at (646) 458-5634) for additional information.
CHANGE OF UNION OR WELFARE FUND MEMBERSHIP
Title changes that result in a change of union or welfare fund membership may require a change in payroll deductions for any
Optional Rider coverage. You should contact your agency health benefits or payroll office or NYCAPS Central at (212) 487-0500
(Department of Education employees should contact HR Connect at (718) 935-4000 and H + H employees should contact Shared
Services at (646) 458-5634) within 30 days if your union or welfare fund has changed.
If you are a DC 37 member enrolled in Med-Team and you will no longer be in DC 37, then you must select another health plan.
TERMINATION AND REINSTATEMENT
WHEN COVERAGE TERMINATES
Coverage terminates:
• for an employee or retiree and covered dependents, the day after the employee’s last day of employment with the City or
Participating Employer or when a retiree stops receiving a pension check (with the exception of employees on FMLA or
SLOAC).
• for an employee and covered dependents, the day after the employee no longer meets the eligibility criteria for
participation in the City Health Benefits Program.
• for a spouse, when divorced from an employee or retiree.
• for a domestic partner, when partnership terminates.
• for dependent children (other than eligible disabled children) at the end of the month in which the child reaches age 26.
• for all dependents, unless otherwise eligible, when the City employee or retiree dies.
11 | Page
If your spouse, or your domestic partner, is eligible for City health coverage as either an employee or a retiree, and is enrolled as
your dependent, the person enrolled as dependent may pick up coverage in his/her own name within 30 days if the employee’s City
coverage terminates.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that the plan administrator issue certificates of
group health plan coverage to employees upon termination of
employment that results in the termination of group health coverage.
Each individual, upon termination, will receive a certificate of coverage from the plan administrator.
REINSTATEMENT OF COVERAGE
If you have been on approved leave without pay, or have been removed from active pay status for
any other reason, your health
coverage may have been interrupted. Contact your agency health benefits or payroll office or NYCAPS Central at (212) 487-0500
(Department of Education employees should contact HR Connect at (718) 935-4000 and H + H employees should contact Shared
Services at (646) 458-5634) within 31 days of your return to work.
• If you are returning from an approved leave of absence or your coverage has been terminated for less than 90 days,
coverage resumes on the date you return to work.
• If
you were not on an approved leave of absence or if your coverage has been terminated for more than 90 days, your
coverage may not become effective until the pay period following the submission of your request for health benefits.
If you have waived or cancelled your City health plan coverage and subsequently wish to
enroll or reinstate your benefits, your
coverage will not start until the beginning of the first payroll period 90 days following the date you submit your request for health
benefits, unless the enrollment or reinstatement is the result of a loss of other group coverage. Contact your agency health
benefits or payroll office or NYCAPS Central at (212) 487-0500 (Department of Education employees should contact HR Connect at
(718) 935-4000 and H + H employees should contact Shared Services at (646) 458-5634).
OPTIONS AVAILABLE WHEN CITY COVERAGE TERMINATES
CONVERSION OPTION
Employees and covered dependents may purchase individual health coverage through their health plan if their City group
coverage ceases for any of the following reasons:
• an employee leaves City employment;
• an employee loses City coverage due to a reduction in the work schedule;
• an employee or retiree dies;
• a dependent spouse is divorced from the employee or retiree;
• a domestic partnership terminates;
• dependent children exceed the age limits established under the group contract;
• coverage under the provisions of COBRA expires.
Unlike COBRA, benefits under this type of policy do not automatically terminate after a limited time, and may vary from the City’s
“basic” benefits package in both the scope of benefits and in cost.
COBRA BENEFITS
The Federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that the City offer employees, retirees and
their families the opportunity to continue group health and/or welfare fund coverage in certain instances where the coverage
would otherwise terminate. The monthly premium will be 102% of the group rate. All group health benefits, including Optional
Riders, are available. The maximum period of coverage is 36 months. Please refer to the COBRA section for more information.
12 | Page
LINE OF DUTY SURVIVOR COVERAGE UNDER NYC ADMINISTRATIVE CODE SECTION 12.126
New York City Administrative Code provides that surviving spouses/domestic partners and dependents of City employees whose
death was the natural and proximate result of an accident or injury sustained while in the performance of duty, or where accidental
death benefits have been awarded in connection with a qualifying World Trade Center condition as defined in paragraph (a) of
subdivision 36 of section 2 of the retirement and social security law, or where the death of a City employee is or was the natural and
proximate result of a complication related to the coronavirus disease, COVID-19, shall be afforded the right to City health insurance
coverage. To be awarded for accidental death benefits from a NYC pension system as a result of COVID-19, the member’s death
must have been caused by COVID-19 or where COVID-19 contributed to such member’s death, on or before December 31, 2022.
Contact the applicable pension plan for information and to obtain the appropriate form to apply.
After you have obtained the accidental death benefits award letter from the deceased member’s pension plan, contact the Health
Benefits Program, in writing, enclosing a copy of the members’ death certificate and the award letter from the pension system. You
will receive a Line of Duty Survivor Health Benefits Application. The application needs to be completed and signed by the applicable
dependent of the deceased member. Once the Application is completed, please submit it to the Health Benefits Program. Survivors
may continue with the same plan they had or chose any other plan for which they are eligible. Please note, if the plan enrolled in has
a survivor cost it may be deducted from any pension payment or the survivor will be billed directly for the cost.
SPECIAL CONTINUATION OF COVERAGE UNDER NYS CHAPTER LAW 436
Effective November 13, 2001, New York State law provides that surviving spouses of retired uniformed members of the New York
City Police and Fire Departments can continue their health benefits coverage for life. Effective August 30, 2010, New York State law
provides that surviving spouses/domestic partners and dependents of members of the Departments of Sanitation and Correction are
also eligible to continue their health benefits coverage for life. Such coverage will be at a premium of 102% of the group rate and
must be elected within one (1) year of the date of
the death of the member. Contact the Health Benefits Program, in writing,
enclose a copy of the members’ death certificate and you will receive a Continuation of Coverage- Chapter 436 Application. The
application needs to be completed and signed by the applicable dependent of the deceased member. Once the Application is
complete it must be sent to the Health Plan. The Health Plan will send you a bill for the monthly premium.
PROVISIONS FOR MEDICARE-ELIGIBLE EMPLOYEES - AGE 65 AND OVER
EMPLOYEES AGE 65 AND OVER
Federal law requires the City of New York to offer employees age 65 and over, and their eligible dependents, the same coverage
under the same conditions as offered to employees under age 65. The same stipulation applies also to dependents 65 and over.
Continuation of primary coverage in the City health plans is automatic (unless waived) and Medicare becomes secondary coverage.
Therefore, do not use your Medicare card when you visit your doctor’s office. Instead, be sure to use the member ID card provided
to you by your current City health plan.
If you are a Medicare-eligible active employee and want Medicare to be your primary coverage, you must waive City health benefits.
By doing so, you will not be eligible for the City’s group health plan. Contact your agency health benefits or payroll office or NYCAPS
Central at (212) 487-0500 (Department of Education employees should contact HR Connect at (718) 935-4000 and H + H employees
should contact Shared Services at (646) 458-5634).
The City does not reimburse employees or their dependents for their Medicare Part B premiums. Medicare Part B premium
reimbursement will be available at retirement when Medicare becomes the primary plan.
SPECIAL PROVISIONS OF THE SOCIAL SECURITY ACT FOR THE DISABLED
Dependents of employees who are covered by Medicare through the Special Provisions of the Social Security Act for the Disabled are
eligible for the same continuation of primary coverage in the City health plans (unless waived) and Medicare becomes secondary
coverage.
13 | Page
The rules differ for persons eligible for Medicare due to end-stage renal disease. Consult your Medicare Handbook or local Social
Security Office for further information.
RETIRING EMPLOYEES WHO ARE MEDICARE ELIGIBLE
In order to enroll in Retiree Health Benefits at retirement, employees must complete a Retiree Health Benefits Application and
submit it to their agency personnel office for certification and verification of eligibility.
At retirement, employees may choose to cover eligible dependents who were not previously covered on their City health plan. The
employee must include their eligible dependent information on the Retiree Health Benefits Application. However, if your
spouse/domestic partner is currently enrolled in a private Medicare plan, they may be disenrolled from their plan as a result of
enrollment in City health benefits coverage as a dependent.
Retired employees may also waive their city health coverage in retirement.
14 | Page
SECTION II – RETIREE HEALTH BENEFITS
YOUR RESPONSIBILITIES
It is important that you know how your health plan works and what is required of you. Here are some important things that you
need to remember:
• Complete an enrollment form to add new dependents (newborn, adoption, marriage) within 30 days after the event;
• Notify the NYC Health Benefits Program and your health plan in writing when your address changes;
• Review your pension check to ensure appropriate premiums are deducted;
• Know your rights and responsibilities under COBRA continuation coverage.
IF YOU NEED ASSISTANCE
Retirees with questions about benefits, services, or claims should write or call their health plan. When writing to the plan, give
your certificate number, name and address.
The Health Benefits Program is also available to provide service and information to City retirees who have questions about or
problems with their health benefits or pension check deductions.
Retirees contacting the Health Benefits Program should always include the following information (please print clearly):
Name, Address, Telephone Number and Email Address
Complete Social Security Number
Agency from which you retired
Union/Welfare Fund
Pension Number
WHO DO I CONTACT AFTER RETIREMENT?
Retirees can contact the Health Benefits Program:
• For questions concerning eligibility and enrollment
• For questions regarding deductions for health benefits taken from your pension check
• For Transfer Period information
• To obtain applications to make changes to your coverage such as adding/dropping dependents, adding/dropping the
optional rider, waiving health coverage and to change plans (excluding Medicare HMOs, which require a special
application from the health plan)
• For notification of enrollment in Medicare
• For questions regarding Medicare Part B premium reimbursements
• To obtain information and an application for COBRA benefits
• To change your address
• If health coverage has been terminated for you and/or your dependents
Contact the Health Benefits Program:
In-person - City of New York Health Benefits Program
22 Cortlandt Street – 12th Floor
New York, NY 10007
Please Note: The Walk-in Center is currently closed. Please call to make an appointment to meet with a Client
Service Representative.
By phone - (212) 513-0470
Visit our website at: www.nyc.gov/hbp
15 | Page
WHEN SHOULD I CONTACT MY HEALTH PLAN?
• If you have questions regarding covered services
• To obtain written information about covered services
• For information about the status of pending claims or claim disputes
• For claim allowances (How much will a plan pay towards a claim?)
• For health plan service areas
When writing to a health plan, include your name and address, certificate number, date(s) of service, and claim number(s), if
applicable. Some plans also allow inquiries through their web sites. (Refer to your health plan identification card or plan booklet for
telephone numbers.)
WHEN SHOULD I CONTACT MY UNION/WELFARE FUND?
For information about:
• Prescription drug coverage (if applicable)
• Vision benefits
• Dental benefits
• Life Insurance (if applicable)
To report all changes in family status, including domestic partnership.
ENROLLMENT ELIGIBILITY FOR CITY HEALTH BENEFITS AS A RETIREE
The following summarizes eligibility policy as of the date of this publication. Your actual eligibility for benefits will be determined
by the City policy in place at the time you retire, and the benefits applicable to you should be ascertained at that time. You should
speak with your current employer to ascertain your eligibility.
RETIREES ARE ELIGIBLE (IF YOU MEET ALL OF THE CRITERIA):
1.
You have at least ten (10) years of credited service as a member of a retirement system maintained by the City or
the Department of Education (if you were an employee of the City on or before December 27, 2001, then you
must have at least five (5) years of credited service as a member of a retirement system maintained by the
City);
OR
2.
You have at least fifteen (15) years of credited service as a member of either the Teachers’ Retirement System
or the Board of Education Retirement System if you were an employee of the City or the Department of
Education appointed on or after April 28, 2010, and held a position represented by the recognized teacher
organization* on the last day of paid service. Where this paragraph and paragraph (1) both apply, this
paragraph controls.
*The current recognized teacher organization is the United Federation of Teachers.
AND
3.
During the minimum period of credited service required for eligibility under paragraph (1) or (2) above, or at the
time of separation from employment with the City or the Department of Education, you were working regularly
for twenty (20) or more hours a week and eligible for City health benefits as an employee of the City or the
Department of Education.
AND
4.
You receive a pension check from a retirement system maintained by the City or the Department of Education.
EXCEPTIONS:
Accidental disability retirement: If you retire from the City or the Department of Education because of an accidental disability,
as a current or former member of a retirement system maintained by the City or the Department of Education, and you receive
a pension check from such system, you are eligible for retiree health benefits.
16 | Page
Other Participating Employers in the City’s Health Benefits Program
Members of retirement systems not maintained by the City or the Department of Education, such as former employees of
some institutions or entities participating in the Cultural Institutions Retirement System and former employees participating in
the Optional Retirement Program of the City University of New York, may be eligible for
health coverage. In addition, former
employees of certain non-City employers that participate in retirement systems maintained by the City or the Department of
Education, such as the NYC School Construction Authority, the NYC Transit Authority, New York City Housing Authority and the
NYC Health + Hospitals, may be eligible for retiree health insurance coverage. Former employees of the foregoing types of
employers should confirm eligibility with the personnel offices of their former employers.
DEPENDENTS ARE ELIGIBLE IF THEIR RELATIONSHIP TO THE ELIGIBLE PARTICIPANT IS ONE OF THE
FOLLOWING:
1. A legally married spouse, but never an ex-spouse.
2. A domestic partner at least 18 years of age, living together with the participant in a current continuous relationship.
More details concerning eligibility are available from the Office of Labor Relations Domestic Partnership Liaison Unit
at 212-306-7605 or online at nyc.gov/hbp.
3. Children under age 26 (whether married or unmarried):
a) natural children;
b) children for whom a court has accepted a consent to adopt and for the support of whom a retiree has entered into
an agreement;
c) children required to be covered under a qualified medical child support order until the court order expires, at
which time the child may continue to be eligible for coverage under (a) or (b) above;
d) children for whom a court of law has named the retiree as legal guardian;
e) any other child who lives with a retiree in a regular parent/child relationship and is the retiree’s tax dependent. A
child is the retiree’s tax dependent if the retiree claims the child on his/her income tax return as a dependent.
Coverage will terminate for children (other than eligible disabled children) at
the end of the month in which the
child reaches age 26.
Exception: Unmarried, disabled children age 26 and older, who cannot support themselves, are eligible for continued
coverage if the following criteria are met:
1. the disability occurred before the age at which the dependent coverage would otherwise terminate, and
2. the proof of disability was approved by the health plan at least 30 days before the date the dependent reached
age 26.
The eligibility for such dependents only applies to current retirees whose disabled dependent children reach the
age limitation while covered by a City health plan. Retirees may not add disabled dependent children to their health
plan coverage, if the child is already over age 26.
HOW TO ENROLL FOR HEALTH BENEFITS
You must file a Retiree Health Benefits Application at your personnel office prior to retirement to continue your coverage into
retirement. If you are Medicare-eligible and are enrolling in an HMO you must complete an additional application form, which must
be obtained directly from the health plan. If you are retired from a cultural institution, library, or the Fashion Institute of
Technology, or if you receive a TIAA pension and are eligible for City health coverage, you must file a Health Benefits Application
with your former employer.
a. If you are adding a spouse to your coverage, and you have been married for more than one year, you must submit a
Government issued Marriage Certificate AND Federal Tax Returns from the last two years, (only send the first page of each
tax return which shows your spouse) OR Proof of Joint Ownership issued within the last six months (with both names) such
as a mortgage statement, lease agreement, utility bills, bank statement, credit card statements and property tax
statements.
b. If you are adding a domestic partner to your coverage, and you have been registered for more than one year, you must
submit a Government issued Certificate of Domestic Partnership AND Proof of Joint Ownership issued within the last six
months (with both names) such as a mortgage statement, lease agreement, utility bills, bank statement, credit card
statements and property tax statements.
17 | Page
WAIVER OF HEALTH BENEFITS
Every retiree eligible for City health benefits must either enroll for coverage or waive membership by completing the appropriate
sections of the Health Benefits Application. Those who waive or cancel City health plan coverage and subsequently wish to enroll
or reinstate benefits will not have coverage until the first of the month following 90 days after the Health Benefits Application is
processed, unless the retiree has lost other coverage.
EFFECTIVE DATES OF COVERAGE
Coverage becomes effective according to the following:
FOR RETIREES
If you file the Health Benefits Application for continuation of coverage into retirement with your agency personnel office prior to
retirement (ideally provide 6 to 8 weeks notice), coverage begins on the day of retirement for most retirees. Employees who had
previously waived coverage can enroll in Retiree Health Benefits upon retirement. Retirees who wish to continue to waive City
health benefits must complete a new Retiree Health Benefits Application selecting to Waive Benefits. The effective date of the
reinstatement will be the date of retirement, or the first day of the month following the processing of the health benefits
application. An enrollment is considered late if an application is submitted more than 30 days after the event that made the retiree
or dependent eligible. In cases of late enrollment, coverage will begin on the first day of the month following the processing of a
Health Benefits Application.
Special Enrollment Qualifying Event for Retirees who are victims of domestic violence or gender-based violence: Retirees who are
victims of domestic violence or gender-based violence who separate from a household member due to an incident or incidents of
domestic or gender-based violence shall be allowed to enroll for City health benefits or make reasonable changes in their current
City health benefits at any time during the calendar year. The effective date of enrollment or benefit change will be the first day of
the month following the processing of the health benefits application.
FOR ELIGIBLE DEPENDENTS
Coverage for eligible dependents listed on your Health Benefits
Application will begin on the day that you become covered.
Dependents acquired after you submit your application will be covered from the date of marriage, domestic partnership, birth or
adoption; provided that you submit the required notification and documentation within 30 days of
the event (see Changes in Family
Status Section).
HEALTH PLAN PREMIUMS
There is no cost for basic coverage under some of the health plans offered through the City Health Benefits Program, but others
require a pension deduction. Enrollees may purchase additional benefits through Optional Riders.
OPTIONAL RIDERS
All health plans, except DC 37 Med-Team have an Optional Rider consisting of benefits that
are not part of the basic plan. You may
elect Optional Rider coverage when you enroll and pay for it through pension deductions. Each rider is a package and you may not
select individual benefits from the rider.
Many retirees get additional health benefits through their welfare funds. If your welfare fund is providing benefits similar to some
(or all) of the benefits in your plan’s Optional Rider, those specific benefits will be provided only by your welfare fund and will not be
available through your health plan rider. Pension deductions will be adjusted accordingly.
If the Optional Rider consists only of a prescription drug plan, and your union welfare fund provides prescription drug benefits,
payroll deductions will not be adjusted automatically to account for union welfare fund benefits if you select the optional rider. You
will then pay for drug benefits through the rider and have those benefits from the rider in addition to your welfare fund.
18 | Page
If there is a premium for your plan’s basic coverage, or if you apply for an Optional Rider, your pension check should reflect the
deduction within two months after submitting a Health Benefits Application. If there are any retroactive premiums owed, they will
be reflected as an additional pension deduction.
INCORRECT DEDUCTIONS FROM YOUR PENSION CHECK
Please review your health deduction carefully to be sure the amount is correct. If the deduction is incorrect, you must contact the
NYC Health Benefits Program within 30 days. Adjustments will be made accordingly. Otherwise, the deduction will be deemed as
accurate.
CHANGES IN ENROLLMENT STATUS
CHANGES IN FAMILY STATUS - ADDING OR DROPPING DEPENDENTS
Retirees should report all changes in family status to the NYC Health Benefits Program within 30 days after the event. Changes
include adding a dependent due to marriage, domestic partnership, birth or adoption of a child, and to
drop dependents due to
death, divorce, termination of domestic partnership, or a child reaching an ineligible age. If a covered dependent loses eligibility,
that person may obtain benefits through the COBRA Continuation of Benefits
provisions.
Changes should also be reported by the retiree to their union/welfare fund.
HEALTH BENEFIT CHANGES
• Fall Transfer Period
Retirees may transfer or add an Optional Rider during the Transfer Period, which takes place annually. During this period,
all retirees may transfer from their current health plan to any other plan for which they are eligible, or they may add
Optional Rider coverage to their present plan (the Optional Rider can be dropped at any time). Exception: When
transferring into a Medicare HMO plan other than during a Transfer Period, transfers will become effective on the first day
of the month following the processing of the special health plan application provided by the health plan.
• Once-in-a-lifetime transfers
Retirees who have been retired for at least one year can take advantage of a once-in-a-lifetime provision to transfer or add
an optional rider at any time. Once-in-a-lifetime transfers become effective on the first of the month following the date that
the Health Benefits Application is processed.
Once your transfer request is submitted your change is Irrevocable.
