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Action needed to continue filling prescriptions for New York State residents with Prime Therapeutics.

Action needed to continue filling prescriptions for New York State residents with Prime Therapeutics.

Action needed to continue filling prescriptions for New York State residents with Prime Therapeutics.

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NYCE PPO makes using your benefits easy:

$0 premium
One ID card
One member portal
One service team

NYCE PPO app

The NYCE PPO is a smarter, simpler, faster way for you to manage your health care benefits, right from the palm of your hand. We’re making it easier to stay connected to your health care and get answers to your benefits questions quickly and easily.

With just a tap, you can access your digital ID card, find an in-network provider, view your most recent claims information and more - on the go.

NYCE PPO app

NYCE PPO benefits at a glance

Benefit
NYCE PPO (In-network)

Primary care provider (PCP) office visit

$0 ACPNY¹/$0 NYC H+H ²
$15 participating

Specialist office visit

$0 ACPNY¹/$0 NYC H+H ²
$30 participating

Urgent care services

$25 NYC H+H²
$50 participating
$100 nonpreferred³

Emergency care

$150

Hospital

$0 H+H²/$0 MSK⁴/$0 HSS⁵
$300 participating

Teladoc Health® telemedicine

$10 per visit

1. AdvantageCare Physicians New York.
2. New York City Health + Hospitals locations.
3. CityMD and ProHealth Urgent Care within the EmblemHealth service area.
4. Memorial Sloan Kettering Cancer Center within the EmblemHealth service area.
5. Hospital for Special Surgery within the EmblemHealth service area.

Find out more about your health plan optionson the NYC Health Benefits Program website.

NYCE PPO Benefit Summary

Quality coverage in New York and nationwide

NYCE PPO offers you access to EmblemHealth network health care providers and facilities in New York City, Long Island and the Hudson Valley (Dutchess, Orange, Putnam, Rockland, Ulster and  Westchester counties). Plus you have nationwide access through the UnitedHealthcare Choice Plus network and the UnitedHealthcare behavioral health network.

Find medical providers
Find behavioral health providers

Frequently asked questions

Find answers to commonly asked questions about the NYCE PPO plan. If you do not find the answer you are looking for, please call Member Services at 212-501-4444 (TTY: 711). You can also print the FAQs for easy reference. Updated 07/08/2026.

  • What is the NYC Employees PPO (NYCE PPO) plan?

NYCE PPO is a 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.  NYCE PPO is available to all City of New York employees, pre-Medicare-eligible retirees, and their eligible dependents enrolled in the NYC Health Benefits Program.

  • What does the NYCE PPO plan include?

The NYCE PPO plan includes health coverage for medical services (doctors and hospitals) and other medical facilities — under one health plan.
• There is one member ID card.
• EmblemHealth provides coverage for doctors and hospitals in New York City, Long Island, and the Hudson Valley (Dutchess, Orange, Putnam, Rockland, Ulster, and Westchester counties). The plan’s network in this area includes 78,000 doctors, health care professionals, and hospitals.
• There is access to mental/behavioral health providers as well, with 39,000 providers in New York State.
• Nationally, 418,000 mental/behavioral health providers in the NYCE PPO network.
• The UnitedHealthcare Choice Plus network provides 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 Customer Service at 212-501-4444 (TTY: 711) 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 are in one place.

  • Do my dependents have their own member ID card?

    Yes, dependents have their own member ID cards.
  • How can I get a duplicate medical ID card?

    You can easily view or download your NYCE PPO member ID card on the member portal or mobile app. You can also call Customer Service at 212-501-4444 (TTY: 711) to ask for a duplicate medical card, or request one through the mobile app.
  • Is prescription drug information listed on my ID card?

    If you get prescription drugs through EmblemHealth, your coverage is through Prime Therapeutics. Use your NYCE PPO member ID card for prescriptions. If you have prescription drug coverage through your union, 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.

