What is the new NYC Employees PPO plan (NYCE PPO)?
NYCE PPO is a new premium-free health plan offered jointly by EmblemHealth and UnitedHealthcare. It includes health coverage for medical services (doctors and hospitals) and other medical facilities — all under one health plan and one member ID card. The current in-network copays — the flat fee you pay for visits with contracted providers — will generally remain the same, while the network will be expanded. NYCE PPO is at the final stages of the City’s procurement process and is expected to be available to all City of New York employees, pre-Medicare-eligible retirees, and their eligible dependents enrolled in the NYC Health Benefits Program, with coverage beginning January 1, 2026.

Will I still have access to my New York City, Long Island, Dutchess, Orange, Putnam, Rockland, Ulster, or Westchester counties EmblemHealth in-network providers with this plan?
Yes, your in-network EmblemHealth doctors and facilities in these areas are in NYCE PPO’s network. Make sure you show your doctor’s office your new ID card when you visit on or after January 1, 2026.

What about mental/behavioral health services?
The UnitedHealthcare behavioral health network will replace Carelon Behavioral Health (formerly Beacon Health Options), which is offered in the current GHI CBP/Anthem BlueCross and BlueShield plan. With NYCE PPO, you will have access to 39,000 providers in New York State, an increase from 12,000 in the current network. Mental/behavioral health providers will also increase nationally, from 61,000 to 418,000. Through the new plan, you will continue to have in-person and virtual care options, including access to 22 specialty mental and behavioral health provider organizations, up from the seven offered in the current plan. Examples include:

• Charlie Health for teens and adults who need mental health, substance use disorder, or eating disorder-specific care.
• Hazelden Betty Ford for virtual/digital therapy for substance use disorders.
• InStride Health for virtual/digital therapy for pediatric anxiety and obsessive-compulsive disorders (OCD).
• Talkspace for virtual/digital therapy via texting, video, or chat with licensed therapists.

• There will be one member ID card (instead of two plans and two member ID cards). 
• EmblemHealth will now provide coverage for doctors and hospitals in New York City, Long Island, and the Hudson Valley (Dutchess, Orange, Putnam, Rockland, Ulster, and Westchester counties). The new plan’s network in this area includes 78,000 doctors, health care professionals, and hospitals – up from 64,000 in the area’s current network. 
• There will be better access to mental/behavioral health providers as well, with 39,000 providers in New York State, an increase from 12,000 in the current network.
• Nationally, mental/behavioral health providers will also increase, from 61,000 to 418,000.
• The UnitedHealthcare Choice Plus network will now provide national coverage for doctors and hospitals outside EmblemHealth’s covered area, with more than 1.6 million in-network providers. That means the Choice Plus network covers areas bordering EmblemHealth’s coverage zone, for example, Bergen County, NJ, Fairfield County, CT, Sullivan County, NY, and other nearby areas, as well as the rest of the United States. You can visit nyceppo.com or call EmblemHealth Customer Service at 212-501-4444 (TTY: 711) from 8 a.m. to 6 p.m. Eastern Standard Time, Monday through Friday, to find out if your doctor outside EmblemHealth’s covered area is in the UnitedHealthcare Choice Plus network.
• With a single member portal, all your health information and documents will be in one place.

When will I get my new medical and hospital ID cards?
Your new member ID card, which will show you are a NYCE PPO member, should arrive before your coverage starts January 1, 2026. You will no longer have separate medical and hospital ID cards. Instead, you’ll have a single member ID card for all your medical needs with the same member ID number that you currently have. Please remember to only use your NYCE PPO member ID card after the plan’s coverage starts in January 2026. If you haven’t received your member ID card by the last week of December, please call 212-501-4444 (TTY: 711). 

Will my dependent still have their own member ID card?
Yes, dependents will receive their own member ID cards.

How can I get a duplicate medical ID card?
You will be able to easily view or download your NYCE PPO member ID card on the member portal or mobile app beginning January 1, 2026. You can also call EmblemHealth Customer Service at 212-501-4444 (TTY: 711) from 8 a.m. to 6 p.m. Eastern Standard Time, Monday through Friday, to ask for a duplicate medical card, or request one through the mobile app. 

What will happen to my prescription drug coverage and ID card?
If you get prescription drugs through EmblemHealth, you will continue that coverage with the new prescription drug benefit manager, Prime Therapeutics. You will use your NYCE PPO member ID card for prescriptions. If you have prescription drug coverage through your union, you will continue using that ID card for your drug coverage. If you have more questions about drug benefits delivered through EmblemHealth, see the “Prescription drugs” section of this FAQ.

When should I stop using my current medical and hospital ID card(s)? 
You should continue to use your GHI CBP and Anthem BlueCross and BlueShield plan member ID cards through December 31, 2025. After that, you’ll use the NYCE PPO member ID card.

What will happen to the GHI CBP/Anthem BlueCross and BlueShield plan, and do I need to do anything? 
If you’re an active member of the EmblemHealth GHI CBP/Anthem BlueCross and BlueShield plan, you and your eligible dependents will be automatically enrolled in NYCE PPO. NYCE PPO will replace the EmblemHealth GHI CBP/Anthem BlueCross and BlueShield plan as of January 1, 2026, unless you elect a different plan during the City’s annual fall transfer period. There will be no gap in coverage.