Required Documentation for Dependent Changes — If you are including a spouse on your coverage, and you have been married
for more than one year, you must submit a Government issued Marriage Certificate AND Federal Tax Returns from the last two
years, (only send the first page of each tax return which shows your spouse) OR Proof of Joint Ownership issued within the last six
months (with both names) such as a mortgage statement, lease agreement, utility bills, bank statement, credit card statements and
property tax statements. If you are including a domestic partner on your coverage, and you have been registered for more than one
year, you must submit a Government issued Certificate of Domestic Partnership AND Proof of Joint Ownership issued within the last
six months (with both names) such as a mortgage statement, lease agreement, utility bills, bank statement, credit card statements
and property tax statements.
19 | Page
TERMINATION AND REINSTATEMENT
WHEN COVERAGE TERMINATES
Coverage terminates:
• for a retiree and covered dependents, when the retiree stops receiving a pension check (including pension suspensions).
• for a spouse, when divorced from a retiree.
• for a domestic partner, when partnership terminates.
• for dependent children (other than eligible disabled children) at the end of the month in which the child reaches age 26.
• for all dependents, unless otherwise eligible, when the retiree dies.
If your spouse, or your domestic partner, is eligible for City health coverage as either an employee or a retiree, and is enrolled as
your dependent, the person enrolled as dependent may pick up coverage in his/her own name within 30 days if the retiree’s City
coverage terminates.
REINSTATEMENT OF COVERAGE
If you have waived or cancelled your City health plan coverage and subsequently wish to
enroll or reinstate your benefits, your
coverage will be effective the first of the month following a 90-day waiting period after receipt of your Health Benefits Application.
This waiting period is waived if the enrollment or reinstatement is the result of a loss of other group coverage.
If your coverage was terminated due to the suspension of your pension check, the reinstatement of coverage will be effective as of
the date your pension is restored.
OPTIONS AVAILABLE WHEN CITY COVERAGE TERMINATES
COBRA BENEFITS
The Federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that the City offer employees, retirees and
their families the opportunity to continue group health and/or welfare fund coverage in certain instances where the coverage
would otherwise terminate. The monthly premium will be 102% of the group rate. All group health benefits, including Optional
Riders, are available. The maximum period of coverage is 36 months.
SPECIAL CONTINUATION OF COVERAGE UNDER NYS CHAPTER LAW 436
Effective November 13, 2001, New York State law provides that surviving spouses/domestic partners of retired uniformed members
of the New York City Police and Fire Departments can continue their health benefits coverage for life. Effective August 30, 2010,
New York State law provides that surviving spouses/domestic partners and dependents of active or retired members of the
Departments of Sanitation and Correction are also eligible to continue their health benefits coverage for life. Such coverage will be
at a premium of 102% of the group rate and must be elected within one (1) year of the date of
the death of the member. Contact
the Health Benefits Program, in writing, enclose a copy of the members’ death certificate and you will receive a Continuation of
Coverage - Chapter 436 Application. The application needs to be completed and signed by the spouse/domestic partner of the
deceased member. Once the Application is complete it must be sent to the Health Plan. The Health Plan will send you a bill for the
monthly premium.
CITY COVERAGE FOR MEDICARE-ELIGIBLE RETIREES
The City’s Health Benefits Program offers both Medicare supplemental health plans and Medicare HMO/Advantage plans. Medicare-
eligible members must be enrolled in Medicare Parts A and B in order to be covered by a Medicare HMO/Advantage plan.
20 | Page
In order to maintain maximum health benefits, it is essential that you join Medicare Part A (Hospital Insurance) and Part B (Medical
Insurance) at your local Social Security Office as soon as you are eligible. If you do not join Medicare, you will lose whatever benefits
Medicare would have provided.
To enroll in Medicare upon becoming age 65, contact your Social Security Office during the three-month period before your 65th
birthday. There are no penalties for late enrollment in Medicare Part B if employees choose the Health Benefits Program as primary
coverage and cancel or delay enrollment in Medicare Part B coverage until retirement or termination of employment (when
Medicare enrollment is permitted for a limited period of time). Medicare Hospital Insurance (Part A) should be maintained. For most
persons, Part A coverage is free. There is a monthly premium for Medicare Part B.
In addition, be sure to forward, at least 45 days before turning age 65, a copy of your (your spouse's) Medicare card, if applicable, to
Health Benefits Program at 22 Cortlandt Street, 12th Floor, New York, NY 10007. When submitting spouse information, please
include the name and Social Security number of the NYC retiree on the copy.
In order to be enrolled in a Medicare advantage plan you (or your spouse) must be entitled to Medicare Part A (Hospital insurance)
and enrolled in Medicare Part B (Medical insurance).
If you are over 65 or eligible for Medicare due to disability and did not join Medicare, contact your Social Security Office to find out
when you may join. If you do not join Medicare Part B when you first become eligible, there is a 10% premium penalty for each year
you were eligible but did not enroll. In addition, under certain circumstances there may be up to a 15-month delay before your
Medicare Part B coverage can begin.
If you or your spouse are ineligible for Medicare Part A although over age 65 (reasons for ineligibility include non-citizenship or
non-eligibility for Social Security benefits for Part A), coverage may be provided under certain health plans. Under this Non-Medicare
eligible coverage, you continue to receive the same hospital benefits as persons not yet age 65.
If you are living outside the USA or its territories, Medicare benefits are not available. Under this Non-Medicare eligible coverage,
you continue to receive the same hospital and/or medical benefits as persons not yet age 65. If you do not join and/or do not
continue to pay for Medicare Part B however, you will be subject to penalties if you return to the USA and attempt to enroll.
If you are eligible for Medicare Part B as a retiree but did not file with Social Security during their enrollment period (January
through March) or prior to your 65th birthday, you will receive supplemental medical coverage only, and only through
GHI/ANTHEMBCBS Senior Care.
MEDICARE & MEDICARE PART B REIMBURSEMENT
You must complete the Medicare Part B Reimbursement Program Application in order to:
• Notify the Health Benefits Program of your Medicare eligibility,
• Receive reimbursement from the City for Medicare Part B premiums paid, excluding any penalties, and
• Adjust your health plan premiums, if applicable.
Certain plans do not provide coverage for Medicare enrollees; these include VYTRA, MetroPlus, and CIGNA (outside of Arizona). They
will have the opportunity to transfer to another plan by completing a Health Benefits Application.
MEDICARE PART B REIMBURSEMENT
The City will reimburse Medicare-eligible retirees and their Medicare-eligible dependent(s) for Medicare Part B premiums, excluding
any penalties, paid during the calendar year, subject to meeting the following conditions:
1. The Medicare card for the Medicare-eligible retiree and/or Medicare-eligible dependent(s) is on file with the New York City
Health Benefits Program; and
2. The Medicare-eligible retiree is receiving a pension from a City of New York pension system; and
21 | Page
3. The Medicare-eligible retiree and/or Medicare-eligible dependent(s) is covered by a health plan offered by the City Health
Benefits Program; and
4. The City offered health plan has the Medicare-eligible retiree and/or Medicare-eligible dependent(s) in Medicare status; and
5. The Medicare-eligible retiree and/or Medicare-eligible dependent(s) is currently paying Medicare Part B premiums and is not
receiving Medicare Part B reimbursement(s) from any other source, including Medicaid.
If a Medicare-eligible retiree and/or Medicare-eligible dependent(s) lives outside of the USA or its territories, they are only eligible
for reimbursement for the months they live in the USA or its territories.
The Medicare Part B reimbursement is issued in April for the prior calendar year (January through December). If you are receiving
your pension payment through Electronic Fund Transfer (EFT) or direct deposit, the Medicare Part B reimbursement for you and
your Medicare-eligible dependent will be deposited directly into your bank account. This payment will be a separate deposit from
your pension payment. If you do not have EFT or direct deposit, you will receive a check for your reimbursement.
If you met the above conditions for Medicare Part B Reimbursement for prior years except that you did not enroll by providing a
copy of your Medicare card to the City Health Benefits Program, reimbursement is limited to the previous three (3) calendar years.
RETIRING EMPLOYEES AGED 65 OR OLDER WHO WAIVED CITY HEALTH BENEFITS
At retirement, employees who have chosen Medicare as their primary plan or whose dependents have not been covered on their
plan because their spouse/domestic partner elected Medicare as the primary plan may re-enroll in the City health benefits program.
This is done by completing a Health Benefits Application and submitting it to their agency health benefits, payroll or personnel
office. Also at retirement, Medicare-eligible employees for whom the City Health Benefits Program had provided primary coverage
are permitted to change health plans effective on the same date as their retiree health coverage.
SECTION III - COBRA
COBRA ELIGIBILITY
EMPLOYEES NOT ELIGIBLE FOR MEDICARE
Employees whose health and/or welfare fund coverages are terminated due to a reduction in hours of employment or termination
of employment (for reasons other than gross misconduct) may continue the benefits received as an active employee for a period of
36 months at 102% of the group cost under COBRA. An additional PICA premium cost may apply for certain health plans.
Termination of employment includes unpaid leaves of absence of any kind. More information concerning situations involving
termination due to gross misconduct is available from your agency benefits representative.
SPOUSE/DOMESTIC PARTNER NOT ELIGIBLE FOR MEDICARE
A Spouse/Domestic Partner may continue the benefits received for a period of 36 months at 102% of the group cost under COBRA
(an additional PICA premium cost may apply for certain health plans) if he/she loses coverage for any of the following reasons:
1. death of the City employee or retiree;
2. termination of the employee’s City employment (for reasons other than gross misconduct);
3. loss of health coverage due to a reduction in the employee’s hours of employment;
4. divorce from the City employee or retiree;
5. termination of domestic partnership with the City employee or retiree;
6. retirement of the employee.
22 | Page
DEPENDENT CHILDREN NOT ELIGIBLE FOR MEDICARE
Dependent children may continue the benefits received for a period of 36 months at 102% of the group cost under COBRA (an
additional PICA premium cost may apply for certain health plans) if they lose coverage for any of the following reasons:
1. death of a covered parent (the City employee or retiree);
2. the termination of a covered parent’s employment (for reasons other than gross misconduct);
3. loss of health coverage due to the covered parent’s reduction in hours of
employment;
4. the dependent ceases to be a “dependent child” under the terms of the Health Benefits Program;
5. retirement of the covered parent.
Note: Individuals covered under another group plan are not eligible for COBRA continuation. However, the COBRA applicant may be
able to purchase certain welfare fund benefits. For more information, contact the appropriate welfare fund.
RETIREES
Retirees who are not eligible to receive City-paid health care coverage and their dependents may continue the benefits received as
an active employee for a period of 36 months at 102% of the group cost under COBRA. For non-Medicare retirees, an additional PICA
premium cost may apply for certain health plans.
Retirees whose welfare fund benefits would be reduced or eliminated at retirement are eligible to maintain those benefits under
COBRA. Contact the union welfare fund for the premium amounts and benefits available.
COBRA PERIODS OF CONTINUATION FOR DEPENDENTS
If dependents lose benefits as a result of death, divorce, domestic partnership termination, or loss of coverage due to the
Medicare-eligibility of the contract holder, or due to the loss of dependent child status, the maximum period for which COBRA can
continue coverage is 36 months. This period will be calculated from the date of the loss of coverage under the City program.
The definition of a qualified beneficiary includes a child born to or adopted by certain qualified beneficiaries during the COBRA
continuation period. Only if you are a qualified beneficiary by reason of having been an employee, will a child born to or adopted by
you during the COBRA continuation period become a qualified beneficiary in his or her own right. This means that if you should lose
your COBRA coverage, your new child may have an independent right to continue his or her coverage for the remainder of the
otherwise applicable continuation period. However, you must cover your new child as a dependent within 30 days of the child’s
birth or adoption in order to have this added protection.
Any increase in COBRA premium due to this change must be paid during the period for which the coverage is in effect.
Continuation of coverage can never exceed 36 months in total, regardless of the number of
events that relate to a loss in
coverage. Coverage during the continuation period will terminate if the enrollee fails to make timely premium payments or becomes
enrolled in another group health plan.
COBRA NOTIFICATION RESPONSIBILITIES
Under Federal law:
• the employee or family member has the responsibility of notifying the City agency payroll or personnel office and the
applicable welfare fund within 60 days of the death, divorce, domestic partnership termination, or change of address of an
employee, or of a child’s losing dependent status. When a qualifying event (such as an employee’s death, termination of
employment, or reduction in hours) occurs, the employee and family will receive a COBRA information packet from the City
describing continuation coverage options.
• the retiree and/or a family member must notify the Health Benefits Program and the applicable welfare fund within 60 days
in the case of death of the retiree or the occurrence of divorce, domestic partnership termination or of a child’s losing
23 | Page
dependent status. After notification of a qualifying event, the family may request a COBRA information packet from the City
describing continuation coverage options.
ELECTION OF COBRA CONTINUATION
To elect COBRA continuation of health coverage, the eligible person must complete a “COBRA - Continuation of Coverage
Application.”
• Employees and/or eligible family members can obtain application forms from their agency payroll or personnel office.
• Retirees and/or eligible family members can obtain application forms from the Health Benefits Program website at
www.nyc.gov/hbp.
Please contact the welfare fund if you wish to purchase its benefits.
Eligible persons electing COBRA continuation coverage must do so within 60 days of the date on which they receive notification of
their rights and must pay the initial premium within 45 days of their election. Premium payments will be made on a monthly basis.
Payments after the initial payment will have a 30-day grace period.
Former employees and dependents who elect COBRA continuation coverage are entitled to the same benefits and rights as
employees. Therefore, COBRA enrollees may take part in any Transfer Period.
Individuals eligible for COBRA may also transfer when a change of address allows or eliminates access to a health plan that requires
residency in a particular Zip Code.
TRANSFERRING HEALTH PLANS WHILE ENROLLED UNDER COBRA
The COBRA application form to be used during the Transfer Period (or after a qualifying event) can be obtained from the Health
Benefits Program website at www.nyc.gov/hbp. Applications should be mailed to the COBRA enrollee’s current health plan, which
will forward enrollment information to the new health plan. Transfer Period changes will become effective on January 1st of the
following year. Information about the effective date for a transfer made as the result of a qualifying event must be obtained from
the new health plan. City agencies, nor the Health Benefits Program, handle COBRA enrollee transfers, or process any future
changes such as adding dependents. All future transactions will be handled by the health plan in which the person eligible for
COBRA is enrolled.
SECTION IV – DISABILITY BENEFITS
Those who have been declared totally disabled, as determined by their health plan, because of an injury or illness on the date of
termination, remain covered for that disability up to a maximum of 18 additional months for the GHI-CBP/ AnthemBCBS plan, and up
to 12 months for all other plans, except GHI Senior Care/AnthemBCBS, which provides only 31 days of additional coverage. This
extension of benefits applies only to the disabled person and only covers the disabling condition. Under the GHI/ AnthemBCBS
plan, if a subscriber is hospitalized at
the time of termination, hospital coverage is extended only to the end of the hospitalization.
Contact your health plan for details.
SECTION V - COORDINATION OF BENEFITS (COB)
You may be covered by two or more group health plans that may provide similar benefits.
If you have coverage through more than
one plan, your City health plan will coordinate benefit payments with the other plan. One plan will pay its full benefit as a primary
insurer, and the other plan will pay secondary benefits. This prevents duplicate payments and overpayments. The plan covering you
as an employee is primary before a plan covering you as dependent. In no event shall payments exceed 100% of a charge.
SPECIAL RULES FOR DEPENDENTS OF SEPARATED OR DIVORCED PARENTS
If two or more plans cover a dependent child of divorced or separated parents, benefits are to be determined in the following order:
24 | Page
1. The plan of the parent who has custody of the child is primary.
2. If the parent with custody of a dependent child remarries, that parent’s plan is primary. The step-parent’s plan is secondary
and the plan covering the parent without custody is third.
3. If the specific decree of the court states one parent is responsible for the health care of the child, the benefits of that
parent’s plan are determined first. You must provide the appropriate plan with a copy of the portion of the court order
showing responsibility for health care expenses of the child.
SECTION VI - TRANSGENDER INCLUSIVE HEALTH BENEFITS COVERAGE
WHAT’S COVERED, OTHER SERVICES? (AFFIRMATIVELY COVERING TRANSGENDER-RELATED SERVICES,
AS WITH OTHER SERVICES.)
New York City Health Benefits Program covers medically necessary treatments and procedures, such as those defined by the World
Professional Association for Transgender Health's Standards of Care for Gender Identity Disorders (www.wpath.org) to the same
extent they are covered for illness, injury and other health conditions.
GENDER TRANSITION
All of the health plans offered through the New York City Health Benefits Program provide benefits for covered services associated
with gender transition when ordered by a health professional. The treatment plan must conform to World Professional Association
for Transgender Health’s standards.
• Psychotherapy – See applicable health plan’s Summary of Benefits and Coverage (SBC) mental health and substance abuse
benefit section for coverage details. For Medicare plans, please contact the applicable health plan directly.
• Pre- and post-surgical hormone therapy – If you selected a health plan optional prescription drug rider, see applicable
health plan’s Summary of Benefits and Coverage (SBC) pharmacy benefit section for coverage details. If you have
prescription drug coverage through your union, contact their pharmacy benefits manager directly. For Medicare plans,
please contact the applicable health plan directly.
• Gender-affirmation surgery/Sex reassignment surgery/ies. See applicable health plan’s Summary of Benefits and Coverage
(SBC) hospital/physician benefit section for coverage details. Surgery must be performed by a qualified provider. You or
your physician must pre-certify the surgery with your selected health plan. If you do not, the surgery may not be covered.
For Medicare plans, please contact the applicable health plan directly.
There is no payroll/pension deduction for basic coverage under some of the health plans offered through the City Health Benefits
Program, but others require a deduction. Additional benefits (e.g., prescription drug coverage) may also be available through an
optional rider with a payroll/pension deduction. Some plans require copayments for certain services. Some plans require you to pay
a yearly deductible and coinsurance before the plans will reimburse you for the use of non-participating providers, so you must
consider the out-of-pocket cost. Please refer to the Section VII – Summary of Health Plans, the applicable health plan’s Summary of
Benefits and Coverage (SBC) available on the Health Benefits Program Web site at nyc.gov/hbp
and the applicable health plan’s
website for more cost information.
SECTION VII - IN-VITRO FERTILIZATION (IVF) AND FERTILITY PRESERVATION
IN-VITRO FERTILIZATION (IVF) AND FERTILITY PRESERVATION HEALTH BENEFITS COVERAGE FOR
EMPLOYEES AND NON-MEDICARE RETIREES AND THEIR DEPENDENTS
WHO IS ELIGIBLE FOR IVF COVERAGE?
Employees and non-Medicare retirees and their dependents covered by the New York City Health Benefits Program seeking IVF
coverage must meet the coverage provisions under applicable New York State Insurance Laws and regulations, and guidance issued
25 | Page
by the New York State Department of Financial Services. Individuals may be eligible for IVF coverage if they are diagnosed with
infertility, which is defined as a disease or condition characterized by the incapacity to impregnate another person or to conceive,
due to the failure to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse or therapeutic donor
insemination, or after six months of regular unprotected sexual intercourse or therapeutic donor insemination for a female 35 years
of age or older. An individual may also be eligible for IVF coverage if they are unable to conceive due to their sexual orientation or
gender identity.
Earlier evaluation and treatment may be warranted based on an individual’s medical history or physical findings.
WHAT’S COVERED, OTHER SERVICES?
New York City Health Benefits Program covers three cycles of IVF, including all treatment that starts when preparatory medications
are administered for ovarian stimulation for oocyte retrieval with the intent of undergoing IVF using a fresh embryo transfer or
medications are administered for endometrial preparation with the intent of undergoing IVF using a frozen embryo transfer.
Costs associated with the fertilization of a donor oocyte and/or with the use of donor sperm for an employee, pre-Medicare retiree,
or dependent are covered, including preparation of the oocyte/sperm, fertilization and culture of embryos, genetic testing of
embryos (if medically necessary), cryopreservation of embryos/sperm, thawing of embryos/sperm, and preparation of an embryo
for transfer. However, treatments/procedures on any individual who is not an employee, non-Medicare retiree, or dependent
enrolled in City Health benefits are not covered. This includes the costs of any treatment associated with oocyte retrieval from a
donor, sperm donation, and the costs of embryo transfer to a surrogate/gestational carrier. Costs associated with procurement of
donor oocytes/sperm/embryo and gestational carrier/surrogate compensation are also not covered.
Any treatments completed prior to July 1, 2020 will not count toward the IVF three-cycle per lifetime limit.
Medications, including prescription drugs, are covered under the IVF coverage. Injectable medications used to treat IVF are available
through the PICA Program. Please refer to the PICA Program under Section VII – Summary of Health Plans.
New York City Health Benefits Program shall provide coverage for standard fertility preservation services for individuals when a
medical treatment will directly or indirectly result in “iatrogenic infertility,” which is an impairment of fertility by surgery, radiation,
chemotherapy, or other medical treatment affecting reproductive organs or processes.
Age restrictions are not permitted for any covered infertility services.
There is no payroll deduction for basic coverage under some of the health plans offered through the City Health Benefits Program,
but others require a deduction. Additional benefits (e.g., prescription drug coverage) may also be available through an optional rider
with a payroll deduction or a union welfare fund. Some plans, including the PICA Program, require copayments for certain services.