  • Is there a NYCE PPO member portal?

Yes, you have a single member portal to help you get the most from your benefits with all your information in one place.

If you have adult dependents, they can register themselves and authorize you to view their information on their portal.

  • Can I sign in to my old EmblemHealth and Anthem portals to see historical documents like Explanations of Benefits (EOBs)?

Yes, if you were registered for an EmblemHealth or Anthem plan before 2026, you can view the previous 2 years of your EOBs and other historical plan materials through the EmblemHealth portal, which is available until July 1, 2027. Your Anthem materials are available in the Anthem portal through December 31, 2027.

  • Is there be a mobile app?

Yes, there is 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. Our suite of programs harnesses 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.

  • How can I update my personal information (address, name, date of birth, etc.)?

    Active members:
    • Employees of NYCAPS Central agencies should use Employee Self-Service (ESS) to update their personal information.
    • Employees of the following agencies must contact either their HR or Benefits/Payroll Office directly:
      • 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.
      • NYC Health + Hospitals (contact Shared Services at 646-458-5634).
      • New York City Construction Authority.
      • Cultural Institutions.
      • Libraries.
      • CUNY Senior Colleges.

Retirees:

For address changes, complete and submit this form.

For other updates, complete and submit the Retiree Health Benefits Application. You must provide legal documentation for a name change, such as a copy of a marriage certificate, court order for legal name change petition, or government issued identification. 

  • How can I pay my COBRA premium?

Your COBRA invoice, containing details of your premium, is mailed to you. There are 3 ways you can make a payment:
• By phone: 212-501-4444 (TTY: 711)
• Online: emblemhealth.com/pay
• Or by mailing a check: NYCE PPO
                                          P.O. Box 21613
                                          New York, NY 10087-1613

  • Do I need to get referrals from my doctor to see specialists with this plan? 

No, NYCE PPO does not require referrals.

  • What is the Customer Service phone number for the NYCE PPO plan?

Call 212-501-4444 (TTY: 711) and our representatives are there to support.

  • Does NYCE PPO use artificial intelligence (AI) for prior authorizations?

All NYCE PPO prior authorizations are made by qualified clinicians using clinical judgement, evidence-based guidelines, and established clinical policies. At no point is the critical decision-making involved in prior authorizations done by anyone – or any tool – that is not a licensed health care professional.

  • Does NYCE PPO follow New York State mandates for health benefit coverage?

Yes, all NYCE PPO benefits either meet or exceed New York State mandates for health benefit coverage as of December 2025. Learn more about New York State’s mandates for health benefit coverage from the New York State Department of Financial Services.

  • Are fertility treatments covered?

Yes, the NYCE PPO plan covers fertility treatments. Coverage is available for up to 3 cycles of in vitro fertilization per lifetime maximum.

  • Does WINFertility manage fertility support?

Yes, WINFertility  provides fertility care support services. For questions, please call 212-501-4444 (TTY: 711).

  • If I’m currently undergoing fertility treatments, do my existing prior authorizations carry over to the NYCE PPO plan?

Yes, your existing prior authorizations carry over. You do not need to take any action if you are currently in treatment.

  • What are the limitations on IVF NYCE PPO?

In vitro fertilization (IVF) limitations remain set.

  • What is the NYCE PPO coverage for gender-affirming care?

Members are covered for gender-affirming care with in-network providers. This means that the member may be responsible for copays or coinsurance, depending on where the services are received. There is also a $2,000 benefit for travel and lodging available each calendar year if a member lives more than 75 miles away from a provider. The travel and lodging reimbursement form is located on the portal in the form center. 

For out-of-network providers, the member must meet the deductible, and then the member pays the difference between the plan allowance and the provider's fee. There is no travel and lodging benefit.

  • Does NYCE PPO include coverage when I travel outside the country?

Urgent or emergency health care services received in a country outside of the United States are covered at the out-of-network benefit level for business or vacation travel and for dependents studying abroad. There is no benefit coverage if the sole purpose of traveling outside the United States is to receive health care services.