What will happen to GHI/Anthem Senior Care members and their dependents? 
If you’re a GHI/Anthem Senior Care member, you will remain on your current plan. If GHI/Anthem Senior Care members have dependents who are enrolled in the GHI CBP/Anthem BlueCross and BlueShield plan who are not Medicare-eligible, those dependents will be moved to the new plan. 

Is there a new member portal?
Yes, you'll have a single, brand new member portal to help you get the most from your benefits. While it will be different from your current EmblemHealth and Anthem member portals, you will have all your information in one place. 
Expect your NYCE PPO welcome package — including guidelines for using the portal and other important plan information — to arrive before January 1, 2026. Once you receive that package, you’ll be able to:

• Register for the new portal.
• Select your preference for paperless or paper communications.

Will I be able to sign in to my old EmblemHealth and Anthem portals to see historical documents like Explanations of Benefits (EOBs)? 
Yes, if you are registered for the EmblemHealth member portal by December 31, 2025, you will be able to view the previous two years of your EOBs and other historical plan materials through the EmblemHealth portal, which will be available until July 1, 2027. Your Anthem materials will be available in the Anthem portal through December 31, 2027.

Will there be a mobile app?
Yes, there will be a mobile app for NYCE PPO with easy, on-the go plan information (like providers, claims, etc.) plus features like live text and chat.

What programs does NYCE PPO offer to support my health journey? 
NYCE PPO is here to support your health journey at every stage. We've developed a suite of programs that harness the combined power of EmblemHealth and UnitedHealthcare. Wherever you are in your health journey, you can benefit from our wellness programs, behavioral health program, Maternity CARE program, disease management program, convenient virtual care, and much more.    

Will I need to get referrals from my doctor to see specialists with this plan? 
No, NYCE PPO will not require referrals.

Do I call the same customer support phone number with the new plan?
Yes. NYCE PPO will keep the same phone number. Just call 212-501-4444 (TTY: 711) from 8 a.m. to 6 p.m. Eastern Standard Time, Monday through Friday, and our representatives will be there to support you as they always have.

Does NYCE PPO use artificial intelligence (AI) for prior authorizations? 
All NYCE PPO prior authorizations will be made by qualified clinicians using clinical judgement, evidence-based guidelines, and established clinical policies. At no point will the critical decision-making involved in prior authorizations be done by anyone – or any tool – that is not a licensed health care professional.

Will limitations on IVF reset with the new plan? 
No, in vitro fertilization (IVF) limitations will remain set at three for a member’s lifetime, regardless of a member’s plan.

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

Are the same downstate 13-county hospitals currently in the GHI CBP/Anthem BlueCross and BlueShield plan covered by NYCE PPO?
With NYCE PPO, you still have access to the same EmblemHealth providers you see today – more than 78,000 premier providers and all hospitals in the 13 downstate New York counties. This includes these highly utilized hospitals and health systems:

• Hospital for Special Surgery 
• Memorial Sloan Kettering Cancer Center 
• Montefiore Health System
• Mount Sinai Health System
• New York Presbyterian Health Care System
• New York City Health and Hospitals (H+H) Corporation
• Northwell Health
• NYU Langone Health System

What if my doctor is not in NYCE PPO’s network?
Your doctor can join EmblemHealth’s or UnitedHealthcare’s network. If your doctor cannot join the network, please see the “Transitioning care” section of this FAQ. You can also continue seeing this doctor using NYCE PPO’s out-of-network benefit, which generally costs more than seeing in-network providers. 

If I see an out-of-network doctor, what can I expect to pay?
Like the current plan, NYCE PPO has a deductible for out-of-network doctors. However, you will typically pay less out of pocket than the current plan when you see out-of-network doctors because NYCE PPO will pay out-of-network doctors the Medicare allowed amount, which is generally more than the current plan pays.

Where can my providers direct questions?
Prior to January 1, 2026, providers can visit emblemhealth.com/nyceppo and uhcprovider.com/ny or call 866-447-9717 with any questions. Providers can also reach out to their relationship manager.

Will I need a primary care provider (PCP)? 
No, a PCP is not required with this plan. However, choosing a PCP can save you time, reduce stress, and help you get the most out of your health benefits. Having a PCP means having someone who knows you — and your health — personally. Your PCP is your go-to for everyday care, preventive checkups, and managing ongoing conditions. They help you stay healthy, catch issues early, and coordinate care if you ever need to see a specialist.

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

How does coverage for Applied Behavioral Analysis (ABA) therapy work? Does NYCE PPO follow New York state mandates?
Yes, all NYCE PPO benefits either meet or exceed New York state mandates. ABA therapy usually requires prior authorization through UnitedHealthcare behavioral health network. There is no limit on visits. 