Some plans require you to pay a yearly deductible and coinsurance before the plans will reimburse you for services, so you must
consider the out-of-pocket cost. Please refer to Section IX – Summary of Health Plans, the applicable health plan’s Summary of
Benefits and Coverage (SBC) available on the Health Benefits Program Web site at nyc.gov/hbp
and the applicable health plan’s
website for more cost information.
SECTION VIII – ANTIRETROVIRAL PRE-EXPOSURE PROPHYLAXIZ (“PrEP”), EFFECTIVE JULY 1, 2020
ANTIRETROVIRAL PRE-EXPOSURE PROPHYLAXIZ (“PREP”) HEALTH BENEFITS COVERAGE TO REDUCE THE
RISK OF CONTRACTING HUMAN IMMUNODEFICIENCY VIRUS (“HIV) INFECTION FOR EMPLOYEES AND
NON-MEDICARE RETIREES AND THEIR DEPENDENTS, EFFECTIVE JULY 1, 2020
WHO IS ELIGIBLE FOR PrEP COVERAGE?
Employees and non-Medicare retirees and their dependents covered by non-grandfathered health plans, as defined in Section IX, of
the New York City Health Benefits Program.
26 | Page
WHAT’S COVERED, OTHER SERVICES?
New York City Health Benefits Program shall cover the cost of health care services and medicines for the detection and prevention of
HIV, including screenings and PrEP.
Coverage for PrEP for the prevention of HIV infection and coverage for screening for HIV infection shall be provided with no cost-
sharing, including copays, coinsurance, or deductibles.
There is no payroll deduction for basic coverage under some of the non-grandfathered health plans offered through the City Health
Benefits Program, but others require a deduction. Please refer to Section IX – Summary of Health Plans, the applicable non-
grandfathered health plan’s Summary of Benefits and Coverage (SBC) available on the Health Benefits Program Web site at
nyc.gov/hbp
and the applicable health plan’s website for more cost information.
SECTION IX – SUMMARY OF HEALTH PLANS
A "non-grandfathered health plan" must comply with certain consumer protections under the Affordable Care Act and cover certain
in-network preventive services with $0 co-payments to the enrolled participants, such as those listed below:
– Routine physicals
– Immunizations
– Colonoscopies
– Mammograms
– Birth control prescriptions and other preventive prescriptions
For a complete list of preventive services and medications, please contact the applicable health plan.
Effective July 1, 2020, the Blue Access Anthem Gated EPO offered to City employees through the City of New York Health Benefits
Program is a “non-grandfathered health plan” under the Affordable Care Act.
Effective July 1, 2017, the HIP HMO Plan offered to City employees through the City of New York Health Benefits Program is a “non-
grandfathered health plan” under the Affordable Care Act.
Effective July 1, 2016, the GHI-Comprehensive Benefits Program/Anthem Blue Cross Blue Shield Plan (GHI-CBP) offered to City
employees through the City of New York Health Benefits Program is a “non-grandfathered health plan” under the Affordable Care
Act.
Effective July 1, 2016, the DC 37 Med-Team offered to DC 37 City employees through the City of New York Health Benefits Program
is a “non-grandfathered health plan” under the Affordable Care Act.
Effective January 1, 2016, the MetroPlus Gold plan offered to City employees through the City of New York Health Benefits Program
is a “non-grandfathered health plan” under the Affordable Care Act.
The City of New York believes that all of the other health plans currently, as of July 2017, offered as health benefits coverage to City
employees through the City of New York Health Benefits Program are “grandfathered health plans” under the Affordable Care Act.
As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in
effect when that law was enacted. Being a grandfathered health plan means that your health plan coverage may not include certain
consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of
preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer
protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might
cause a plan to change from grandfathered health plan status can be directed, in writing only, to:
City of New York Health Benefits Program
22 Cortlandt Street, 12th Floor
New York, NY 10007
Attention: Grandfathered Plan Status
You may also contact the U.S. Department of Health and Human Services at www.healthreform.gov
27 | Page
CHOOSING A HEALTH PLAN
Contact the health plans in which you are interested for benefits packages and provider directories. Telephone numbers, addresses
and web sites are listed at the beginning of each plan description. To select a health plan that best meets your needs, you should
consider at least four factors:
Coverage - The services covered by the plans differ. For example, some provide preventive services while others do not cover
them at all; some plans cover routine podiatric (foot) care, while others do not.
Choice of Doctor - Some plans provide partial reimbursement when non-participating providers are used. Other plans only pay
for, or allow the use of, participating providers.
Convenience of Access - Certain plans may have participating providers or centers that are more convenient to your home or
workplace. You should consider the location of physicians’ offices and hospital affiliations.
Cost - There is no cost for basic coverage under some of the health plans offered through the City Health Benefits Program,
but others require a payroll deduction. Additional benefits (e.g., prescription drug coverage) may be available through
an Optional Rider. These costs are compared on the rates charts which are available on the Health Benefits Program Web site at
nyc.gov/hbp. Some plans require copayments for certain services. Some plans require you to pay a yearly deductible and
coinsurance before the plans will reimburse you for the use of non-participating providers. If a plan does not cover certain types
of services that you expect to use, you must also consider the out-of-pocket cost of these services. The plan you have chosen will
send you information regarding your health benefits coverage when you enroll.
28 | Page
GLOSSARY OF IMPORTANT TERMS
PLAN TYPE
EXCLUSIVE PROVIDER ORGANIZATION (EPO) Members can see any provider in the EPO network, which contains family
and general practitioners as well as specialists in all areas of medicine. There is no need to choose a primary care physician
and no referrals are necessary to see a specialist. An EPO provides members with a local, national and worldwide network
of providers. There are no claim forms to file and members will usually never have to pay more than the copayment for
covered services. There is no out-of-network coverage.
POINT-OF-SERVICE (POS) plans offer the freedom to use either a network provider or an out-of network provider for
medical and hospital care. If the subscriber uses a network provider, health care delivery resembles that of a traditional
HMO, with prepaid comprehensive coverage and little out-of-pocket costs for services. When the subscriber uses an out-of-
network provider, health care delivery resembles that of an indemnity insurance product, with less comprehensive
coverage and subject to deductibles and/or coinsurance.
PARTICIPATING PROVIDER ORGANIZATION (PPO)/INDEMNITY PLANS offer the freedom to use either a network
provider or an out-of-network provider for medical and hospital care. Participating Provider Organization (PPO)/Indemnity
plans contract with health care providers who agree to accept a negotiated lower payment from the health plan, with
copayments from the subscribers, as payment in full for medical services. When the subscriber uses a non-participating
provider, the subscriber is subject to deductibles and/or coinsurance.
A HEALTH MAINTENANCE ORGANIZATION (HMO) is a system of health care that provides managed, pre-paid hospital
and medical services to its members. An HMO member chooses a Primary Care Physician (PCP) from within the HMO
network, and the PCP manages all medical services, provides referrals, and is responsible for non-emergency admissions.
Individuals and/or families who choose to join an HMO can receive health care at little or no out-of-pocket cost, provided
they use the HMO’s doctors and facilities. Because the HMO provides all necessary services, there are usually no
deductibles to meet or claim forms to file. In most plans, if a physician outside of the health plan is used without a referral
from the PCP, the patient is responsible for all bills incurred.
MEDICARE ADVANTAGE PLANS replace both traditional Medicare and a Medicare supplemental plan with a single
integrated program administered by an insurer approved by Medicare. A Plan must follow Medicare rules and provide all
benefits provided by Medicare.
MEDICARE SUPPLEMENTAL PLANS allow for the use of any provider and reimburses the enrollee who may be subject to
Medicare or plan deductibles and coinsurance.
MEDICARE HMO PLANS are those in which medical and hospital care is only provided by the HMO. Any services, other
than emergency services, that are received outside the HMO, that have not been authorized by the HMO, will not be
covered by either the HMO or Medicare. Any cost incurred would be the responsibility of the enrollee.
OTHER TERMS
COPAYMENTS are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the
service.
COINSURANCE is your share of the costs of a covered service, calculated as a percent of the allowed amount for the
service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of
20% would be $200. This may change if you haven’t met your deductible. The amount the plan pays for covered services is
based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay
the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is
$1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-
network providers by charging you lower deductibles, copayments and coinsurance amounts.
DEDUCTIBLE is the amount you are responsible for before the Health Plan begins to pay for covered services.
29 | Page
The ALLOWED CHARGE is the amount the health plan will reimburse you for covered services rendered by non-
participating Providers.
BALANCE BILLING is billing a member or other responsible party for the difference between the insurer's payment and the
actual charge.
IN-NETWORK PROVIDER/SUPPLIER is a healthcare provider such as a physician, skilled nursing facility, home health
agency, laboratory etc., who has an agreement with health plan to provide covered services to members.
NON-PARTICIPATING PROVIDER is a healthcare provider such as a physician, skilled nursing facility, home health agency,
laboratory etc., who does not have an agreement with the health plan to provide covered services to members.
OUT-OF-NETWORK BENEFITS are generally subject to a deductible and coinsurance and, therefore, have higher out-of-
pocket costs. Depending on your contract, out-of-network services may not be covered. Please refer to your contract for
specific benefit coverage.
PARTICIPATING PROVIDER/NETWORK PROVIDER is a participating provider is a physician or other Provider who has
agreed to accept the health plan's scheduled or negotiated rates as payment in full or covered services (except for any
applicable copayments, coinsurance or deductibles). A Participating Provider is a member of the health plan network of
Participating Providers applicable to your Certificate. Therefore, they are sometimes referred to as "Network Providers."
Payment is made directly to a Participating Provider. Please consult your health plan directory to search for Participating
Providers.
30 | Page
HEALTH PLANS & PICA PROGRAM FOR EMPLOYEES AND NON-MEDICARE RETIREES
The following health plans are offered by the Health Benefits Program for employees and non-Medicare retirees and their
dependents:
Health Plan
Plan Type
Phone Number
Website Address
Aetna EPO
EPO
(800) 445-8742
www.Aetna.com
CIGNA HealthCare
HMO
(800) 244-6224
www.cigna.com
DC 37 Med-Team (DC 37 members only)
PPO
(800) 624-2414
www.emblemhealth.com/city
Anthem EPO
EPO
(800) 767-8672
www.anthem.com/nyc
Anthem Blue Access Gated EPO
EPO
(833) 924-1055
www.anthem.com/nyc
GHI-CBP/Anthem Blue Cross Blue Shield
GHI Emblem Health
Anthem Blue Cross Blue Shield
PPO
(800) 624-2414
(800) 433-9592
www.emblemhealth.com/city
www.anthem.com/nyc
GHI HMO
HMO
(877) 244-4466
www.emblemhealth.com/city
HIP HMO Preferred
HMO
(800) 447-6929
www.emblemhealth.com/city
HIP Prime POS
POS
(800) 447-6929
www.emblemhealth.com/city
MetroPlusHealth Gold
HMO
(800) 475-3795
www.metroplus.org
Vytra Health Plan
HMO
(800) 448-2527
www.emblemhealth.com/city
31 | Page
AETNA EPO
The Aetna Open Access Elect Choice (EPO) Plan lets you visit any doctor in the Aetna EPO network.
You do not have to choose a primary care physician (PCP) and there are no referrals necessary to
visit any Aetna EPO provider you choose.
At a Glance
Plan Type
EPO
Geographic Service Area National
Does this plan use a network of providers?
Yes. Visit the Web site www.Aetna.com or call 1-800-445-8742 for a list of participating
providers.
Do I need a referral to see a specialist?
No
Contact Information
Aetna
100 Park Avenue, 12
th
Floor
New York, NY 10017
Attn: City of New York Department
1-800-445-8742 (Representatives are available Monday through Friday, 8:00 a.m. to 6:00 p.m.)
Web Site
www.Aetna.com
Plan Features
Cost
What is the overall deductible for this plan?
• $0
What are the costs when you visit a health
care provider’s office or clinic?
• Primary care visit to treat an injury or illness: $15 co-pay/visit
• Specialist visit: $20 co-pay/visit
• Other practitioner office visit Chiropractor: $20 co-pay/visit
•
Preventive care/screening/immunization: No charge
What are the costs if you have a test?
Diagnostic test (x-ray, blood work):
• Laboratory No charge
• X-Ray:$20 co-pay
• Imaging (CT/PET scans, MRIs): $20 co-pay
What are the costs if you have outpatient
surgery?
Facility fee (e.g., ambulatory surgery center): $75 co-pay/visit
No charge to non-participating provider
Physician/surgeon fees: No charge
Not covered for non-participating provider
What are the costs if you need immediate
medical attention?
Emergency room services: $75 co-pay/visit
$75 co-pay to non-participating provider
Emergency medical transportation: No charge
No charge for non-participating provider
What are the costs if you have a hospital
stay?
Facility fee (e.g., hospital room): $300 per continuous stay
Not covered for non-participating provider
Physician/surgeon fee: No charge
Not covered for non-participating provider
What are the costs if you are pregnant?
Prenatal and postnatal care: $15 co-pay first visit only
Delivery and all inpatient services: $300 per continuous stay
Limited to 48 hours for natural delivery and 96 hours for caesarean delivery.
Prior approval required.
Not covered for non-participating provider
32 | Page
WHAT ARE THE COSTS IF YOU HAVE MENTAL HEALTH, BEHAVIORAL HEALTH, OR SUBSTANCE ABUSE NEEDS?
Service
Cost
Mental/Behavioral health
Outpatient services
• $15 co-pay/visit
•
Not covered for non-participating provider
Mental/Behavioral health
Inpatient services
• $300 co-pay per continuous stay
•
Not covered for non-participating provider
Substance abuse
Outpatient services
• $15 co-pay/visit
• Not covered for non-participating provider
Substance abuse
Inpatient services
• $300 per continuous stay
• Not covered for non-participating provider
WHAT ARE THE COSTS IF YOU NEED HELP RECOVERING OR HAVE OTHER SPECIAL HEALTH NEEDS?
Service
Cost
Home health care
• No charge
•
Not covered for non-participating provider
Skilled nursing care
• $300 co-pay per stay
• Not covered for non-participating provider
Durable medical equipment (DME)
• No charge
• Not covered for non-participating provider
Hospice service Inpatient
• $300 co-pay continuous stay
•
Not covered for non-participating provider
Hospice service Outpatient
• No charge
•
Not covered for non-participating provider
OPTIONAL RIDER
WHAT IS THE COST IF YOU NEED DRUGS TO TREAT YOUR ILLNESS OR CONDITION?
Retail
Mail Order
Generic drugs
$10 co-pay/30 day supply
$20 copay/90 day supply
Preferred brand drugs
30% coinsurance/30 day supply
30% coinsurance/90 day supply
Non-preferred brand drugs
50% coinsurance/30 day supply
50% coinsurance/90 day supply
Specialty drugs*
Generic drugs
$10 co-pay/30 day supply
$10 co-pay/30 day supply
Preferred brand drugs
30% coinsurance /30 day supply
30% coinsurance /30 day supply
Non-preferred brand drugs
50% coinsurance/30 day supply
50% coinsurance/90 day supply
Covers up to 30-day supply (retail prescription): 31-90 day supply (mail order prescription). Includes contraceptive drugs and devices obtainable from a pharmacy.
No charge for formulary generic FDA-approved Women’s contraceptives in-network. Precertification required. Step therapy required.
*Aetna Specialty CareRx-First Prescription must be filled at a participating retail pharmacy or Aetna Specialty Pharmacy. Subsequent fills must be through Aetna
Specialty Pharmacy.
Please refer to the Summary of Benefits and Coverage (SBC) for additional information and to see what this plan covers and any
cost-sharing responsibilities.
33 | Page
ANTHEM EPO
Non-Medicare EPO
Anthem’s EPO, an Exclusive Provider Organization, provides all active and non-Medicare retirees
access to the Blue Cross and Blue Shield Association
TM
BlueCard® PPO Network. This network is very
large with more than 784,000 provider locations and more than 5,800 hospitals nationwide. That’s
more than 94 percent of hospitals and 84 percent of physicians in the nation. Plus, you do not need
to choose a primary care physician and there are NO REFERRALS NECESSARY to see a specialist for
covered services and no claim forms to complete.
At a Glance
Plan Type:
EPO
Geographic Service Area
National
Does this plan use a network of providers?
Yes. Visit the Web or call for a list of participating providers.
Do I need a referral to see a specialist?
No
Contact Information
Anthem Blue Cross and Blue Shield
City of New York - Dedicated Service Center
P.O. Box 1407
Church Street Station
New York, NY 10008
1-800-767-8672 (Representatives are available Monday through Friday, 8:30 a.m. to 5:00 p.m.)
Web Site
www.anthem.com/nyc
Plan Features
Cost
What is the overall deductible for this plan?
$250/$625 per hospital admission/ maximum per calendar year per contract
What are the costs when you visit a health
care provider’s office or clinic?
• Primary care visit to treat an injury or illness: $15 co-pay
• Specialist visit: $15 co-pay
Other practitioner office visit Chiropractor: $15 co-pay
Anthem’s network provider must obtain authorization for clinical/medical necessity for in-
network services. Anthem’s network providers cannot bill members for covered services.
• Preventive care/screening/immunization: No charge
• Urgent Care Center: $15 co-pay
What are the costs if you have a test?
Diagnostic test (x-ray, blood work): No charge
Imaging (CT/PET scans, MRIs): No charge
What are the costs if you have outpatient
surgery?
Facility fee (e.g., ambulatory surgery center): No charge
You are responsible for obtaining precertification from Anthem’s Medical Management
Program for these services provided in-network.
For ambulatory surgery, precertification is required for reconstructive surgery, outpatient
transplants and opthalmological or eye related procedures. Precertification is also required
for cosmetic surgery, an excluded benefit except when medically necessary.
Physician/surgeon fees: No charge
What are the costs if you need immediate
medical attention?
Emergency room services: $35 co-pay/visit
$35 co-pay to non-participating provider (waived if admitted)
Emergency medical transportation: No charge
Not covered for non-participating provider
What are the costs if you have a hospital
stay?
Facility fee (e.g., hospital room): $250/$625 per admission/maximum per calendar year per
contract
Precertification from Anthem’s Medical Management Program is required. You will be
responsible for penalties applied if no precertification is obtained.
Physician/surgeon fee: No charge
What are the costs if you are pregnant?
Prenatal and postnatal care: No charge
Not covered for non-participating provider
Facility fee (e.g., hospital room): $250/$625 per admission/maximum per calendar year per
contract
34 | Page
You must obtain precertification from Anthem’s Medical Management Program for these
services. You will be responsible for penalties applied if no precertification is obtained.
WHAT ARE THE COSTS IF YOU HAVE MENTAL HEALTH, BEHAVIORAL HEALTH, OR SUBSTANCE ABUSE NEEDS?
Service
Cost
Mental/Behavioral health
Outpatient services
• $15 co-pay
Precertification is required by Anthem’s Behavioral Healthcare Management Program.
Mental/Behavioral health
Inpatient services
• Facility fee (e.g., hospital room): $250 / $625 per admission/maximum per calendar year
per contract
Precertification is required by Anthem’s Behavioral Healthcare Management Program.
Substance abuse
Outpatient services
• $15 co-pay
• Not covered for non-participating provider
Precertification is required by Anthem’s Behavioral Healthcare Management Program.
Substance abuse
Inpatient services
• Facility fee (e.g., hospital room): $250/$625 per admission/maximum per calendar year
per contract
• Not covered for non-participating provider
Precertification is required by Anthem’s Behavioral Healthcare Management Program.
WHAT ARE THE COSTS IF YOU NEED HELP RECOVERING OR HAVE OTHER SPECIAL HEALTH NEEDS?
Service
Cost
Home health care
• No charge
• Not covered for non-participating provider
• Coverage limited to 200 visits/year
Rehabilitation service
• $15 co-pay
• Not covered for non-participating provider
• Coverage is limited to 30 visits annual max.
• Pre-certified in network providers cannot bill members beyond in-network co-payment
for covered services.
Habilitation service
•
$15 co-pay
• Not covered for non-participating provider
Skilled nursing care
• No charge
• Not covered for non-participating provider
• Coverage is up to 60 days per calendar year.
•
You will be responsible for penalties applied if no precertification is obtained.
Durable medical equipment (DME)
• No charge
• Not covered
• For services rendered from an Anthem network provider, the provider must pre-certify
in-network services.
Hospice service
• No charge - Coverage limited to 210 days
OPTIONAL RIDER
What is the cost if you need drugs to treat your illness or condition?
Retail
Mail Order
Generic drugs*
$10 copay/prescription
One copay for each 30 day supply
Covers up to a 30-day supply (retail prescription);
90 day supply (mail order prescription). After Anthem Pharmacy
Management has paid $3,000 in drugs expenses, all drugs have 50%
coinsurance for each benefit year.
Preferred brand drugs
$25 copay/prescription
One copay for each 30 day supply
Covers up to a 30-day supply (retail prescription);
90 day supply (mail order prescription). After Anthem Pharmacy
Management has paid $3,000 in drugs expenses, all drugs have 50%
coinsurance for each benefit year.