  • What if I have a claim from outside the country?

If you receive medical care outside the United States and the provider will not coordinate payment directly with the plan, you will need to pay the claim upfront. You must submit the claim to the plan for reimbursement within 180 days from the date of service. Please refer to the SPD for more information about submitting international claims or call 212-501-4444 (TTY: 711).

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

    You can visit nyceppo.com or call Customer Service at 212-501-4444 (TTY: 711) to find out if your doctor is in NYCE PPO’s network.

  • Can I receive care from a UnitedHealthcare provider with my NYCE PPO plan?

With NYCE PPO you have access to care from an EmblemHealth network of more than 78,000 world-class providers in New York CIty, Long Island, and the Hudson Valley (Dutchess, Orange, Putnam, Rockland, Ulster, and Westchester counties) - up from 64,000 in the current network.

Outside of the downstate EmblemHealth coverage area, you have access to UnitedHealthcare's national Choice Plus network. You can choose from more than 1.6 million providers nationwide as part of your network.

Please note that if you choose a UnitedHealthcare provider within the downstate EmblemHealth coverage area, thay are only considered in-network if they are also affiliated with EmblemHealth's network. If not, thare are considered out-of-network, and you would use your out-of-network benefits for any visits.

  • Which downstate 13-county hospitals are covered by NYCE PPO?

    With NYCE PPO, you have access EmblemHealth providers – more than 78,000 premier providers and all hospitals in the 13 downstate New York counties. This includes these highly utilized hospitals and health systems:

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

  • What providers and hospitals are part of the NYCE PPO network in New Jersey?

In New Jersey, NYCE PPO plan members will have access to care from:
• 82 hospitals.
• 486 urgent care centers.
• More than 53,000 doctors and health care professionals.
• More than 15,000 mental health providers.

This includes but is not limited to large health systems such as:
• RWJ Barnabas.
• Hackensack Meridian Health.
• Atlantic Health System.
• Summit Medical Group.
• Valley Hospital.

  • Does NYCE PPO have providers in Puerto Rico?

NYCE PPO members traveling to or living in Puerto Rico have in-network coverage through the MAPFRE network of health care professionals. Look for the MAPFRE logo and contact information on the back of your member ID card. You must bring your member ID card when visiting a MAPFRE provider.

  • How do I find a durable medical equipment (DME) provider?

Using the Find a provider tool, search under the Hospital/Facility tile.

  • What if my doctor is not in NYCE PPO’s network?

Your doctor can join EmblemHealth or UnitedHealthcare 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?

NYCE PPO has a deductible for out-of-network doctors. NYCE PPO pays out-of-network doctors the Medicare allowed amount.

  • Where can my providers direct questions?

Providers can visit emblemhealth.com/nyceppo and uhcprovider.com/ny or call 212-501-4444 (TTY: 711) with any questions. Providers can also reach out to their relationship manager.

  • Do 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 a selection of doctors, health care professionals, and facilities through which NYCE PPO members will likely pay less or even $0 for certain health care services.

Preferred providers are only available in the downstate New York coverage area of New York City, Long Island, and the Hudson Valley (Dutchess, Orange, Putnam, Rockland, Ulster, and Westchester counties). They include AdvantageCare Physicians New York and New York City Health + Hospitals locations, as well as Memorial Sloan Kettering Cancer Center facilities and Hospital for Special Surgery facilities. See the NYCE PPO Summary Plan Document, or SPD, for more details on preferred providers.

Please note: A doctor, health care professional, or facility is only considered a preferred provider when offering treatment within the downstate coverage area. If you visit a preferred provider with locations outside the downstate coverage area, the provider would not be preferred, for example, in New Jersey.

  • What if I paid a bill at my provider’s office but my explanation of benefits (EOB) shows an amount I may owe?