I get my prescription drug coverage through my union. How does prescription drug coverage work?
If you have prescription drug coverage through your union, you will continue using that coverage for your drug benefit. All members will continue to be covered for Affordable Care Act (ACA)/New York State mandated drugs (such as diabetic medication) through NYCE PPO. For these drugs, there will be a new pharmacy benefits manager, Prime Therapeutics. You will receive more information about Prime Therapeutics, including retail and home delivery options, in the near future.

I currently use PICA to cover certain specialty drugs. Is anything changing? 
No, your PICA drug coverage with Express Scripts^® (ESI) is remaining the same. 

I get prescription drug coverage through EmblemHealth — will that continue?
You will continue getting prescription drugs through EmblemHealth. However, there will be a new pharmacy benefits manager, Prime Therapeutics. You will receive more information about Prime Therapeutics, including retail and home delivery options, in the near future. 

I get prescription drug coverage through my union — is anything changing?
NYCE PPO does not change anything about your prescription drug coverage through your union. It will continue to be managed through your union. Just like now, those who do not have coverage through their welfare fund can purchase the optional prescription drug rider. For more information on the cost of the optional prescription drug rider, visit the Office of Labor Relations.

Will I need to get new prescriptions with this plan?
No, if you get your prescription drug coverage through EmblemHealth, any active prescriptions, including mail order, will be transferred to Prime Therapeutics as long as the pharmacy you use remains in-network.

If I get prescription drug coverage through EmblemHealth, will my drugs be covered under my 2026 plan?
Every year, we review our formulary (drug list) to update the drugs your plan will cover. Your formulary may change at any time. If we change coverage for any medicine you are taking, you will receive a letter from Prime Therapeutics. If the medicine you are currently taking will now require an authorization, the letter will provide alternatives and instructions to share with your doctor. If the medicine that you are currently taking will no longer be covered, alternative medicines will be provided in the letter. If you have an existing authorization for a covered drug, the authorization will remain in effect under your 2026 prescription benefit and no further action is required.

If I get my prescription drug coverage through EmblemHealth, will I be able to obtain my specialty medicines from Accredo Specialty Pharmacy?   
Prime Therapeutics has a large network of more than 60,000 participating pharmacies to provide you access to the medicines that you need. Accredo Specialty Pharmacy participates in Prime Therapeutics pharmacy networks. You will be able to continue to get your specialty medicines with no disruption.

If I get prescription drug coverage through EmblemHealth, will I be able to obtain a 90-day supply of maintenance medicines from a retail pharmacy and/or through home delivery?
Prime Therapeutics has a large network of more than 60,000 participating pharmacies to provide you access to the medicines that you need, as well as more retail pharmacy options so that you can obtain a 90-day supply of your maintenance medicines. If you use Walgreens for your 90-day supply of maintenance medications, you may continue to do so. If your current pharmacy is not in Prime Therapeutic’s network, you will receive a letter letting you know how you can find a new pharmacy to meet your needs. Just ask your pharmacy to transfer your prescription to any participating network pharmacy that you choose that provides a 90-day supply of your maintenance medicines. (A link to Prime Therapeutics’ pharmacy network will soon be available for you to search.) 

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

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

Are GLP-1s covered by NYCE PPO?
GLP-1 medicines may be covered for diabetes (subject to prior authorization) under NYCE PPO’s medical benefit. For additional information and requirements, you can call Customer Service at 212-501-4444 (TTY: 711).

Will I need to get new prior authorizations with this plan? 
No. Your GHI CBP and Anthem BlueCross and BlueShield plan’s prior authorizations will all be transferred to NYCE PPO for you.

I’m currently in treatment or scheduled for surgery when this plan begins. How will it work moving to the new plan?
There are two things to keep in mind:

1. Prior authorization: We’ll make sure your prior authorization information is transferred smoothly so your care continues without interruption. For services starting January 1, 2026, doctors can begin submitting prior authorization requests for this plan on December 1, 2025.
2. Are your doctor and facility in-network? Given the expanded network, in the rare instance when a current in-network provider is not contracted with the NYCE PPO plan, you may qualify for transition of care coverage if you are under active treatment for certain medical conditions – for example, if you are in the second or third trimester of pregnancy. Transition of care coverage allows you to continue seeing that doctor for up to 90 days from January 1, 2026, while you transition to an in-network doctor or facility. (If you are pregnant, you may continue care through delivery and any post-partum services directly related to the delivery.) You will be able to submit a request starting December 1, 2025, and if approved, your provider will be treated as in-network during the transition period. It is important to remember to submit this request before your first 2026 doctor visit. We will review your clinical needs to help ensure your care continues smoothly. To check if your doctor is in-network, visit the provider medical search at nyceppo.com. Mental/behavioral health services work the same way. 

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

I have an appointment with a doctor after January 1, 2026. Do I need to do anything? 
You will be able to keep appointments with your currently contracted/in-network EmblemHealth providers in New York City, Long Island, and the Hudson Valley (Dutchess, Orange, Putnam, Rockland, Ulster, and Westchester counties). In-network providers have a contract to deliver services to members of this health plan. For providers outside this area, you can always visit nyceppo.com to confirm your provider is in-network.