Non-preferred brand drugs
$50 copay/prescription
One copay for each 30 day supply
Covers up to a 30-day supply (retail prescription);
90 day supply (mail order prescription). ). After Anthem Pharmacy
Management has paid $3,000 in drugs expenses, all drugs have 50%
coinsurance for each benefit year.
35 | Page
Specialty drugs
Not Covered by Anthem Blue
Cross & Blue Shield
Not Covered by Anthem Blue Cross & Blue Shield
Please refer to the Summary of Benefits and Coverage (SBC) for additional information and to see what this plan covers and any
cost-sharing responsibilities.
36 | Page
ANTHEM BLUE ACCESS GATED EPO
This program features a full range of in-network benefits with low out-of-pocket costs, no claim
forms, and access to quality health care for you and your family. With Anthem’s Blue Access Gated
EPO, every family member can choose his or her own Primary Care Physician (PCP).
At a Glance
Plan Type:
Anthem Blue Access Gated EPO
Geographic Service Area
Anthem’s service area includes the 28 county NY service area, the 7 bordering New Jersey
counties of Hudson, Union, Sussex, Passaic, Monmouth, Middlesex and Bergen and the 2
bordering Connecticut counties of Fairfield and Litchfield.
Does this plan use a network of providers?
Yes. Visit the website or call for a list of in-network participating providers.
Do I need a referral to see a specialist?
Yes, written approval is required by your primary care physician before you can see a specialist.
Contact Information
Anthem Blue Cross and Blue Shield
City of New York - Dedicated Service Center
P.O. Box 1407
Church Street Station
New York, NY 10008
1-833-924-1055 (Representatives will be available Monday through Friday, 8:30 a.m. to 5:00
p.m.)
Web Site
www.anthem.com/nyc
Plan Features
Cost
What is the Medical Out-of-Pocket
Maximum?
• $3,000 person/$7,500 family (all in network medical ONLY no RX) per calendar year
What are the costs when you visit a health
care provider’s office or clinic?
• Primary care visit to treat an injury or illness: $15 co-pay
• Specialist visit: $15 co-pay
• Other practitioner office visit: $15 co-pay for chiropractor and no charge for acupuncture
• Preventive care/screening/immunization: No charge
What are the costs if you have a test?
Diagnostic test (x-ray, blood work): No charge
Imaging (CT/PET scans, MRIs): No charge
Pre certify in-network services
What are the costs if you have outpatient
surgery?
Facility fee (e.g., ambulatory surgery center): No charge
Not covered for non-participating provider
Prior approval is required for cosmetic/reconstructive procedures, outpatient transplants and
ophthalmological or eye-related procedures.
Physician/surgeon fees: No charge
Not covered for non-participating provider
What are the costs if you need immediate
medical attention?
Emergency room services: $35 co-pay/visit
$35 co-pay to non-participating provider
Co-pay waived if admitted within 24 hours
Emergency medical transportation: No charge
No charge to non-participating provider
What are the costs if you have a hospital
stay?
Facility fee (e.g., hospital room): $300 copay per admission
Not covered non-participating provider
Prior approval required
Physician/surgeon fee: No charge
Not covered for non-participating provider
Urgent care: $15 co-pay
Not covered for non-participating provider
Non-Medicare
Blue Access Gated EPO
37 | Page
WHAT ARE THE COSTS IF YOU HAVE MENTAL HEALTH, BEHAVIORAL HEALTH, OR SUBSTANCE ABUSE NEEDS?
Service
Cost
Mental/Behavioral health
Outpatient services
• $15 co-pay
•
Prior approval required
Mental/Behavioral health
Inpatient services
• $300 copay per admission
• Prior approval required
•
Not covered for non-participating provider
Substance abuse
Outpatient services
• $15 co-pay
• Prior approval required
• Not covered for non-participating provider
Substance abuse
Inpatient services
•
$300 copay per admission
• Prior approval required
• Not covered for non-participating provider
What are the costs if you need help recovering or have other special health needs?
Service
Cost
Home health care
• No charge
• Coverage limited to 200 visits/year
• Not covered for non-participating provider
Skilled nursing care
• No charge
• (limited to 60 visits/year)
• Prior approval required
• Not covered for non-participating provider
Durable medical equipment (DME)
• 50% coinsurance - Prior approval required
•
Not covered for non-participating provider
Hospice service
• No charge - Unlimited days per lifetime
•
Not covered for non-participating provider
OPTIONAL RIDER
What is the cost if you need drugs to treat your illness or condition?
Retail
Mail Order
Generic drugs*
$10 co-pay/30 day supply
After Anthem Pharmacy management has paid $3,000 in drug
expenses, all drugs have 50% coinsurance for each benefit year.
Preferred brand drugs
$25 co-pay/30 day supply
After Anthem Pharmacy management has paid $3,000 in drug
expenses, all drugs have 50% coinsurance for each benefit year.
Non-preferred brand drugs
$50 co-pay/30 day supply
After Anthem Pharmacy management has paid $3,000 in drug
expenses, all drugs have 50% coinsurance for each benefit year
Specialty drugs
Not covered
Not covered
*Must be dispensed by a Participating Pharmacy.
Please refer to the Summary of Benefits and Coverage (SBC) for additional information and to see what this plan covers and any
cost-sharing responsibilities.
38 | Page
CIGNA
Cigna’s group of highly qualified doctors who meet our standards of care is one of the largest in the
New York and New Jersey area with over 30,000 personal doctors and over 115,000 specialists.
You’re free to choose your own doctors, and each member of your family can elect his or her own
Primary Care Physician from our network. With the Cigna HealthCare Open Access Plus In-Network
plan you may visit any doctor who participates in the Cigna HealthCare Open Access Plus network.
At a Glance
Plan Type:
HMO Open Access
Geographic Service Area
Cigna HealthCare provides coverage to NYC employees and non-Medicare eligible retirees
living in New York, New Jersey, Connecticut, Los Angeles, CA, and Phoenix, AZ.
Does this plan use a network of providers?
Yes. Visit the website at www.myCigna.com or call 1-800-CIGNA24 (1-800-564-7642) for a list
of participating providers.
Do I need a referral to see a specialist?
No, you don’t need a referral to see a specialist.
Contact Information
Cigna HealthCare
Attn: Dan Moskowitz
499 Washington Blvd, 2
nd
Floor
Jersey City, NJ 07405
1-800-CIGNA24 (1-800-564-7642). Please inform the representatives that you are calling for
information on account number 3211464 (The City of New York).
Web Site
www.cigna.com
Plan Features
Cost
What is the overall deductible for this plan?
• $0
What are the costs when you visit a health
care provider’s office or clinic?
•
Primary care visit to treat an injury or illness: $15
• Specialist visit: $25
• Other practitioner office visit Chiropractor: $25
• Preventive care/screening/immunization: No charge
What are the costs if you have a test?
Diagnostic test (x-ray, blood work): No charge
Imaging (CT/PET scans, MRIs): No charge
What are the costs if you have outpatient
surgery?
Facility fee (e.g., ambulatory surgery center): No charge
Not covered for non-participating provider
Physician/surgeon fees: No charge
Not covered for non-participating provider
What are the costs if you need immediate
medical attention?
Emergency room services: $50 co-pay/visit
$50 co-pay/visit for non-participating provider
Per visit is waived if admitted
Emergency medical transportation: No charge
No charge for non-participating provider
What are the costs if you have a hospital stay?
Facility fee (e.g., hospital room): $150 co-pay/admission
Not covered for non-
participating provider
Physician/surgeon fee: No charge
Not covered for non-participating provider
What are the costs if you are pregnant?
Prenatal and postnatal care: No charge
Not covered for non-participating provider
Delivery and all inpatient services: $150 co-pay/admission
Limited to 48 hours for natural delivery and 96 hours for caesarean delivery.
Prior approval required.
39 | Page
WHAT ARE THE COSTS IF YOU HAVE MENTAL HEALTH, BEHAVIORAL HEALTH, OR SUBSTANCE ABUSE NEEDS?
Service
Cost
Mental/Behavioral health
Outpatient services
• $25 co-pay/visit
•
Not covered for non-participating provider
Mental/Behavioral health
Inpatient services
• $150 co-pay/admission
•
Not covered for non-participating provider
Substance abuse
Outpatient services
• $25 co-pay/visit
• Not covered for non-participating provider
Substance abuse
Inpatient services
• $150 co-pay/admission
• Not covered for non-participating provider
WHAT ARE THE COSTS IF YOU NEED HELP RECOVERING OR HAVE OTHER SPECIAL HEALTH NEEDS?
Service
Cost
Home health care
• No charge
• Not covered for non-participating provider
Skilled nursing care
• No charge
• Limited to 60 days annual max
• Not covered for non-participating provider
Durable medical equipment (DME)
• No charge
• Not covered for non-participating provider
Hospice service
• No charge
•
Not covered for non-participating provider
OPTIONAL RIDER
WHAT IS THE COST IF YOU NEED DRUGS TO TREAT YOUR ILLNESS OR CONDITION?
Retail
Mail Order
Generic drugs*
$5 co-pay/30 day supply
$10 copay/90 day supply
Preferred brand drugs*
$20 co-pay/30 day supply
$40 co-pay/90 day supply
Non-preferred brand drugs*
$50 co-pay/30 day supply
$100 co-pay/90 day supply
*Must be dispensed by a Participating Pharmacy.
Please refer to the Summary of Benefits and Coverage (SBC) for additional information and to see what this plan covers and any
cost-sharing responsibilities.
40 | Page
DC 37 MED-TEAM
The DC 37 Med-Team health insurance plan is offered to DC 37 Med-Team active employees and non-
Medicare eligible retirees living in the states of New York and New Jersey. You may choose in-network
or out-of-network providers. There is no payroll deduction for this plan.
SOME ADVANTAGES OF THE DC 37 MED-TEAM HEALTH INSURANCE PLAN:
• You can get care with participating providers using the Bridge network, (This includes Qualcare, as well as access to the FHN
network).
• You can receive benefits for covered services even when you choose out-of-network doctors. Remember that your out-of-
pocket costs are lowest when you receive care in-network.
• You never need a physician referral to see a specialist.
• No copays are required for in-network office visits and diagnostic tests like X-rays or lab work for unmarried dependent
children through the end of the month in which they reach age 26.
• There are educational programs for eligible members to learn to manage chronic conditions such as asthma and diabetes.
• Through the personalized my GHI section of GHI’s website, www.emblemhealth.com/city, you can find a doctor, check you
benefits and claim status, order ID cards, keep an online personal health record and more.
• There are discounts on health care products and services and the latest news on consumer health and medical issues on
GHI’s website www.emblemhealth.com/city.
• Vision Plan- exams/eyeglasses
Hospitals: The DC 37 Med-Team Program also provides in-network benefits utilizing the Bridge network (this includes QualCare, as
well as access to the FHN network).
At a Glance
Plan Type:
PPO
Geographic Service Area
The DC 37 Med-Team health insurance plan is offered to DC 37 Med-Team active employees
and non-Medicare eligible retirees.
Does this plan use a network of providers?
Yes. Visit the Web site www.emblemhealth.com/city or call 1-800-624-2414 for a list of
participating providers.
Do I need a referral to see a specialist?
No
Contact Information
D.C. 37 Med Team
55 Water Street - 23
rd
Floor
New York, NY 10041
1-800-624-2414 (Representatives are available Monday through Friday, 8:00 a.m. to 8:00 p.m.
(Please identify yourself as a DC 37 member.)
Web Site
Emblemhealth.com/city
41 | Page
Plan Features
Cost
What is the overall deductible for this plan?
For out-of-network providers is $1,000 individual / $3,000 family.
Does not apply to preventive care and generic drugs.
Out-of-network co-insurance and co-payment don't count toward the deductible.
What is the out-of-pocket limit on my
expenses (applies to in-network services
only)?
For 7/01/23 – 6/30/2024 – the limit is $7,150 Individual/$14,300 Family
What are the costs for preventive services?
Visit emblemhealth.com/city for a full list of
preventive services.
Preventive services are available with $0 copayments when using a participating provider.
After deductible is met 30% co-insurance when using a non-participating provider.
What are the costs when you visit a health
care provider’s office or clinic?
• Primary care visit to treat an injury or illness: $25 co-pay/visit
• Specialist visit: $25 co-pay/visit
• Other practitioner office visit Chiropractor: $25 co-pay/visit
• Preventive care/screening/immunization: No charge
• After deductible is met 30% co-insurance when using a non-participating provider.
What are the costs if you have a test?
• Diagnostic test (x-ray, blood work): $25 co-pay/visit
• Hi-tech Radiology (CT/PET scans, MRIs): $50 co-pay/visit
•
After deductible is met 30% co-insurance when using a non-participating provider.
What are the costs if you have outpatient
surgery?
Facility fee (e.g., ambulatory surgery center): $50
After deductible is met 30% co-insurance for non-
participating provider
Prior approval required
Physician/surgeon fees: $25 charge
After deductible is met S30% co-insurance for non-participating provider
What are the costs if you need immediate
medical attention?
Emergency room services: $150 co-pay/visit
After deductible is met 30% co-insurance for non-
participating provider
Emergency medical transportation: Not covered
Ground 100% UCR/air 100%
Covered at 100% of usual and customary allowance
What are the costs if you have a hospital stay?
Facility fee (e.g., hospital room): $250 copay per continuous stay
After deductible is met 30% co-insurance for non-participating provider
Prior approval required
Physician/surgeon fee: No charge
After deductible is met 30% co-insurance for non-participating provider
What are the costs if you are pregnant?
Prenatal and postnatal care: No charge
After deductible is met 30% co-insurance for non-participating provider
Delivery and all inpatient services: No charge
After deductible is met 30% co-insurance for non-participating provider
Limited to 48 hours for natural delivery and 96 hours for caesarean delivery.
Prior approval required.
WHAT ARE THE COSTS IF YOU HAVE MENTAL HEALTH, BEHAVIORAL HEALTH, OR SUBSTANCE ABUSE NEEDS?
Service
Cost
Mental/Behavioral health
Outpatient services
• $25 co-pay/visit
• After deductible is met 30% co-insurance for non-participating provider
Mental/Behavioral health
Inpatient services
• $250 per continuous stay
• After deductible is met 30% co-insurance for non-participating provider
•
Prior approval required
Substance abuse
Outpatient services
• $25 co-pay/visit
• After deductible is met 30% co-insurance for non-participating provider
Substance abuse
Inpatient services
• $250 per continuous stay
• After deductible is met 30% co-insurance for non-participating provider
•
Par only. Rehab not covered
42 | Page
WHAT ARE THE COSTS IF YOU NEED HELP RECOVERING OR HAVE OTHER SPECIAL HEALTH NEEDS?
Service
Cost
Home health care
• No charge
• After deductible is met 30%co-insurnace for non-participating provider
• Coverage limited to 200 visits/year
•
Prior approval required
Skilled nursing care
• No charge
• After deductible is met 30% co-insurance for non-participating provider
• Coverage limited to 60 days/year
•
Prior approval required
Durable medical equipment (DME)
• No charge
• Not covered for non-participating provider
• Prior approval required for over $2,000
Hospice service
• No charge
• Not covered for non-participating provider
• Coverage limited to 210 days lifetime
• Prior approval required
PRESCRIPTION DRUGS
WHAT IS THE COST IF YOU NEED DRUGS TO TREAT YOUR ILLNESS OR CONDITION?
The DC 37 Health and Security Plan provides prescription drug benefits.
Please refer to the Summary of Benefits and Coverage (SBC) for additional information and to see what this plan covers and any
cost-sharing responsibilities.
43 | Page
GHI-COMPREHENSIVE BENEFITS PLAN/ANTHEM BLUE CROSS AND BLUE SHIELD HOSPITAL PLAN (GHI-CBP)
GHI-Anthem CBP option consists of two components:
• GHI, an EmblemHealth company, offering benefits for medical/physician services, and
• Anthem Blue Cross and Blue Shield offering benefits for services provided at hospital and
out-patient facilities.
GHI Emblem Health (GHI): You have the freedom to choose any provider worldwide. You can select a
GHI participating provider and not pay any deductibles or coinsurance, or go out-of-network and still
receive coverage, subject to deductibles and coinsurance. GHI’s provider network includes all
medical specialties. When you need specialty care, you select the specialist and make the
appointment. Payment for services will be made directly to the provider - you will not have to file a
claim form when you use a GHI participating provider.
Anthem Blue Cross and Blue Shield (AnthemBCBS): 96% of the nation’s hospitals participate in the
Blue Cross and Blue Shield Association BlueCard® PPO Program network, which provides you with
access to network care across the country, it should be easy to find a participating facility in a
convenient location.
NEW IN 2020
You can now visit Memorial Sloan Kettering Cancer Center (MSK) for cancer treatment and Hospital
for Special Surgery (HSS) for orthopedic treatment, and your hospital inpatient copays will be waived
when you utilize these two nationally recognized hospitals. You must use a doctor who participates
in your GHI-CBP plan and participates with MSK or HSS. If you prefer, you can still go to any hospital
of your choice and your benefits and costs will remain the same as they are today.
At a Glance
Plan Type:
PPO
Geographic Service Area
Nationwide
Does this plan use a network of providers?
GHI: Yes. Visit the website www.emblemhealth.com/city or call 1-800-624-2414 for a list of
participating medical providers.
Anthem Blue Cross and Blue Shield: Yes. Visit the website www.anthem.com/nyc or call
1-800-433-9592 for a list of participating hospital and out-patient facilities.
Do I need a referral to see a specialist?
No
Contact Information
EmblemHealth
55 Water Street
New York, NY 10041
1-800-624-2414
Anthem Blue Cross and Blue Shield
City of New York
Dedicated Service Center
P.O. Box 1407
Church Street Station
New York, NY 10008-3598
1-800-433-9592 (Monday through Friday 8:30 a.m. to 5:30 p.m.)
Web Sites
emblemhealth.com/city
anthem.com/nyc
44 | Page
Plan Features
Cost
What is the overall medical deductible for this
plan?
GHI: In-network: $0
Out-of-network: $200 individual/$500 family
What is the out-of-pocket limit on my
expenses (applies to in-network services
only)?
GHI Medical:
For 7/01/23 – 6/30/24 the limit is $4,550 individual/$9,100 family.
AnthemBCBS Hospital:
For 7/01/23 – 6/30/24 the limit is $2,600 individual/$5,200 family.
What are the costs for preventive services?
Visit emblemhealth.com/city for a full list of
preventive services.
Preventive services are available with $0 copayments when using a participating provider.
What are the costs when you visit an
AdvantageCare Physician’s (ACPNY) office?
• ACPNY primary care visit to treat an injury or illness: $0 copay/visit
• ACPNY specialist visit: $0 copay/visit
What are the costs when you visit a health
care provider’s office?
• In-network primary care visit to treat an injury or illness: $15 copay/visit
• ACPNY: $0 copay/visit
• Non-participating provider: After deductible is met 0% coinsurance
• In-network specialist visit: $30 co-pay/visit
• Non-participating provider: After deductible is met 0% coinsurance
• In-network other practitioner office visit: $15 copay/visit
• Non-participating provider: After deductible is met 0% coinsurance
• In-network preventive care/screening/immunization: $0 copay/visit
• Non-participating provider: After deductible is met 0% coinsurance
What are the costs when you use Teladoc?
• Teladoc is an easy, convenient way to access doctors for treatment of non-emergency
conditions, including cold and flu symptoms, respiratory infections, sinus problems,
bronchitis, skin problems, and allergies.
• Your first visit is free. After that, Teladoc visits have a $10 copay.
• Visit Teladoc/Emblemhealth or call 800-835-2362 (800-Teladoc) (TTY: 711) to set up your
account. Once you register, you are just a call or click away from getting treatment.
What are the costs if you have a test?
• In-network diagnostic test (x-ray, blood work): $20 co-pay/visit
• Non-participating provider: After the deductible is met 0% co-insurance
• In-network imaging (CT/PET scans, MRIs): $50 co-pay for Preferred providers, $100 copay
for Non-preferred providers. (Pre-certification required)
• Non-participating provider: After deductible is met 0% co-insurance
What are the costs if you have outpatient
surgery?
• AnthemBCBS: Facility fee:
In-network: 20% coinsurance of allowed amount to a maximum of $200 per
person per calendar year.
Out-of-Network provider: $500 deductible per person per visit and 20%
coinsurance per person and balance billing.
• GHI: Physician/surgeon fees:
In-network: Covered
Non-participating provider: After deductible is met 0% co-insurance
You must call NYC Healthline 1-800- 521-9574 for pre-certification.
What are the costs if you need immediate
medical attention?
• AnthemBCBS: Emergency room services:
In-network: $150 copay/visit; Co-pay waived if admitted.
Out-of-network: $150 copay/visit; Co-pay waived if admitted
• GHI: Emergency medical transportation:
In-network: Not covered
Out-of-network: 100% of the 80% percentile of Fair Health
• GHI: Urgent Care:
In-network: $50 copay/visit Preferred $100 copay/visit Non-preferred
Non-participating provider: After the deductible is met 0% co-insurance
What are the costs if you have a hospital stay?