If you paid a bill at your providers’ office, like a copay, it may appear in your EOB. Keep in mind that an EOB is not a bill, it’s an explanation of your benefits. If you owe an amount for your visit, your provider will send you a bill, which will show if you have already paid some or all of the amount owed. You can check the status of your claims anytime at nyceppo.com or on the NYCE PPO app. If you have questions, call Customer Service at 212-501-4444 (TTY: 711).

  • How do I submit a claim for out-of-network service?

There are 2 ways to submit a claim for an out-of-network service:
1) The out-of-network provider can submit the claim directly to NYCE PPO for processing.
Or
2) You can submit a claim from an out-of-network provider in one of the following ways:

Electronically:
• Secure NYCE PPO member portal: Sign in and select Claims and EOBs, then Submit a claim.
• Mobile app: Sign in and scroll to the bottom of the home page, then select Claims Submission.

Paper: Fill out this form and submit by mail or fax.

  • Are mental/behavioral health services covered by NYCE PPO?

With NYCE PPO, you have access to 39,000 providers in New York State and 418,000 providers nationwide through the UnitedHealthcare behavioral health network. You have in-person and virtual care options, including access to 20 specialty mental and behavioral health provider organizations.

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.

• InStrider 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

  • 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 as of December 2025. ABA therapy does not require prior authorization through the NYCE PPO plan. There is no limit on the number of visits. Learn more about New York State’s ABA mandate from the Department of Financial Services

  • What is Prime Therapeutics?

If you have prescription drug coverage through EmblemHealth, your pharmacy benefits manager is Prime Therapeutics. Prime Therapeutics is EmblemHealth’s pharmacy benefits manager. EmblemHealth and Prime Therapeutics work together to make sure members get the medicines they need to feel better and live well. (Note: Prime Therapeutics is not related to Amazon Prime).

Watch this video to learn how you can use the Prime Therapeutics member portal, PrimeCentral™, to easily access and make the most of your 2026 pharmacy benefits. 

  • Does NYCE PPO cover Affordable Care Act (ACA)/New York State mandated drugs (such as medicine for diabetes)?

Yes, NYCE PPO covers Affordable Care Act (ACA)/New York State mandated drugs (such as medicine for diabetes) as of December 2025. Please refer to the NYCE PPO formulary documents for more information.

  • Does Express Scripts manage the PICA drug program? 

Yes, Express Scripts(R) manages your PICA drug coverage.

  • I get my prescription drug coverage through my union. How does prescription drug coverage work?

If you have prescription drug coverage through your union, that coverage is for your drug benefit. All members are covered for Affordable Care Act (ACA)/New York State mandated drugs (such as diabetic medication) through NYCE PPO. For these drugs, the pharmacy benefits manager is Prime Therapeutics. If you have a prescription drug plan not provided by EmblemHealth, there is no change to your coverage. 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.

Watch this video to learn how you can use the Prime Therapeutics member portal, PrimeCentral™, to easily access and make the most of your 2026 pharmacy benefits.

  • Where can I find my pharmacy benefits?

Your personalized pharmacy information is available in your NYCE PPO member portal, as well as the mobile app. After signing in, select Pharmacy from the purple navigation bar, then select Visit the pharmacy to sign in to Prime Therapeutics member portal, PrimeCentral™. You can find general NYCE PPO pharmacy documents, including the drug list (or formulary) here. If you need to see your 2025 EmblemHealth pharmacy coverage with Express Scripts, continue to sign in using your Express Scripts username and password at express-scripts.com/login. If you receive medicine through PICA, continue to sign in at Express Scripts using your PICA member ID. This does not apply to the pharmacy benefits you receive through your union.

  • Who do I call with questions about the PrimeCentral member portal?

If you are trying to access PrimeCentral™ and are not able to get into the system, please contact PrimeCentral™ technical support at: 866-394-0513 (TTY: 711). Please note: benefit-specific questions should be directed to Customer Service at: 212-501-4444 (TTY: 711).