• GHI: Physician/surgeon fees:
In-network: Covered
Non-participating provider: After the deductible is met 0% co-insurance
• ANTHEM: Facility fee (e.g., hospital room):
In-network (e.g., hospital room): $300 per person up to $750 maximum individual co-
pay per calendar year.
45 | Page
Out-of-network: $500 per person up to $1,250 in a calendar year. After the individual
co-payment is met, Anthem will pay 80% of the allowed amount and you will be
charged 20% co-insurance and balance billing.
You must call NYC Healthline 1-800- 521-9574 for approval. If there is no call, claim is subject
to a penalty of $250 per day up to a maximum of $500. There has to be a gap of 90 days
between admissions before the 365 days will renew.
What are the costs if you are pregnant?
• GHI: Prenatal and postnatal care:
In-network: No charge
Out-of-Network: After the deductible is met 0% co-insurance
• GHI: Delivery and inpatient physician/surgeon services:
In-network: No charge
Out-of Network: After the deductible is met 0% co-insurance
• ANTHEM: Delivery and all inpatient services:
In-network: $300 per person up to $750 maximum deductible.
Out-of-network: $500 per person up to $1,250 maximum deductible. Doesn’t apply to
copayments.
You must call NYC Healthline 1-800- 521-9574 for approval. If there is no call, claim is subject
to a penalty of $250 per day up to a maximum of $500.
WHAT ARE THE COSTS IF YOU HAVE MENTAL HEALTH, BEHAVIORAL HEALTH, OR SUBSTANCE ABUSE NEEDS?
Service
Cost
Mental/Behavioral health
Outpatient services
• GHI: In-network: $15 co-pay/visit
Out-of-Network: After the deductible is met 0% coinsurance.
Mental/Behavioral health
Inpatient services
• GHI: In-network: $300 co-pay per admission
Out-of-Network: $500 co-pay per admission/$1,250 maximum per calendar year.
*20% to max of $2,000 per person per calendar year.
Substance abuse
Outpatient services
• GHI: In-network: $15 co-pay/visit
Out-of-network: After the deductible is met 0% coinsurance.
Substance abuse
Inpatient services
• GHI: In-network: $300 co-pay per admission
Out-of-Network: $500 co-pay per admission/ $1,250 maximum per calendar year
*20% to max of $2,000 per person per calendar year.
WHAT ARE THE COSTS IF YOU NEED HELP RECOVERING OR HAVE OTHER SPECIAL HEALTH NEEDS?
Service
Cost
Home health care
• GHI:
− In-network: No charge
− Out-of-Network: $50 deductible per episode; 20% coinsurance
− 200 visits per member per year
− Pre-certification required
Skilled nursing care
• ANTHEM:
− In-network: $300 deductible per admission, up to a maximum of $750 per person
per calendar year
− Out-of-network: $500 deductible per person per visit and 20% co-insurance per
person and balance billing.
− Coverage is limited to 90 days annual max.
Durable medical equipment (DME)
•
GHI:
− In-network: $100 deductible
− Out-of-network: $100 deductible; 50% of usual and customary charge
− Pre-certification required on items greater than $2,000
−
You must call NYC Healthline 1-800- 521-9574 for approval.
Hospice service
• ANTHEM:
− In-network: No charge
− Out-of-Network: No charge
− Coverage is limited to 210 days lifetime max.
46 | Page
OPTIONAL RIDER – PRESCRIPTION DRUGS PROVIDED THROUGH GHI-EMBLEMHEALTH
WHAT IS THE COST IF YOU NEED DRUGS TO TREAT YOUR ILLNESS OR CONDITION?
Retail
Mail Order: Smart90 Program
Generic drugs
Retail - 30 days supply - 2 fills;
20% co-insurance with min charge of $5 or
actual cost, if less.
Mandatory mail order –90 day supply; $12.50 co-pay.
Prescriptions will not be filled at retail after 2 fills. The
90 day supply can be obtained through Express Scripts
or participating Duane Reade or Walgreens.
Preferred brand drugs
Retail - 30 days supply - 2 fills;
40% co-insurance with min charge of $25
or actual cost, if less.
Mandatory mail order - 90 day supply; $50 co-pay.
Prescriptions will not be filled at retail after 2 fills.
Prior authorization is required for certain brand name
medications. The 90 day supply can be obtained
through Express Scripts or participating Duane Reade or
Walgreens.
Non-preferred brand drugs
Retail - 30 days supply - 2 fills;
50% co-insurance with min charge of $40
or actual cost if less
Mandatory mail order - 90 day supply; $75 co-pay.
Prescriptions will not be filled at retail after 2 fills. The
90 day supply can be obtained through Express Scripts
or participating Duane Reade or Walgreens.
Specialty drugs*
Covered (cost based on above categories)
Must be dispensed by the Specialty Pharmacy Program
Provider. Pre-certification required contact NYC
Healthline at 1-800-521-9574.
*Must be dispensed by a Specialty Pharmacy.
OPTIONAL RIDER – ENHANCED SCHEDULE FOR OUT-OF-NETWORK MEDICAL/PHYSICIAN SERVICES PROVIDED
THROUGH GHI-EMBLEM HEALTH
Enhanced schedule increases the reimbursement of the basic program's non-participating provider fee schedule, on average,
by 75%.
GHI-EMBLEM: NON-PARTICIPATING (OUT-OF-NETWORK) PROVIDER BENEFITS:
Payment for services provided by out-of-network providers is made directly to you under the NYC Non-Participating Provider
Schedule of Allowable Charges (Schedule). The reimbursement rates (allowed amounts) in the Schedule are not related to usual and
customary rates or to what the provider may charge but are set at a fixed amount based on GHI's 1983 reimbursement rates. Most
of the reimbursement rates have not increased since that time and will likely be less (and in many instances substantially less) than
the fee charged by the out of- network provider. You will be responsible for any difference between the provider’s fee and the
amount of the reimbursement; therefore, you may have a substantial out-of-pocket expense.
Once a member, if you intend to use an out-of-network provider, you can call GHI-Emblem Customer Service with the medical
procedure code/s (CPT Code) of the service(s) you anticipate receiving to find out what you would be reimbursed.
Below are some examples of what you would typically pay out of pocket if you were to receive care or services from an out-of-
network provider.
Typical Out-of-Pocket Costs for Receiving Care from Out-of-Network Providers:
Established Patient Office Visit (typically 15 minutes) CPT Code 99213
Estimated Charge for a Doctor in Manhattan
$225.00
Reimbursement Under the Schedule
- $ 33.36
Member Out-of-Pocket Responsibility
$191.64
Routine Maternity Care and Delivery CPT Code 59400
Estimated Charge for a Doctor in Manhattan
$9,040.00
Reimbursement Under the Schedule
-$1,379.00
Member Out-of-Pocket Responsibility
$7,661.00
Total Hip Replacement Surgery CPT Code 27130
47 | Page
Estimated Charge for a Doctor in Manhattan
$20,099.95
Reimbursement under the Schedule
- $ 3,011.00
Member Out-of-Pocket Responsibility
$17,088.95
Please note that deductibles may apply and that you could be eligible for additional reimbursement if your catastrophic coverage
kicks in or you have purchased the Enhanced Non-Participating Provider Schedule, an Optional Rider benefit that provides lower out-
of-pocket costs for some surgical and in-hospital services from out-of-network doctors.
Effective for services received on or after April 1, 2015, GHI-EmblemHealth has set up new protections to ensure that — in the
following circumstances — members won't be responsible for costs other than the in-network cost-sharing (in-network copay,
coinsurance and/or deductible) that applies under the plan. These two cases are:
• If you receive out-of-network emergency services in a hospital in the State of New York
• If you receive a non-emergency "surprise bill" for out-of-network services rendered in the State of New York
You will not be responsible for the costs of "emergency services" you receive in a hospital, other than any in-network cost-sharing
(in-network copay, coinsurance and/or deductible) that applies to such services under your plan.
You will not be responsible for the costs of "surprise bills" for out-of-network services, other than any in-network cost-sharing (in-
network copay, coinsurance and/or deductible) that applies under your plan. For more information on what is “surprise bill”, please
call or visit the EmblemHealth website.
Please refer to the GHI-CBP Basic Plan, GHI-CBP with Enhanced Schedule and Prescription Drugs and Anthem Blue Cross and Blue
Shield (companion to GHI-CBP medical coverage) for additional information and to see what this plan covers and any cost-sharing
responsibilities.
Please refer to the Summary of Benefits and Coverage (SBC) for additional information and to see what this plan covers and any
cost-sharing responsibilities.
48 | Page
GHI HMO
As a GHI HMO member, you and each member of your family will choose a PCP from GHI HMO’s list
of participating providers. For adults, the PCP will specialize in either internal medicine or family
practice and, for children, specialization will be in either pediatrics or family practice. Your PCP will
coordinate all health care services, including referrals, which must be arranged for and authorized by
your PCP.
At a Glance
Plan Type:
HMO
Geographic Service Area
GHI HMO’s service area includes the counties of Bronx, Kings, Manhattan, Queens, Richmond,
Rockland, Nassau, Suffolk, Westchester, Broome, Otsego, Albany, Columbia, Fulton, Greene,
Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington, Delaware,
Dutchess, Orange, Putnam, Sullivan and Ulster counties.
Does this plan use a network of providers?
Yes. See www.Emblemhealth.com/city or call 1-877-244-4466 for a list of participating
providers.
Do I need a referral to see a specialist?
Yes, written approval is required to see a specialist.
Contact Information
1-877-244-4466
Web Site
Emblemhealth.com/city
Plan Features
Cost
What is the overall deductible for this plan?
• $0
What are the costs when you visit a health
care provider’s office or clinic?
• Primary care visit to treat an injury or illness: $15 co-pay/visit
Not covered for non-participating provider
• Specialist visit: $15 co-pay/visit
Not covered for non-participating provider
• Other practitioner office visit (Chiropractor): $15 co-pay/visit
Not covered for non-participating provider
• Preventive care/screening/immunization: No charge
Not covered for non-participating provider
What are the costs if you have a test?
Diagnostic test (x-ray, blood work): No charge
Not covered for non-participating provider
Imaging (CT/PET scans, MRIs): $15 co-pay/test
Not covered for non-participating provider
What are the costs if you have outpatient
surgery?
Facility fee (e.g., ambulatory surgery center): No charge
Not covered for non-participating provider
Prior approval required
Physician/surgeon fees: No charge
Not covered for non-participating provider
Prior approval required
What are the costs if you need immediate
medical attention?
Emergency room services: $35 co-pay/visit
$35 co-pay/visit to non-participating provider
Co-pay waived if admitted
Emergency medical transportation: No charge
No charge to non-participating provider
Urgent Care: $15 co-pay/visit
Not covered for non-participating provider
What are the costs if you have a hospital
stay?
Facility fee (e.g., hospital room): No charge per continuous confinement
Prior approval required Not covered for non-participating provider
Physician/surgeon fee: No charge
Not covered for non-participating provider
What are the costs if you are pregnant?
Prenatal and postnatal care: No charge
49 | Page
Not covered for non-participating provider
Delivery and all inpatient services: No charge per continuous stay
Limited to 48 hours for natural delivery and 96 hours for caesarean delivery.
Not covered for non-participating provider
Prior approval required
WHAT ARE THE COSTS IF YOU HAVE MENTAL HEALTH, BEHAVIORAL HEALTH, OR SUBSTANCE ABUSE NEEDS?
Service
Cost
Mental/Behavioral health
Outpatient services
• $15 co-pay/visit
• Not covered for non-participating provider
Mental/Behavioral health
Inpatient services
• No charge per continuous confinement
• Prior approval required
•
Not covered for non-participating provider
Substance abuse
Outpatient services
• $15 co-pay/visit
•
Not covered for non-participating provider
Substance abuse
Inpatient services
• No charge per continuous confinement
• Prior approval required
•
Not covered for non-participating provider
What are the costs if you need help recovering or have other special health needs?
Service
Cost
Home health care
• No charge
• 40 visits per member per year
• Not covered for non-participating provider
Skilled nursing care
• No charge
• 120 days per member per year
• Prior approval required
• Not covered for non-participating provider
Durable medical equipment (DME)
• 20% coinsurance
• Prior approval required
• Not covered for non-participating provider
• $1500 annual maximum
Hospice service
• No charge
• Not covered for non-participating provider
• Limited to 210 days
OPTIONAL RIDER
What is the cost if you need drugs to treat your illness or condition?
Retail
Mail Order
Generic drugs*
$8 co-pay/30 day supply
$16 co-pay/90 day supply
Preferred brand drugs
$16 co-pay/30 day supply
$32 co-pay/90 day supply
Non-preferred brand drugs
$30 co-pay/30day supply
$50 co-pay/90 day supply
Specialty drugs**
Generic drugs
$8 co-pay/30 day supply
Not covered
Preferred brand drugs
$16 co-pay/30 day supply
Not covered
Non-preferred brand drugs
$30 co-pay/30 day supply
Not covered
Members requesting a brand name drug must pay the difference between the brand name drug and the generic drug when available, plus
the generic co-payment.
*Must be dispensed by a Participating Pharmacy.
**Must be dispensed by a Specialty Pharmacy. Written referral required.
Please refer to the Summary of Benefits and Coverage (SBC) for additional information and to see what this plan covers and any
cost-sharing responsibilities.
50 | Page
HIP HMO PREFERRED
EmblemHealth was founded more than 60 years ago to provide city workers and union members
high quality, affordable health insurance. It continues that tradition today, offering members choice,
convenience, and access to a large regional network of health care professionals.
With the HIP HMO Preferred plan, there is a $0 monthly premium for the base plan. There is also a
$0 copay for all preventative services. Members can visit the Hospital for Special Surgery (HSS), the
nation’s top-ranked orthopedic hospital, and Memorial Sloan Kettering Cancer Center (MSK), one of
the country’s leading cancer centers, through HMO Preferred’s new Centers of Excellence program.
To get started, members and their families must pick a primary care doctor (PCP). This is the doctor
who gives everyday care. PCPs can refer members to health care professionals who treat certain
health conditions. When members choose a preferred provider in the Prime network, they will be
covered and pay less. All doctors in the AdvantageCare Physicians network are part of the preferred
provider network.
At a Glance
Plan Type:
HMO
Geographic Service Area
The Prime Network service area includes the tristate area, plus additional coverage in upstate
New York and New Jersey.
Does this plan use a network of providers?
Yes. Visit emblemhealth.com/gold or call 833-CNY-GOLD (833-269-4653) (TTY:711) to learn
more about our participating providers.
Do I need a referral to see a specialist?
Yes, written approval is required to see a specialist.
Contact Information
EmblemHealth
55 Water Street
New York, NY 10041
833-CNY-GOLD (833-269-4653) (TTY:711)
A Gold Line agent is available Monday through Friday, 8:00 a.m. to 8:00 p.m. and Saturdays
8 a.m. to 1 p.m. to answer your questions.
Web Site
Emblemhealth.com/gold
Plan Features
Cost
What is the overall deductible for this plan?
• $0
What are the costs when you visit a health
care provider’s office or clinic?
Primary care visit to treat an injury or illness: Preferred $0 copay/visit
Non-preferred $10 copay/visit
Not covered for non-participating provider
Specialist visit: Members with a Preferred PCP $0 copay/visit
Members with a Non-preferred $10 co-pay/visit
Not covered for non-participating provider
Other practitioner office visit Chiropractor: Members with a Preferred PCP $0 copay/visit
Members with a Non-Preferred PCP $10
copay/visit
Not covered for non-participating provider
Preventive care/screening/immunization: Preferred $0 copay/visit
Non-preferred $0 copay/visit
Not covered for non-participating provider
What are the costs if you have a test?
Diagnostic test (x-ray, blood work): Members with a Preferred PCP $0 copay/visit
Members with a Non-preferred PCP $10 co-pay/visit
Outpatient Hospital $100 co-pay/visit
Not covered for non-participating provider
Imaging (CT/PET scans, MRIs): Members with a Preferred PCP $0 copay/visit
Members with a Non-preferred PCP $10 co-pay/visit
Outpatient Hospital $100 co-pay/visit
Not covered for non-participating provider
Prior approval required
51 | Page
What are the costs if you have outpatient
surgery?
Facility fee: $50 co-pay Ambulatory surgery center
$150 co-pay Outpatient hospital
Not covered for non-participating provider
Prior approval required
Physician/surgeon fees: No charge
Not covered for non-participating provider
Prior approval required
What are the costs if you need immediate
medical attention?
Emergency room services: $150 copay/visit (waived if admitted)
Emergency medical transportation: No charge
Urgent Care: $50 copay/visit
What are the costs if you have a hospital
stay?
Facility fee (e.g., hospital room): $100 copay per continuous stay
Not covered for non-participating provider
Prior approval required
Physician/surgeon fee included in hospital admission copay
Not covered for non-participating provider
What are the costs if you are pregnant?
Prenatal and postnatal care: No charge
Not covered for non-participating provider
Delivery and all inpatient services: $100 copay per continuous stay
Limited to 48 hours for natural delivery and 96 hours for caesarean delivery. Prior approval
required.
WHAT ARE THE COSTS IF YOU HAVE MENTAL HEALTH, BEHAVIORAL HEALTH, OR SUBSTANCE ABUSE NEEDS?
Service
Cost
Mental/Behavioral health
Outpatient services
• Members with a Preferred PCP $0 copay/visit
• Members with a Non-preferred PCP $10 copay/visit
• Not covered for non-participating provider
Mental/Behavioral health
Inpatient services
• $100 copay per continuous stay
• Not covered for non-participating provider
•
Prior approval required
Substance abuse
Outpatient services
• Members with a Preferred PCP $0 copay/visit
• Members with a Non-preferred PCP $10 copay/visit
• Not covered for non-participating provider
•
Certain services may not be covered, see plan documents for details
Substance abuse
Inpatient services
• $100 copay per continuous stay
• Not covered for non-participating provider
•
Prior approval required
WHAT ARE THE COSTS IF YOU NEED HELP RECOVERING OR HAVE OTHER SPECIAL HEALTH NEEDS?
Service
Cost
Home health care
• $0 copay/visit
• Coverage limited to 200 visits per year
• Not covered for non-participating provider
•
Prior approval required
Rehabilitation services Inpatient
• $100 copay per continuous confinement
• Not covered for non-participating provider
• Limited to 90 visits per year
•
Prior approval required
Rehabilitation services Outpatient
• Members with a Preferred PCP $0 copay/visit
• Members with a Non-preferred PCP $10 copay/visit
• Not covered for non-participating provider
•
Limited to 90 visits per year
52 | Page
• Prior approval required
Habilitation services Inpatient
• $100 copay per continuous confinement
• Not covered for non-participating provider
• Limited to 90 visits per year
• Prior approval required
Habilitation services Outpatient
• Members with a Preferred PCP $0 copay/visit
• Members with a Non-preferred PCP $10 copay/visit
• Not covered for non-participating provider
• Limited to 90 visits per year
• Prior approval required
Skilled nursing care
• $0 copay unlimited days
• Not covered for non-participating provider
•
Prior approval required
Durable medical equipment (DME)
• Not covered under Basic coverage (Only with Optional Rider)
• No charge
• Not covered for non-participating provider
•
Prior approval required
Hospice service
• $0 copay/visit
• Not covered for non-participating provider
• Limited to 210 days
OPTIONAL RIDER
WHAT IS THE COST IF YOU NEED DRUGS TO TREAT YOUR ILLNESS OR CONDITION?
Retail
Mail Order
Generic drugs*
Retail 20% coinsurance but not
less than a $5 co-pay/30 day
supply
$12.50 co-pay/90 day supply
Preferred brand drugs
Retail 40% coinsurance but not
less than a $25 co-pay/30 day
supply
$50 co-pay/90 day supply
Non-preferred brand drugs
Retail 50% coinsurance but not
less than a $40 co-pay/30 day
supply
$75 co-pay/90 day supply
Specialty drugs**
Generic drugs
Retail 20% coinsurance but not
less than a $5 co-pay/30 day
supply
Not covered
Preferred brand drugs
Retail 40% coinsurance but not
less than a $25 co-pay/30 day
supply
Not covered
Non-preferred brand drugs
Retail 50% coinsurance but not
less than a $40 co-pay/30 day
supply
Not covered
*Must be dispensed by a Participating Pharmacy.
**Must be dispensed by a Specialty Pharmacy. Written referral required.
Please refer to the Summary of Benefits and Coverage (SBC) for additional information and to see what this plan covers and any
cost-sharing responsibilities.
53 | Page
HIP PRIME POS
Members have access to top quality health care providers through HIP’s alliances with outstanding
medical groups and hospitals, including Montefiore Medical Center, Lenox Hill Hospital, St. Barnabas
Hospital, St. Luke’s Roosevelt Hospital and Beth Israel Medical Center.
HIP Prime POS is a point-of-service plan offering both in- and out-of-network coverage. Members can
go to virtually any doctor or specialist at any location and still take advantage of HIP’s value. Non-
referred and out-of-network services are subject to deductibles and coinsurance.
At a Glance
Plan Type:
POS
Geographic Service Area
HIP’s service area includes Bronx, Kings, Manhattan, Queens, Richmond, Rockland, Nassau,
Suffolk, Westchester, Broome, Otsego, Albany, Columbia, Fulton, Greene, Montgomery,
Rensselaer, Saratoga, Schenectady, Schoharie, Warren, Washington, Delaware, Dutchess,
Orange, Putnam, Sullivan and Ulster counties.
Does this plan use a network of providers?
Yes. Visit the Web site www.emblemhealth.com/city or call 1-800-447-8255
Do I need a referral to see a specialist?
Yes, written approval is required to see a specialist.
Contact Information
EmblemHealth
HIP
55 Water Street
New York, NY 10041
1-800-447-8255. Representatives will be available Monday through Friday, 8:00 a.m. to 8:00
p.m. to answer your questions.
Web Site
Emblemhealth.com/city
Plan Features
Cost
What is the overall deductible for this plan?
• $750 for out-of-network provider per person/$2,250 family
What are the costs when you visit a health
care provider’s office or clinic?
• Primary care visit to treat an injury or illness:
• In-network: $10 co-pay
• Out of network: After the deductible is met 30% coinsurance
• Specialist visit:
• In-network $15 co-pay
• Out of network: After the deductible is met 30% coinsurance
• Other practitioner office visit Chiropractor:
• In-network: $15 co-pay
• Out of network: After the deductible is met 30% coinsurance
• Preventive care/screening/immunization:
• In-network: No charge
•
Out of network: After the deductible is met 30% coinsurance
What are the costs if you have a test?
Diagnostic test (x-ray, blood work):
In-network: No charge
Out of network: After the deductible is met 30% coinsurance
Imaging (CT/PET scans, MRIs):
In-network: No charge
Out of network: After the deductible is met 30% coinsurance
Prior approval required
What are the costs if you have outpatient
surgery?
Facility fee (e.g., ambulatory surgery center): $100 co-pay
30% co-insurance for non-participating provider
Prior approval required
Physician/surgeon fees: No charge
30% co-insurance for non-participating provider
Prior approval required
54 | Page
What are the costs if you need immediate
medical attention?
Emergency room services: $100 co-pay/visit
$100 co-pay to non-participating provider
Waived if admitted
Emergency medical transportation: No charge
No charge to non-participating provider
Urgent Care: In-network: $10 co-pay/visit
Out of network: After the deductible is met 30% coinsurance
What are the costs if you have a hospital
stay?
Facility fee (e.g., hospital room): $100 per continuous stay
30% co-insurance for non-participating provider
Prior approval required
Physician/surgeon fee: No charge
30% co-insurance for non-participating provider
What are the costs if you are pregnant?
Prenatal and postnatal care: In-network: No charge
Out of network: After the deductible is met 30% coinsurance
Delivery and all inpatient services: In-network: $100 per continuous stay
Out of network: After the deductible is met 30%
coinsurance
Limited to 48 hours for natural delivery and 96 hours for caesarean delivery.
Prior approval required.
WHAT ARE THE COSTS IF YOU HAVE MENTAL HEALTH, BEHAVIORAL HEALTH, OR SUBSTANCE ABUSE NEEDS?
Service
Cost
Mental/Behavioral health
Outpatient services
• In-network: $10 co-pay/visit
• Out of network: After the deductible is met 30% coinsurance
Mental/Behavioral health
Inpatient services
• In-network: $100 per continuous stay
• Out of network: After the deductible is met 30% coinsurance
• Prior approval required
Substance abuse
Outpatient services
• In-network: $10 co-pay/visit
• Out of network: After the deductible is met 30% coinsurance
Substance abuse
Inpatient services
• In-network: $100 per continuous stay
• Out of network: After the deductible is met 30% co-insurance
• Prior approval required
What are the costs if you need help recovering or have other special health needs?
Service
Cost
Home health care
• In-network: No charge
• Out of network: After the deductible is met 30% co-insurance
• Coverage limited to 200 visits per year for both in and out of network combined.
•
Prior approval required
Rehabilitation services Inpatient
• In-network: $100 per continuous confinement
• Out of network: After the deductible is met 30% co-insurance
• Limited to 90 visits per year for both in and out of network combined
•
Prior approval required
Rehabilitation services Outpatient
• In-network: $15 co-pay/visit
• Out of network: After the deductible is met 30% co-insurance
• Limited to 90 visits per year for both in and out of network combined
•
Prior approval required
Habilitation services Inpatient
• In-network: $100 per continuous confinement
• Out of network: After the deductible is met 30% co-insurance
• Limited to 90 visits per year for both in and out of network combined
• Prior approval required
Habilitation services Outpatient
• In-network: 15 co-pay/visit
• Out of network: After the deductible is met 30% co-insurance
•
Limited to 90 visits per year for both in and out of network combined
55 | Page
• Prior approval required
Skilled nursing care
• In-network: No charge
• Not covered for non-participating provider
•
Prior approval required
Durable medical equipment (DME)
• In-network: No charge
• Not covered for non-participating provider
• Prior approval required
Hospice service
• In-network: No charge
• Not covered for non-participating provider
• Limited to 210 days
OPTIONAL RIDER
WHAT IS THE COST IF YOU NEED DRUGS TO TREAT YOUR ILLNESS OR CONDITION?
Retail
Mail Order
Generic drugs*
$10 co-pay/30 day supply
$15 copay/90 day supply
Preferred brand drugs*
$35 co-pay/30 day supply
$52.50 co-pay/90 day supply
Non-preferred brand drugs
Not covered
Not covered
Specialty drugs**
Generic drugs
$10 co-pay/30 day supply
$15 co-pay/90 day supply
Preferred brand drugs
$35 co-pay/30 day supply
$52.50 co-pay/90 day supply
Non-preferred brand drugs
Not covered
*Must be dispensed by a Participating Pharmacy.
**Must be dispensed by a Specialty Pharmacy. Written referral required.
Please refer to the Summary of Benefits and Coverage (SBC) for additional information and to see what this plan covers and any
cost-sharing responsibilities.
56 | Page
METROPLUSHEALTH GOLD
MetroPlusHealth Gold is available to all NYC employees, non-Medicare eligible retirees, their
spouses or qualified domestic partners, and eligible dependents. $0* copays $0 doctor visits, $0
unlimited telehealth, $0 mental health care, Up to $1,400 to work out at the gym. Our network
includes 34,000+ of the City’s top doctors, 40+ hospitals including NYU Langone, Mount Sinai, and
NY Health + Hospitals, and 110+ urgent care centers, including CityMD locations.
At a Glance
Plan Type:
HMO
Geographic Service Area
MetroPlusHealth service area includes Manhattan, Brooklyn, Queens, the Bronx and
Staten Island.
Does this plan use a network of providers?
Yes. Visit the Web site at www.metroplus.org for the most current list of
participating providers.
Do I need a referral to see a specialist?
While a written referral is not required, all referrals should still be directed by the member’s PCP.
Contact Information
877.475.3795 Representatives are available Monday through Friday 8AM to 6PM and Saturday
9am to 5pm.
Web Site
www.metroplus.org
Plan Features
Cost
What is the overall deductible for this plan?
• $0
What are the costs when you visit a health
care provider’s office or clinic?
• Primary care visit to treat an injury or illness: No charge. Not covered for
non-participating providers.
• Specialist visit: No charge. Not covered for non-participating providers.
• Other practitioner office visit Chiropractor: No charge. Not covered for
non-participating providers.
• Preventive care/screening/immunization: No charge. Not covered for
non-participating providers.
• Adult physical examinations, Mammograms (limits based on age), Cervical cytology,
Routine gynecological services, Bone density exams, Screening for Prostate & Colon
cancer (limits based on age).
What are the costs if you have a test?
• Diagnostic test (x-ray, blood work): No charge.
• Not covered for non-participating providers.
• Imaging (CT/PET scans, MRIs): No charge.
• Not covered for non-participating providers
What are the costs if you have outpatient
surgery?
• Facility fee (e.g., ambulatory surgery center): No charge.
• Not covered for non-participating providers.
• Physician/surgeon fees: No charge.
• Not covered for non-participating providers.
What are the costs if you need immediate
medical attention?
• Emergency room services: $100 Copay, waived if admitted.
• Emergency medical transportation: No charge.
• No charge for non-participating providers.
• Urgent Care: $25 Copay.
• Not covered for non-participating providers.
What are the costs if you have a hospital stay?
• Facility fee (e.g., hospital room): No charge.
• Not covered for non-participating providers.
• Physician/surgeon fee: No charge. Not covered for non-participating providers.
What are the costs if you are pregnant?
• Prenatal and postnatal care: No charge. Not covered for non-participating providers.
• Delivery and all inpatient services: No charge. Not covered for non-participating
providers. Limited to 48 hours for natural delivery and 96 hours for caesarean delivery.
57 | Page
WHAT ARE THE COSTS IF YOU HAVE MENTAL HEALTH, BEHAVIORAL HEALTH, OR SUBSTANCE ABUSE NEEDS?
Service
Cost
Mental/Behavioral health
Outpatient services
• No charge
•
Not covered for non-participating provider
Mental/Behavioral health
Inpatient services
• No charge
• Not covered for non-participating provider
•
Unlimited days per calendar year
Substance abuse
Outpatient services
• No charge
• Not covered for non-participating provider
Substance abuse
Inpatient services
• No charge
• Not covered for non-participating provider
•
Unlimited days per calendar year
What are the costs if you need help recovering or have other special health needs?
Service
Cost
Home health care
• No charge
• Not covered for non-participating provider
• Coverage limited to 40 visits per year
Rehabilitation services
• No charge
• Not covered for non-participating provider
• 20 visits per condition, per year combined therapies
Habilitation services
• No charge
• Not covered for non-participating provider
•
20 visits per condition, per year combined therapies
Skilled nursing care
• No charge
• Not covered for non-participating provider
•
200 days per Plan Year
Durable medical equipment (DME)
• 0% coinsurance
• Not covered for non-participating provider
Hospice service
• No charge
• Not covered for non-participating provider
• 210 days per plan year/ Five (5) visits for family bereavement counseling
OPTIONAL RIDER
What is the cost if you need drugs to treat your illness or condition?
New Member RX1 Rider
Retail – 30 Day Supply
Mail Order – 90 Day Supply
Generic drugs (Tier 1)
$0 copayment
$0 copayment
Brand drugs (Tier 2)
$35 copayment
$70 copayment
Non-formulary (Tier 3)
$70 copayment
$140 copayment
New Member RX2 Rider
Retail – 30 Day Supply
Mail Order – 90 Day Supply
Generic drugs (Tier 1)
20% copayment
20% copayment
Brand drugs (Tier 2)
40% copayment
40% copayment
Non-formulary (Tier 3)
50% copayment
50% copayment
Please refer to the Summary of Benefits and Coverage (SBC) for additional information and to see what this plan covers and any
cost-sharing responsibilities.
58 | Page
VYTRA HEALTH PLANS
Vytra Health Plans offers New York City employees and retirees an opportunity to access quality
healthcare in Queens, Nassau and Suffolk counties. More than 13,000 private practice physicians and
provider locations are available in the tri-county service area. Through a strict credentialing process
and an ongoing quality assurance program, Vytra Health Plans ensures that members receive the
best medical care available.
At the heart of Vytra’s healthcare plan is your Primary Care Physician (PCP). This is a family
practitioner or internist or in the case of children, a pediatrician, whom you select from our extensive
medical directory.
At a Glance
Plan Type:
HMO
Geographic Service Area
Vytra’s service area includes Queens, Nassau and Suffolk counties.
Does this plan use a network of providers?
Yes. Visit Emblemhealth.com/city or call 1-866-409-0999 for a list of participating providers.
Do I need a referral to see a specialist?
Yes, written approval is required to see a specialist.
Contact Information
1-866-409-0999. Representatives will be available Monday through Friday, 8:00 a.m. to 8:00
p.m. to answer your questions.
Web Site
Emblemhealth.com/city
Plan Features
Cost
What is the overall deductible for this plan?
• $0
What are the costs when you visit a health
care provider’s office or clinic?
• Primary care visit to treat an injury or illness: $5 co-pay/visit
Not covered for non-participating provider
• Specialist visit: $5 co-pay/visit
Referral required
Not covered for non-participating provider
• Other practitioner office visit: $5 co-pay
Referral required
Not covered for non-participating provider
• Preventive care/screening/immunization: No charge
Not covered for non-participating provider
What are the costs if you have a test?
Diagnostic test (x-ray, blood work): No charge
Not covered for non-participating provider
Imaging (CT/PET scans, MRIs): No charge
Prior approval required
Not covered for non-participating provider
What are the costs if you have outpatient
surgery?
Facility fee (e.g., ambulatory surgery center): No charge
Prior approval required
Not covered for non-participating provider
Physician/surgeon fees: No charge
Prior approval required
Not covered for non-participating provider
What are the costs if you need immediate
medical attention?
Emergency room services: $25 co-pay/visit
$25 co-pay/visit non-participating provider
Waived if admitted
Out-of-network is covered if emergent
Emergency medical transportation: No charge
No charge non-participating provider
Urgent care: $5 co-pay/visit
Not covered for non-participating provider
What are the costs if you have a hospital
stay?
Facility fee (e.g., hospital room): No charge
Prior approval required
Not covered for non-participating provider
59 | Page
Physician/surgeon fee: No charge
Not covered for non-participating provider
What are the costs if you are pregnant?
Prenatal and postnatal care: No charge
Not covered for non-participating provider
Delivery and all inpatient services: No charge
Prior approval required
Not covered for non-participating provider
WHAT ARE THE COSTS IF YOU HAVE MENTAL HEALTH, BEHAVIORAL HEALTH, OR SUBSTANCE ABUSE NEEDS?
Service
Cost
Mental/Behavioral health
Outpatient services
• $5 co-pay/visit
• Not covered for non-participating provider
Mental/Behavioral health
Inpatient services
• No charge
• Prior approval required
• Not covered for non-participating provider
Substance abuse
Outpatient services
• $5 co-pay/visit
•
Not covered for non-participating provider
Substance abuse
Inpatient services
• No charge
• Prior approval required
•
Not covered for non-participating provider
WHAT ARE THE COSTS IF YOU NEED HELP RECOVERING OR HAVE OTHER SPECIAL HEALTH NEEDS?
Service
Cost
Home health care
• $5 co-pay/visit
• Coverage limited to 40 visits/year
• Prior approval required
•
Not covered for non-participating provider
Skilled nursing care
• No charge
• Coverage limited to 45 visits/year
• Prior approval required
•
Not covered for non-participating provider
Rehabilitation service Inpatient
• No charge
• Prior approval required
• Not covered for non-participating provider
• 60 days per calendar year combined therapies
Rehabilitation service Outpatient
• $5 co-pay
• Prior approval required
• Not covered for non-participating provider
• 60 days per calendar year combined therapies
Habilitation service Inpatient
• No charge
• Prior approval required
• Not covered for non-participating provider
• 60 days per calendar year combined therapies
Habilitation service Outpatient
• $5 co-pay
• Prior approval required
• Not covered for non-participating provider
• 60 days per calendar year combined therapies
Durable medical equipment (DME)
• No charge
• Prior approval required
• Not covered for non-participating provider
Hospice service
• No charge
• Covered limited to 210 days
•
Not covered for non-participating provider
60 | Page
OPTIONAL RIDER
WHAT IS THE COST IF YOU NEED DRUGS TO TREAT YOUR ILLNESS OR CONDITION?
Retail
Mail Order
Generic drugs*
$7 co-pay/30 day supply
$10.50 co-pay/90 day supply
Preferred brand drugs*
$14 co-pay/30 day supply
$21 co-pay/90 day supply
Non-preferred brand drugs*
Not covered
Not covered
Specialty drugs*
Generic drugs
$7 co-pay/30 day supply
$10.50 co-pay/90 day supply
Preferred brand drugs
$14 co-pay/30 day supply
$21 co-pay/90 day supply
Non-preferred brand drugs
Not covered
There is an annual $50 per
person deductible.
There’s no annual limit.
Not covered
*Must be dispensed by a Participating Pharmacy.
**Must be dispensed by a Specialty Pharmacy. Written referral required.
Please refer to the Summary of Benefits and Coverage (SBC) for additional information and to see what this plan covers and any
cost-sharing responsibilities.
61 | Page
PICA PROGRAM
The PICA Program is a prescription drug benefit that is provided to all NYC employees, non-Medicare retirees and their non-
Medicare eligible dependents who are enrolled in a health plan offered by the City's Health Benefits Program. It is made available
through the joint efforts of the City of New York Office of Labor Relations and the Municipal Labor Committee.
PICA BENEFIT OVERVIEW
PICA covers medications in two specific drug categories:
• Self-Injectable Medications
1. Most injectable medications not requiring administration by a health care professional
• Chemotherapy Medications
1. Medications used to treat cancer
2. Medications used to treat certain side effects of chemotherapy
Express Scripts, Inc. is administering the benefits under the PICA program.
Retail (Up to a 30-day supply at a retail pharmacy):
• $10 Generic
• $25 Preferred Brand (Formulary)
• $45 Non-Preferred Brand (Non-Formulary)
Express Scripts (ESI) Home Delivery Pharmacy (Up to a 90-day supply at ESI Home Delivery for non-specialty medications):
• $20 Generic
• $50 Preferred Brand (Formulary)
• $90 Non-Preferred Brand (Non-Formulary)
Specialty Medications (Up to a 30-day supply at Accredo Specialty Pharmacy or Freedom Fertility Pharmacy):
• $10 Generic
• $25 Preferred (Formulary)
• $45 Non-preferred (Non-Formulary)
For brand medications that have FDA approved generic equivalents, PICA will pay for the generic medication only. If the brand is
dispensed, the member must pay the difference in cost between the generic and brand drug plus the applicable brand copay.
There is an annual deductible of $100 per person. This deductible is independent of any other deductible and must be satisfied
before copayments are applied.
To find out if a medication is Preferred or Non-preferred, please call Express Scripts' Customer Service Department at (800) 467-
2006 or visit www.express-scripts.com.
MAIL ORDER PROGRAM
Specialty Maintenance Medications
Accredo, an Express Scripts specialty pharmacy, provides individualized care and convenient delivery of specialty medications. All
specialty medications such as self-injectables or cancer medications must be obtained through Accredo Specialty Pharmacy.
Specialty "stat" drugs are the exception. Medication such as Lovenox which is a blood thinner that is needed immediately after
surgery would be allowed to be obtained through your retail pharmacy. A member may obtain up to 2 fills of a specialty "stat"
medication at the retail pharmacy per year.
To order/refill specialty medications or determine if your medication qualifies as a specialty "stat drug", please call Accredo Specialty
Pharmacy at 877-895-9697.
62 | Page
Non-Specialty Maintenance Medications
Non-specialty maintenance medications must be sent to ESI Home Delivery Pharmacy. A maintenance drug is a medication that you
will be utilizing on a regular basis over an extended period of time. Please note that if your physician changes the strength of your
maintenance medication or prescribes a different maintenance medication, you may go to a retail pharmacy for up to two 30 day
fills and then you must transfer to ESI Home Delivery Pharmacy. Medications a member may take for an extended period of time
such as those to treat nausea while undergoing cancer treatment would be considered non-specialty maintenance medications.
You may mail your prescription to:
Express Scripts Home Delivery Service
P.O Box 66568
St. Louis, MO 63166-6568
You may also call Express Scripts' Customer Service at 800-467-2006
REFILLING MEDICATION
By Phone: Interactive Voice Response (IVR) System IVR enables you to renew prescriptions over the telephone at any time
of the day or night. Call (800) 233-7139 and follow the instructions that are given to you over the phone. Over the
Over the Internet: Log onto Express Scripts' website at www.expressscripts.com and register as a member. Once you are
registered you can order refills online.
FERTILITY MEDICATIONS
The fertility medication benefit program is available exclusively from Freedom Fertility Pharmacy. Injectable medication used to
treat infertility is only available to PICA members whose health plan covers the treatment that require this medication. This
medication is limited to a lifetime maximum of three (3) cycles of therapy. Administration of the medication(s) is usually given daily
for 7-10 days early in the cycle. Even though fertility medication(s) is physically administered for about 7-10 days, clinically, it is used
as a treatment for 1 FULL cycle.
The Freedom Advantage®, offered to PICA members features a dedicated team of fertility only care coordinators, free shipping, free
patient education materials and emergency same-day services. For questions, call Freedom Fertility Pharmacy at (800) 660-4283 or
visit www.freedomfertility.com.
GENERICS PREFERRED PROGRAM
When you fill a prescription, the pharmacy will see if a generic equivalent is available.
• If a generic is available and you choose it, you pay the standard copayment for a generic drug. This will be less than for
a brand name drug.
• If there is a generic equivalent and you choose a brand name medication, you will pay the brand name copay, PLUS the
difference in cost between the generic and the brand name drug.
PRIOR AUTHORIZATION PROGRAM
Prior authorization is a program that monitors certain prescription drugs to get you the medication you require while monitoring
your safety. Similar to healthcare plans that approve a medical procedure before it's done to ensure the necessity of the test, if
you're prescribed a certain medication, that drug may need a prior authorization. This program makes sure you're getting a
prescription that is suitable for the intended use and covered by your pharmacy benefit. Your own medical professionals are
consulted, since your plan will cover it only when your doctor prescribes it to treat a medical condition that will promote your health
and wellness. When your pharmacist tells you that your prescription needs a prior authorization, it simply means that more
information is needed to see if your plan covers the drug. Only your physician can provide this information and request a prior
authorization.
63 | Page
Drugs impacted by your prior authorization program include:
• Prescriptions used outside of the specific, approved medical conditions
• Prescriptions that could be used for non-medical purposes
If you are currently taking one of these medications, your physician will still need to call Express Scripts at 800-753-2851 to obtain a
Prior Authorization (PA). The PA team is available 24/7. The physician may fax information to the PA team at 800-357-9577. The
turnaround time for a request is 48 hours.
STEP THERAPY PROGRAM
Step therapy is a program for people who take certain prescription drugs regularly to treat a medical condition, such as arthritis or
high blood pressure. It allows you and your family to receive the affordable treatment you need and helps your organization
continue with prescription-drug coverage.
In step therapy, drugs are grouped in categories, based on treatment and cost:
• Front-line drugs - the first step - are generic and sometimes lower-cost brand drugs proven to be safe, effective
and affordable. In most cases, you should try these drugs first because they usually provide the same health
benefit as a more expensive drug, at a lower cost.
• Ba
ck-up drugs - Step 2 and step 3 drugs - are brand-name drugs that generally are necessary for only a small
number of patients. Back-up drugs are the most expensive option.
DRUG QUANTITY MANAGEMENT
Drug quantity management, also known as DQM, is a program in your pharmacy benefit that's designed to make the use of
prescription drugs safer and more affordable. It provides the medication you need for your good health and the health of your
family, while making sure you receive them in the amount - or quantity - considered safe. Certain prescriptions are included in this
program. For these drugs, you can receive an amount to last you a certain number of days. For instance, the program could provide
a maximum of 30 pills for a medication you take once a day. This gives you the right amount to take the daily dose considered safe
and effective, according to guidelines from the U.S Food & Drug Administration (FDA).
Split Fill:
Split-Fill is designed to improve patient therapy adherence and waste reduction. Accredo has clinically identified a select list of
specialty drugs which have a very high risk for early discontinuation in new patients. Reasons include:
• Side effect intolerance
• Therapy ineffectiveness
• Drug switching
• Dose changes
• Hospitalization
• Death
Split-Fill addresses waste associated with unused drug by splitting the initial 28 or 30 day cycle into two equal partial fills (either 14
or 15 days) for the first three months of therapy. Split-Fill addresses therapy adherence by reducing the high drop-off rate as a result
of increased member contact and clinical support during the first three months of therapy. Member copays will be prorated as the
member will only pay half of the 30-day copay when only a 14 or 15 day supply of medication is dispensed.
PICA AND ESI PRESCRIPTION DRUG BENEFITS THROUGH YOUR WELFARE FUND
If you have prescription benefits with ESI through your welfare fund continue to use the same prescription drug card. PICA and non-
PICA drugs will be covered by the same card.
PICA AND OTHER DRUG PLANS
In general, PICA drugs are not covered by a health plan's optional prescription drug rider or union welfare fund. Use your
prescription drug card for medications not covered by PICA.
64 | Page
HEALTH PLANS FOR MEDICARE-ELIGIBLE RETIREES AND THEIR MEDICARE-ELIGIBLE DEPENDENTS
IMPORTANT INFORMATION ABOUT HEALTH PLAN ENROLLMENT AND DISENROLLMENT
Many Medicare HMOs (even those not participating in the City’s program) market directly to Medicare-eligible retirees. Because of
certain rules set up by the Federal Government a retiree wishing to enroll in a Medicare HMO must complete a special application
directly with the health plan he or she elects to join. For those plans participating in the Health Benefits Program, the procedure is to
have the retiree complete the application with the health plan (each enrollee must complete a separate application). The health plan
then sends a copy of each application to the Health Benefits Program in order to update the retiree's record to ensure that the
correct deductions, if applicable, are taken from the retiree's pension check.
Problems can arise when the retiree does not tell the health plan that he/she is a City of New York retiree, in which case the
application is not forwarded to the Health Benefits Program Office. This can cause several problems such as: incorrect pension
deductions and insufficient health coverage. Therefore, there are several rules you should follow to ensure that you do not
jeopardize your health plan coverage under the Health Benefits Program.
ENROLLING
When you enroll directly with the Medicare HMO make sure that you inform the health plan representative that you are a “City of
New York” retiree. If your spouse is also covered by you for health benefits, make sure that he/she also completes an enrollment
application. Both the retiree and covered dependent(s) must be enrolled in the same health plan under the City’s program. To enroll
in a Medicare supplemental plan you must do so through the Health Benefits Program Office.
TRANSFERRING FROM A MEDICARE HMO TO A SUPPLEMENTAL PLAN
If you disenroll from a Medicare HMO and you wish to transfer to a Medicare supplemental plan, such as GHI/ANTHEM Senior Care,
you can do so only during the Transfer Period. If you wish to transfer at any other time, unless you are moving out of the health
plan's service area or the health plan is closing in your area, you must use your Once-in-a-Lifetime Option. If you wish to transfer to a
supplemental plan, you must notify the HMO or the Social Security Administration, in writing, that you no longer wish to participate
in that HMO.
TRANSFERRING FROM A MEDICARE HMO TO ANOTHER MEDICARE HMO
If you wish to disenroll from a Medicare HMO and wish to join another Medicare HMO you can do so by enrolling directly in the new
plan. If you wish to disenroll from a Medicare HMO and are not enrolling in another Medicare HMO, you must notify the health plan
or the Social Security Administration, in writing, that you no longer wish to participate in that plan. If you do not notify the health
plan or the Social Security Administration that you no longer wish to participate you will not have any coverage from either the
health plan or from Medicare.
PRESCRIPTION DRUG COVERAGE
Medicare-eligible retirees enrolled in these plans will receive enhanced prescription drug coverage from the Medicare HMO (as
described in each plan’s summary page) if their union welfare fund does not provide prescription drug coverage, or does not provide
coverage deemed to be equivalent, as determined by the Health Benefits Program, to the HMO enhanced coverage. The cost of this
coverage will be deducted from the retiree’s pension check. Some welfare funds may pay the cost of the coverage on behalf of the
retiree or reimburse the retiree for all or part of the cost of the coverage. Consult your welfare fund for details.
65 | Page
MEDICARE SUPPLEMENTAL PLANS
The traditional Medicare supplemental plan allows for the use of any provider and reimburses the enrollee who may be subject to
Medicare or plan deductibles and coinsurance.
The following are supplemental plans:
Supplemental Health Plan
Phone Number
Website Address
DC 37 Med-Team Senior Care (DC 37 members only)
(800) 624-2414
www.emblemhealth.com/city
Anthem Medicare-Related Coverage
(800) 767-8672
www.anthem.com/nyc
GHI/ANTHEM Senior Care:
Group Health Incorporated
Anthem Blue Cross and Blue Shield
(800) 624-2414
(800) 767-8672
www.emblemhealth.com/city
www.anthem.com/nyc
MEDICARE HMOS & MEDICARE ADVANTAGE PLANS
Medicare HMO plans are those in which medical and hospital care is only provided by the HMO. Any services, other than emergency
services, that are received outside the HMO, that have not been authorized by the HMO, will not be covered by either the HMO or
Medicare. Any cost incurred would be the responsibility of the enrollee.
The following plans are approved Medicare HMOs and Medicare Advantage Plans:
Health Plan Available in NY Metro Area
Phone Number
Website Address
Aetna Medicare Advantage Plan (PPO)
with an Extended Service Area (ESA)
(800) 307-4830
cony.AetnaMedicare.com
Elderplan
(866) 360-1934
www.elderplan.org
Anthem Medicare Preferred (PPO)
(833) 848-8730
www.anthem.com/nyc
HIP VIP Premier Medicare Plan
(800) 447-6929
www.emblemhealth.com/city
United HealthCare Group Medicare Advantage Plan
(800) 457-8506
www.uhc.com
Health Plan Available outside NY Metro Area
Phone Number
Website Address
Aetna Medicare Advantage Plan (PPO)
with an Extended Service Area (ESA)
(800) 307-4830
cony.AetnaMedicare.com
AvMed Medicare Plan (FL only)
(800) 782-8633
www.avmed.org
BlueCross BlueShield of Florida Health Options, Inc.
(CLOSED TO NEW ENROLLMENTS)
(800) 876-2227
www.bcbsfl.com
CIGNA Medicare (Arizona only)
(800) 592-9231
www.cigna.com
Humana Gold Plus (Florida only)
(800) 833-1289
www.humana.com
MEDICARE COORDINATION OF BENEFIT PLANS
Health Plan
Phone Number
Website Address
GHI HMO Medicare Senior Supplement
(877) 244-4466
www.emblemhealth.com/city
Important: Retirees wishing to enroll in the Aetna Medicare Plan or a Medicare HMO must complete a special application directly
with the health plan he or she elects to join. To enroll the retiree must complete the specific health plan application (each enrollee
must complete a separate application) and return it to the health plan. A copy of the application is sent to the Health Benefits
Program (HBP) from the health plan in order for HBP to update its files and to make sure that the correct deductions, if applicable,
are taken from the retiree’s pension check.
66 | Page
DC 37 MED-TEAM SENIOR CARE
The DC 37 Med-Team Senior Care health insurance plan is offered by GHI to DC 37 Med-Team
Medicare-eligible retirees. This plan, which supplements Medicare, has no pension deduction.
At a Glance
Plan Type
Medicare Supplemental Plan
Geographic Service Area
Nationwide
Contact Information
(212) 501-4444 or (800) 624-2414 (Representatives are available Monday through Friday, 9:00
am to 5:00 pm). TDD, call toll-free at 1.866.248.0640. Please identify yourself as a DC 37
member. You may also write to: DC 37 125 Barclay St., 3rd Fl., New York, NY 10007.
Web Site
emblemhealth.com/city
DC 37 Med-Team’s hospital coverage supplements Medicare Part A to provide benefits for such services as semi-private room and
board and general nursing care. The plan’s medical coverage supplements Medicare Part B to provide benefits for such services as
physician visits and supplies.
With DC 37 Med-Team Senior Care, you can go to any provider.
• If you go to providers who accept Medicare and the services are covered, the plan will cover all but a $50 deductible per
person per calendar year.
• If you go to providers who do not accept Medicare, you may have more out-of-pocket expenses.
Each Medicare Part A inpatient hospital admission is subject to a $100 deductible.
Some services are subject to deductibles, copays, and maximum benefits.
Precertification: Certain services require precertification. Failure to comply with the pre-certification requirements may result in a
reduction of benefits.
67 | Page
ANTHEM MEDICARE-RELATED COVERAGE
Anthem Medicare-related coverage offers Medicare-eligible retirees protection from costly health
care by filling the gaps in Medicare coverage.
At a Glance
Plan Type
Medicare Supplemental Plan
Geographic Service Area
Nationwide
Contact Information
Call 1-800-767-8672 (Monday through Friday, 8:30 a.m. to 5:00 p.m.) or write:
Anthem Blue Cross and Blue Shield City of New York Dedicated Service Center P.O. Box 1407
Church Street Station N.Y., NY 10008-3598
Web Site
www.anthem.com/nyc
While Medicare Parts A and B cover hospital and medical care, most benefits are subject to deductibles or coinsurance. This
Medicare Supplement plan helps retirees with Medicare Parts A and B avoid out-of-pocket costs by reimbursing the deductible and
coinsurance amounts.
For example, if you are hospitalized because you need surgery, the plan’s hospital coverage, combined with Medicare Part A,
provides benefits for room, board, general nursing, and other hospital services. The plan’s medical coverage, with Medicare Part B,
provides benefits for physician services and supplies.
PRESCRIPTION DRUG COVERAGE
Retiree must purchase the Optional Rider in order to receive the following prescription drug benefit.
Retail*: $10/$25/$50 and 25% for biologicals up to 30-day supply.
Mail*: $20/$50/$100 and 25% for biologicals up to 30-day supply.
Member pays copays up to $4,130. After member reaches $4,130 member pays a $10 Generic copay, pays 25% coinsurance for
preferred brand and non-preferred drug costs up to $6,550. After $6,550 in out-of-pocket costs, member pays for Generic drugs 5%
coinsurance with a minimum copay of $3.70 and a maximum copay of $10, and for brand name drugs member pays 5% coinsurance
with a minimum copay of $9.20 and a maximum copay of $25 (Specialty limited to 30-day supply).
*$0 copay for Select Drugs - this plan gives you access to some of the most commonly prescribed and proven generic drugs —
treating conditions like diabetes, hypertension and high cholesterol — with zero out-of-pocket expenses.
A comprehensive nationwide pharmacy network provides access to 66,000 locations that includes most national chains and many
local pharmacies.
68 | Page
GHI/ANTHEM SENIOR CARE
If you are a Medicare-eligible retiree enrolled in either GHI/ANTHEM or GHI Type C/Anthem Senior
Care supplements your Medicare coverage. After you have satisfied the Medicare Part B deductible,
you will be responsible for an additional $50 of covered Senior Care services per individual, per
calendar year. GHI then pays the Medicare Part B coinsurance (that is, 20% of Medicare Allowed
Charges) for covered services for that calendar year.
If you have Anthem Senior Care, Anthem Blue Cross and Blue Shield supplements your Medicare
coverage for inpatient hospital services, and pays the Medicare Part A inpatient deductible less a
$300 deductible per person per admission (maximum $750 per year). Anthem also supplements
some hospital Medicare Part B coverage. Such as ambulatory/surgical procedures, Chemotherapy,
Emergency Room Care. Emergency room coverage is subject to a $50 copay. The Member is
responsible for the Part B deductible.
At a Glance
Plan Type
Medicare Supplemental Plan
Geographic Service Area
Nationwide
Contact Information
EmblemHealth
55 Water St.
New York, NY 10041
(800) 624-2414
Anthem Blue Cross and Blue Shield
City of New York
Dedicated Service Center
P.O. Box 1407 Church Street Station
N.Y., NY 10008-3598
1-800-767-8672
Web Site
www.emblemhealth.com/city
www.anthem.com/nyc
Plan Type:
Medicare Supplemental Plan
OPTIONAL RIDER
From GHI: Prescription Drug Coverage
There is no deductible under this plan. There is a $120 monthly premium for this plan.
The member pays 25% of eligible prescription drug expenses between $0 and $5,030 of true-out-of-pocket costs in this initial
phase of coverage. The member then pays 25% of eligible prescription drug expenses between $5,030 up to $8,000 of true-
out-of-pocket costs in this gap phase of coverage. After the member has exceeded $8,000 of true-out-of-pocket costs in this
catastrophic phase of coverage, the member will pay $0 copay.
Members must use network pharmacies to access their prescription drug benefits, except in non-routine circumstances, and
quantity limitations and restrictions may apply. Open Formulary, Prior Authorization, Step Therapy and Quantity Level Limits all
apply.
From Anthem BlueCross BlueShield: 365-day hospital coverage
69 | Page
AETNA MEDICARE ADVANTAGE PPO ESA PLAN (PPO)
The Aetna Medicare Advantage PPO ESA Plan offers comprehensive coverage, all in one plan.
Everything from routine physicals to preventive care beyond Original Medicare and hospitalization is
covered, with the flexibility to visit a doctor or hospital of your choice. If your provider does not
participate in the Aetna Medicare network but is willing to accept your PPO plan and the provider is
eligible to receive Medicare payment, you can receive covered services at the same in-network cost
sharing amount.
At a Glance
Plan Type
National PPO Medicare Advantage Plan
Geographic Service Area
National plan. The Aetna Medicare Advantage PPO ESA Plan is available in all 50 states to City of
New York retirees who are Medicare eligible and are entitled to Medicare Part A and enrolled in
Part B, including those who are entitled to Medicare due to disability.
The Aetna Medicare Advantage PPO ESA Plan benefits for those residing in New York, New
Jersey and Pennsylvania does not have cost sharing, for those residing in all other states, the
plan pays at 100% for all covered services.
Contact Information
1-800-307-4830 (Representatives are available Monday through Friday, 8:00 a.m. to 6:00 p.m.)
Web Site
cony.AetnaMedicare.com
Aetna’s member website (
cony.AetnaMedicare.com) provides a single source for online health and benefits information 24 hours a
day, 7 days a week, including Doc Find, an online provider list and much more.
HEALTH AND WELLNESS
• Vision reimbursement – to help cover the cost toward the purchases of lenses and frames.
• Hearing aid reimbursement - to help cover some of the cost toward the purchase or repair of hearing aids.
• Fitness – access to over 17,000 gyms nationally through Silver Sneakers, at no cost to you.
• Meals – 14 healthy meals delivered to your home post inpatient or skilled nursing facility stay.
• Non-emergency transportation – 24 one-way rides, up to 60 miles one-way, so you can get to and from medical
appointments.
• MDLIVE®– convenient access to virtual behavioral health services. Confidentially meet with a MDLIVE licensed therapist or
board certified psychiatrist by phone or video appointment. You’ll have no limits on the number of visits and $0 copay.
• Teladoc® – Connect with a Teladoc physician by web, phone or mobile app from home, for nonemergency medical, 24/7.
• Resources For Living® program - Get referrals to services in your area that offer help such as house cleaning and lawn care,
transportation, social and recreational activities, and caregiver support. You just pay for the cost of the services you use.
CARE MANAGEMENT PROGRAMS
• Disease Management Program - specially trained medical professionals will work with you and your health care provider to
help you manage one or more chronic conditions.
• Cancer Screenings - receive reminders to have regular screenings for breast, colorectal and cervical cancers.
• Nurse Support - talk to our registered nurses, day or night. Based on your symptoms, they can help you decide if you need a
doctor or urgent care visit.
• National Medical Excellence Program - a registered nurse manager or a case manager will help you manage through a
difficult procedure or an unfamiliar health care system while traveling far from home.
70 | Page
OPTIONAL PRESCRIPTION DRUG PLAN (PDP) RIDER
City of New York Retirees eligible for the Aetna Medicare Advantage PPO ESA Plan have the option of adding a prescription drug plan
rider.
Formulary Open
Pharmacy Preferred Standard Day Supply
Tier 1: Preferred Generics 0% 25% 30 or 90-day (retail or mail)
Tier 2: Generics 25% 25% 30 or 90-day (retail or mail)
Tier 3: Preferred Brands 25% 25% 30 or 90-day (retail or mail)
Tier 4: Non-preferred Brands 25% 25% 30 or 90-day (retail or mail)
Tier 5: Specialty 25% 25% 30-day supply
What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you. Call Aetna Member Services for more
information.
What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan. Call
Member Services for more information.
Coinsurance up to the catastrophic phase of $8,000. Once you reach the catastrophic phase of $8,000, you pay $0 for the remainder
of the year.
71 | Page
ELDERPLAN
Elderplan is a not-for-profit organization founded right here in New York. Their primary objective is
ensuring that members of the community receive the care and support they deserve. They offer a
variety of Medicare Advantage plans tailored to fit the changing needs of Medicare and dual
Medicare and Medicaid beneficiaries at every level of health.
Elderplan is a member of MJHS Health System, a not-for-profit organization founded by Four
Brooklyn Ladies in 1907 based on the core values of compassion, dignity and respect.
Elderplan is proud to care for people of every race, ethnicity, faith, national origin, gender identity or
expression, sexual orientation or military status.
At a Glance
Plan Type
Medicare HMO
Geographic Service Area
Brooklyn, Queens, Manhattan, Bronx, Westchester
Contact Information
Elderplan
6323 Seventh Avenue
Brooklyn, NY 11220
(866) 360-1934
Contact the Enrollment Services Department between 8:00 a.m. and 8:00 p.m. 7 days a week
TTY: 711 (for hearing impaired)
Web Site
www.elderplan.org
BENEFITS
Visits to your PCP are just $0; when referred to a network specialist you pay $35. Medically necessary hospitalization is covered with
a $350 co-payment per days 1-5, $0 from days 6-90
• Routine Laboratory $0
• Routine X-Ray $20
• Preventive & Comprehensive Dental
• Routine Vision $150 every year towards glasses
• Routine Hearing $500 towards 1 hearing aid every 3 years
• Acupuncture $0 co-pay 20 visits per year
• Over the Counter (OTC) $55 every quarter (cannot be carried over) used towards health-related items at participating
pharmacies
PRESCRIPTION DRUG COVERAGE
Prescription drug coverage has a $445 deductible for tiers 4 and 5 only
*Retail: Tier 1 $4 generic Tier 2 $10 preferred generic Tier 3 $47 preferred Brand drugs Tier 4 $100 non-preferred Drugs
Tier 5 Specialty Drugs 25% coinsurance for a 30 day
**Mail: Tier 1 $8 generic Tier 2 $20 preferred generic Tier 3 $94 preferred Brand drugs Tier 4 $200 non-preferred Drugs
Tier 5 Specialty Drugs 25% coinsurance for a 30 day
*One-month supply for Standard retail (in-network), Long-term care (31-day), and Out-of-network cost share.
**60-Day supply is also available for Standard retail (in-network).
72 | Page
ANTHEM MEDICARE PREFERRED (PPO)
With Anthem Medicare Preferred (PPO), you will receive all the coverage provided by Medicare and
most Medicare supplement plans combined, plus important extra coverage. You have National Access
Plus, which allows you to see any doctor who accepts Medicare and our plan. You’re not tied to a
provider network and, if applicable, you pay the same copay or coinsurance percentage whether your
provider is in- or out-of-network.
At a Glance
Plan Type:
Medicare PPO
Geographic Service Area
The Anthem Medicare Preferred (PPO) plan offers coverage in our CMS-defined geographic
service area of all 50 states, Washington, D.C., and all U.S. territories.
Contact Information
1-833-848-8730 if you have any questions or to reserve a place at an information meeting in
your community. Please identify yourself as a City of New York retiree.
Web Site
www.anthem.com/nyc
The Anthem Medicare Preferred (PPO) plan offers a wealth of benefits designed to help you take advantage of many health resources
while keeping expenses down. See some of the key plan highlights and services below.
•
$0 copay for an annual routine physical
•
Freedom to choose providers who accept Medicare and the plan, nationwide, without a referral
•
Access to emergency care both inside and outside of the U.S.
•
Doctors available anytime, anywhere with Live Health Online
•
Silver Sneakers
R
, free membership to a participating gym
•
24-Hour Nurse Information Line, a toll-free health information hotline available to members 24 hours a day, 7 days
a week.
•
Many preventive care services are covered at 100% - using preventive care services helps you stay healthier.
•
Many routine services are included at no cost: Annual wellness visits, flu and pneumonia shots, smoking
cessation counseling, mammograms, screenings for prostate cancer, diabetes, colorectal cancer and
cardiovascular disease
•
The House Call program offers a personalized visit in your home or other appropriate health care setting that
can lead to a treatment plan tailored just for you. The House Call program is available at no additional cost for
members who qualify, based on their health needs.
•
MyHealth Advantage is a program that helps to find and suggest ways to both improve your health and help
save you money, including: regular reminders about needed care, tests or preventive health steps you can take,
prescription drug cost-cutting tips and access to health specialists ready to answer your questions, at no
additional cost.
There is a $0 co-payment for primary care providers and specialists; $50 copayment for emergency room visits; and $300 co-payment
per admission for inpatient hospital care. The plan has a $235 deductible with a $985 out-of-pocket maximum combined in-and-out
of network.
Prescription Drugs - Retirees who receive prescription drugs through their union welfare fund do not have prescription coverage
through Anthem BCBS. Retirees who do not receive prescription drugs through their union welfare fund will automatically receive
the following prescription drug benefit:
Copay or Coinsurance - $0 Select/25% Generic/25% Preferred/25% Non-Preferred for 30-day supply
Member is responsible for 25% of the drug price until your costs reaches $6,550. After the members out-of-pocket costs reach
$6,550, then the member pays 5% of the drug price or $3.70 for generics and $9.20 for brands, whichever is greater.
$0 copay for Select Drugs - this plan gives you access to some of the most commonly prescribed and proven generic drugs — treating
conditions like diabetes, hypertension and high cholesterol — with zero out-of-pocket expenses.
A comprehensive nationwide pharmacy network provides access to 66,000 locations that includes most national chains and many
local pharmacies.
73 | Page
VIP® PREMIER (HMO) MEDICARE (FORMERLY HIP VIP MEDICARE)
The VIP® Premier (HMO) Medicare plan is available to residents of Manhattan, Brooklyn, Bronx,
Staten Island, Queens, Nassau, Suffolk, Westchester, Rockland and Orange counties. If you or your
spouse is enrolled in Medicare Parts A & B, you can sign up to join the VIP® Premier (HMO) Medicare
plan. You will get all the benefits covered under Medicare, plus extra benefits provided by
EmblemHealth.
At a Glance
Plan Type:
Medicare HMO
Geographic Service Area
Manhattan, Brooklyn, Bronx, Staten Island, Queens, Nassau, Suffolk, Westchester, Rockland and
Orange counties
Contact Information
1-877-344-7364
Representatives are available Monday through Friday 8:00 a.m. to 5 p.m.
Web Site
www.emblemhealth.com/city
Now available in English, Spanish, Chinese and Korean.
As a member of the VIP® Premier (HMO) Medicare plan, you can choose a primary care physician (PCP) practicing in his or her
private office or in one of HIP’s neighborhood health care centers located throughout the New York metropolitan area. You may visit
your PCP as often as you need.
Your PCP can also refer you to the right specialists for treatment and services. You and your dependents will be covered for in-
network hospital and health services that include routine exams, health screenings, X-rays, mammography services, home care,
urgent care, mental health services, a preventive dental program and more. Any medical care – except for covered emergencies or
urgently needed care out of the area – that is not provided by your PCP or allowed by EmblemHealth will not be covered by either
EmblemHealth or Medicare.
Retirees who get prescription drug coverage through their union welfare fund are not entitled to prescription coverage under the
HIP VIP plan.
PRESCRIPTION DRUG COVERAGE THROUGH OPTIONAL RIDER ONLY
Drugs prescribed by your doctors must be received through HIP participating pharmacies. Retirees in union welfare funds where
prescription drugs are not covered will automatically get the following prescription drug benefit:
Preferred Retail: $10 copay for preferred formulary generic drugs − 30-day supply; $15 copay for preferred formulary brand
drugs – 30-day supply; $100 copay for non-preferred generic and brand drugs; 25% for coinsurance for specialty formulary,
generic and brand drugs.
Mail Order: $15 copay for preferred formulary generic drugs – 90-day supply; $22.50 copay for preferred formulary brand
drugs – 90-day supply; $100 copay for non-preferred formulary and brand drugs; 25% coinsurance specialty for formulary
generic and brand drugs.
74 | Page
UNITEDHEALTHCARE GROUP MEDICARE ADVANTAGE PLAN
If you are eligible for Medicare Parts A and B then you can be a part of UnitedHealthcare Group
Medicare Advantage, a Medicare-contracted Health Maintenance Organization. UnitedHealthcare
Group Medicare Advantage offers you a comprehensive health plan with no deductibles, and
virtually no paperwork.
At a Glance
Plan Type:
Medicare HMO
Geographic Service Area
NY - Bronx, Dutchess, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland,
Suffolk, Sullivan, Ulster, Westchester
NJ - Atlantic, Bergen, Burlington, Camden, Cape May, Cumberland, Essex, Gloucester, Hudson,
Hunterdon, Mercer, Middlesex, Monmouth, Morris, Ocean, Passaic, Salem, Somerset, Sussex,
Union, Warren
Contact Information
Pre-Enrollment - 1-877-714-0178, TTY 711
Monday - Friday 8am - 8pm. Potential retirees should identify themselves as a City of New York
retiree.
Post Enrollment: 1-800-457-8506, TTY 711 Monday - Friday 8am - 8pm
Web Site
retiree.uhc.com
FREEDOM TO CHOOSE YOUR DOCTOR
When you join the plan you have the freedom to choose your personal doctor from our list of highly-credentialed private-practice
physicians. The doctor you choose will become your primary care physician (PCP) and will work with you to coordinate all of your
health care needs, including referrals to specialists and admissions to hospitals. Doctor visits are $15 and your annual physical is
free. Chiropractic visits are a $10 copay. As a UnitedHealthcare Group Medicare Advantage Member, you’ll receive full coverage for
hospitalization when arranged or authorized by your PCP. And, in the case of an emergency, members are covered anywhere in the
world.
UnitedHealthcare Group Medicare Advantage encourages its members to take care of themselves, which is why you are entitled to a
free annual physical, free yearly mammograms and Pap smears for women, as well as podiatry, vision and hearing aid benefits.
PRESCRIPTION DRUG COVERAGE
Retirees who receive prescription drug coverage through their union welfare fund are entitled to basic prescription coverage as
follows:
Retail: $4/$28/$58/$33 to $5,030 with Part D “donut hole” up to $8,000 (member Responsible for 100% of RX cost up to
$8,000.)
Mail: $8/$74/$164/33%
If a member reaches $8,000 in true-out-of-pocket costs, member will pay $0 for both generics and brand medications.
Retirees in a union welfare fund where prescription drugs are not covered will automatically receive the following prescription
drug benefits:
Retail: $4/$20/$40/$40
Mail Order: $8/$50/$110/$110
Mail order and retail copays up to $8,000. If a member reaches $8,000 in true-out-of-pocket costs, member will pay $0 for both
generics and brand medications.
75 | Page
AvMED MEDICARE CHOICE HMO
AvMed’s mission is to improve the health of our members, which is why we pride ourselves in being
the health plan with your health in mind. We provide members with quality, cost-effective plans and
excellent member services. Our vision is to be the health plan of choice.
As an AvMed member, you are also offered additional benefits such as: Dental Plan and Silver
Sneakers gym membership.
At a Glance
Plan Type:
Medicare HMO
Geographic Service Area
Miami-Dade and Broward Counties - Florida
Contact Information
For more details about AvMed Medicare Plans, you should write or call:
AvMed Health Plans 9400 South Dadeland Blvd. Miami, Florida 33156
1-800-782-8633
Web Site
www.avmed.org
Health Management Programs: Disease Management Programs, Medication Therapy Management Program.
Miami-Dade and Broward Counties:
Visits to your PCP are $0 per visit; visits to Specialists range from $0 to $25 copay for each specialist visit for Medicare covered
benefits.
Inpatient Hospital: Days 1-5 $0 copay per day; Days 6-20 $75 copay per day; Days 21-90 $0 copay per day
Diagnostic tests, x-rays, lab services and radiology services copays and/or coinsurance:
$0 Lab services
$25 copay for Medicare covered x-rays
20% PET Scans
$25 - $60 copay for Medicare covered therapeutic radiology services
$50 - $175 Complex outpatient diagnostic tests (CT, MRI, MRA and nuclear cardiac imaging studies)
PRESCRIPTION DRUG COVERAGE
Retail: $0/$0/$25/$50/33%
Preferred Generic/Non Preferred Generic/Preferred Brand/Non Preferred Brand/Specialty Mail Order is available 3 X the
co-pay for 90 day supply
Initial coverage: $4,000
After member reaches $4,000 – Plan covers all generics through gap.
Member pays 47.5% of cost for Brand name drugs until member’s yearly out-of-pocket costs reaches $4,750. Member then pays the
greater of $2.65 for generic and $6.60 copay for brand or 5% coinsurance (whichever is greater).
76 | Page
BLUECROSS BLUESHIELD OF FLORIDA HEALTH OPTIONS - MEDICARE & MORE (FLORIDA RESIDENTS)
CLOSED TO NEW ENROLLMENTS
Health Options Medicare & More, backed by BlueCross BlueShield of Florida, is a federally qualified HMO with a Medicare contract,
available to New York City retirees who reside in Broward, Dade and Palm Beach counties. Medicare & More provides
comprehensive, preventive health care coverage, unlimited hospital and doctor care, home health care, skilled nursing facility care,
lab tests, x-rays, periodic health assessments, and prescription drugs.
When you enroll in Medicare & More, you select a Primary Care Physician (PCP) from our contracting network of health care
providers. You can be assured that any care you receive is covered if it has been provided or arranged by your PCP and there are
virtually no claims to file. The PCP you choose will provide or arrange all of your routine health care, including referrals to Medicare
& More specialists, when appropriate, and inpatient care at a Medicare & More hospital or skilled nursing facility, when necessary.
Your PCP coordinates your health care to ensure that you get the care that is right for you and to assist you in getting the most from
your Medicare & More coverage.
Should you need specialty care, your PCP will arrange it for you. Except for emergencies anywhere and out-of-area urgent care, all
care you receive must be obtained from the health care professionals and facilities in the Medicare & More provider network.
PRESCRIPTION DRUG COVERAGE
Retail: $4.00 generic drugs (31-day supply)
Mail Order: $4.00/$30.00/$70.00 for 31 days $12/$90/$210 for 90 days
After yearly out-of-pocket drug costs reach $2,930, you pay 50% until your yearly out-of pocket drug costs reach $4,700. After
member reaches $4,700 member then pays the greater of $2.60 and $6.50 or 5% coinsurance (whichever is greater).
77 | Page
CIGNA MEDICARE (ARIZONA ONLY)
Cigna Medicare Select Plus Rx is available to retirees with Parts A and B of Medicare and live in the
service area of Maricopa County and the City of Apache Junction and Queen Creek in Pinal County.
With the Cigna Medicare Preferred with RX HMO plan, you are subject to a $0 copay for PCP visits,
$15 copay for Specialist visits. Plus you’ll find extras, like annual physicals, routine services not
covered by Traditional Medicare and worldwide emergency care.
At a Glance
Plan Type:
Medicare HMO
Geographic Service Area
Maricopa County and the City of Apache Junction and Queen Creek in Pinal County, Arizona
Contact Information
Cigna Phoenix, AZ: 1-800-592-9231
Web Site
www.cigna.com
LITTLE OR NO PAPERWORK
With Cigna Medicare Select Plus Rx, there is virtually no paperwork. Each time you go for a visit, you simply show your Cigna ID card
when using a plan provider.
PRESCRIPTION DRUG COVERAGE
Retirees who receive prescription drug coverage through their union welfare fund will continue to access that coverage.
Retirees in union welfare funds where prescription drugs are not covered will automatically receive the following prescription drug
benefit:
Tier 30-day retail 90-day retail 90-day mail order
Tier 1 $3 $9 $6
Tier 2 $5 $15 $10
Tier 3 $30 $90 $60
Tier 4 $30 $90 $60
Tier 5 $30 $90 $60
You pay copays until your out-of-pocket costs reach $4,750 then you pay the greater of $2.65 for generic drugs and $6.60 for brand
drugs or 5%, whichever is greater.
78 | Page
HUMANA GOLD PLUS
Humana Gold Plus plan offers all the benefits of Original Medicare plus extra services at no
additional cost.
At a Glance
Plan Type:
Medicare HMO
Geographic Service Area
Florida: Daytona (Flagler, Volusia); Jacksonville (Baker, Duvall, Nassau); Tampa Bay (Hernando,
Hillsborough, Pasco & Pinellas); and South Florida (Broward, Dade & Palm Beach)
Contact Information
For more details or to request an enrollment kit, call: (800) 833-1289 TDD 1-877-833-4486
between 8:00 a.m. - 9:00 p.m. EST, Monday - Friday. A representative will help you with your
questions and arrange an appointment with a Humana representative to complete your
enrollment application. Please identify yourself as a City of New York retiree.
Web Site
www.humana.com
ADVANTAGES OF HUMANA MEDICARE+CHOICE PLANS
HumanaFirst® Nurse Advice Line – If you have questions about symptoms you’re having but aren’t sure if you need to see your
doctor, Humana can help. Call HumanaFirst, our toll-free, 24-hour health information line. HumanaFirst is available seven days a
week for members. It’s staffed by nurses who can help address your health concerns and answer questions about medical
conditions.
SilverSneakers® Fitness – This is a total health and physical activity program that can help people at all fitness levels.
Disease Management Program – If you have a chronic condition, we want to help you avoid complications and improve the quality
of your life. We have specific programs for many different conditions and continue to add more all the time.
MyHumana® - Whether you prefer using a desktop, laptop or smartphone, you can access your healthcare information in one
convenient place. Once you register, you can view your coverage and benefi t details, check the status of your claims, track
healthcare spending, compare drug prices, and much more!
PRESCRIPTION DRUG COVERAGE
Retail: $10 generic/$20 preferred/$40 non-preferred/25% for biologicals for 30-day supply.
Mail: $0 generic/$40 preferred/$80 non-preferred for 90-day supply. 25% for biologicals for 30- day supply.
Once member reaches true out-of-pocket costs of $4,700, the member pays the greater of $2.65 for generic (including brand drugs
treated as generic) and $6.60 for all other drugs, or 5% coinsurance.
79 | Page
GHI HMO MEDICARE SENIOR SUPPLEMENT
Retirees with both Medicare Parts A and B and age 65 and older are eligible for GHI HMO Medicare
Senior Supplement.
At a Glance
Plan Type:
Medicare Coordination of Benefits Plan
Geographic Service Area
The counties of Albany, Bronx, Broome, Columbia, Delaware, Dutchess, Fulton, Greene, Kings,
Montgomery, New York, Orange, Otsego, Putnam, Queens, Rensselaer, Rockland, Saratoga,
Schenectady, Schoharie, Sullivan, Ulster, Warren, Washington, and Westchester in New York
Contact Information
1-877- 244-4466 Monday through Friday, 8:00 a.m. to 8:00 p.m.
Web Site
www.emblemhealth.com/city
This plan provides the same comprehensive benefits of the standard GHI HMO program, and includes coverage for deductibles,
coinsurance, and services not covered by Medicare Parts A and B, but not to exceed the standard coverage provided through GHI
HMO’s program. To be covered in full, Medicare-eligibles must use GHI HMO’s participating physicians. If a non-participating
physician is used, only Medicare coverage is applicable and treatment is subject to deductibles, copayments and exclusions.
PRESCRIPTION DRUG COVERAGE
For the first $400 in eligible prescription drug expenses incurred in each calendar year, the plan pays nothing---this is known as
the yearly deductible (this $400 counts towards true-out-of-pocket costs). The member pays 25% of eligible prescription drug
expenses between $400 and $5,030 up to true-out-of-pocket costs of $825 in this phase of coverage. The member then pays
40% Brand/51% Generic of eligible prescription drug expenses up to true-out-of pocket costs of $5,030 in this phase of
coverage. After the member has reached in total, $8,000 towards true out-of-pocket costs, the member pays $0 copay.
80 | Page
SECTION X – THE CITY OF NEW YORK’S EMPLOYEE ASSISTANCE PROGRAMS
The City of New York offers its employees and their dependents a helping hand through a network of Employee Assistance Programs
(listed below). The network of Employee Assistance Programs (EAPs) are staffed by professional counselors who can help employees
and their eligible dependents handle problems in areas such as stress, alcoholism, drug abuse, mental health, and family difficulties.
An EAP will provide education, information, counseling and individualized referrals to assist with a wide range of personal or social
problems.
Communication with an Employee Assistance Program is private, privileged and strictly confidential. No information will be shared
with anyone at any time without your written consent. More information can be found on our website on www.nyc.gov/eap.
If you do not have an EAP in your agency or union, you can call the New York City Employee Assistance Program (NYC EAP) at (212)
306-7660 or e-mail us at [email protected] for additional information.
Employees of the Police and Correction Departments may use their agencies’ EAPs or the New York City EAP for alcohol abuse
treatment services. If you wish to use substance abuse treatment services you must self-refer through your health plan.
Agency EAPs
Union EAPs
Department of Sanitation
Employee Assistance Unit
(212) 437-4867
DC 37 Health & Security
Personal Services Unit
(212) 815-1250
NYC Fire Department
Counseling Services Unit
(212) 570-1693
New York City Police
Organization Providing Peer Assistance (POPPA)
(212) 298-9111
NYC Health + Hospitals
NYC Employee Assistance Program (NYC EAP)
(212) 306-7660 or e-mail eap@olr.nyc.gov
United Federation of Teachers
Member Assistance Program
(212) 701-9411
New York City Agencies (non-uniform)
NYC Employee Assistance Program (NYC EAP)
(212) 306-7660 or e-mail eap@olr.nyc.gov
NYC Housing Authority
NYC Employee Assistance Program (NYC EAP)
(212) 306-7660 or e-mail eap@olr.nyc.gov
NYC Police Department
Counseling Unit
(718) 834-8816
Corrections Department
Care Unit (Peer Counselors)
(718) 546-2273
81 | Page
SECTION XI – THE EMPLOYEE BLOOD PROGRAM
Your health plan covers the cost of administering transfusions and pays blood processing fees for employees, retirees and eligible
family members. It does not pay for the storage of your own blood for future use.
Blood replacement fees are not covered by any health plan offered by the City. To help our community maintain blood reserves
the Employee Blood Program sponsors a voluntary donor program for City employees, called the City Donor Corps. City Donor Corps
members who donate once a year are entitled to certain benefits for themselves and family members.
For further information:
Employees, please contact your agency Blood Program Coordinator.
Retirees, please call or write the central office:
NYC Employee Blood Program
Department of Citywide Administrative Services
1 Centre Street, 24th Floor
(212)-386-0554
You may also call 311 and ask for the NYC Employee Blood Program or Call (212)-NEW-YORK if outside of NYC.
The City of New York
Oce of Labor Relations
Employee Benets Program
22 Cortlandt St, 12th Floor, New York, NY 10007
nyc.gov/hbp