  • Why can’t I see all my information on the PrimeCentral website?

If you have not yet signed in to your profile, the website has limited features and is only intended to show if a medicine is covered (on the formulary) and the tier. You can sign in to your profile to understand more specific details about your coverage and costs beyond a 30-day supply.

  • Who is Levrx and why do they appear in my PrimeCentral™ portal or communications?

The Prime Therapeutics member portal, PrimeCentral™, is powered by Levrx, a technology company. You may see their name or logo on some materials or communications.

  • If I get prescription drug coverage through EmblemHealth, how do I find out if my drugs are covered?

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.

  • How do I request a formulary exception?

If your medicine is not on the formulary and your doctor believes there are no appropriate covered alternatives, your doctor may request an exception to our formulary. Your doctor can submit a Coverage Exception request with a statement by phone, fax, mail, or the provider portal:

Phone: 866-799-7919 (TTY: 711).
Fax: 855-212-8100
Mail:    Prime Therapeutics LLC
             2900 Ames Crossing Road, Suite 200
             Eagan, MN  55121

Provider portal: covermymeds.com or covermymeds.health

  • If I get my prescription drug coverage through EmblemHealth, can I 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. Accredo continues to provide your specialty medicines (that are not covered by the PICA program) with no changes.

  • If I get prescription drug coverage through EmblemHealth, can I obtain a 90-day supply of maintenance medicines from a retail pharmacy and/or through home delivery?

Yes. 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. You can use Walgreens for your 90-day supply of maintenance medications. 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 Find a pharmacy near you.

  • Which pharmacies can fill 90-day prescriptions?

NYCE PPO mail order and retail options:
• Mail order 90-day prescriptions are filled through Amazon Pharmacy.
• Retail 90-day prescriptions are filled at: Walgreens; Wal-Mart; Costco; Sam’s Club; Stop & Shop Pharmacy; Wegmans Food Markets, Inc.; New York Cancer & Blood Specialists; Genoa Healthcare, LLC; Hannaford Food and Drug; Hannaford Supermarket & Pharmacy; Kinney Drugs; Price Chopper Pharmacy; Quick Rx; Tops Pharmacy; and others. Find a pharmacy near you.

  • How do I sign up for Amazon Pharmacy?

All NYCE PPO members have access to prescription medicine from Amazon Pharmacy home delivery (and you don’t need an Amazon Prime membership). It's easy to get started; go to amazon.com/emblemhealth and sign up. If you have an active prescription, you will receive more information about Amazon Pharmacy in the mail. For new prescriptions, ask your doctor to e-prescribe directly to Amazon Pharmacy. With Amazon Pharmacy, you can expect:

• Easy online sign-up.
• Free home delivery in 5 days or less.
• 24/7 help from a pharmacist; you can also talk or chat with a customer care representative to ask general questions.
• Clear pricing and easy, automatic refills (optional).
• The ability to manage your medicine and order history online.
You can purchase your prescription drugs using either your drug plan copay, your rider benefits, or Amazon’s MedsYourWay discount pricing.

  • Where do I tell my doctor to send my prescriptions?

Your doctor can send your prescription to the retail pharmacy of your choice. If your doctor is ordering a mail order supply, they can send the prescription to Amazon Pharmacy (fax: 512-884-5981).

  • 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).

  • I’m currently in treatment or scheduled for surgery. How does it work moving to NYCE PPO?

    There are 2 things to keep in mind:
  1. Prior authorizations approved before January 1, 2026 were transferred to NYCE PPO so your care could continue without interruption. Foar all future services requiring prior authorization, doctors can submit prior authorization requests at nyceppo.com

  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 fromfrom the day you start on NYCE PPO, 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 submit a request and 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 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 medical provider search at nyceppo.com. Mental/behavioral health services work the same way.

    To start a transition of care request, please review, complete and submit the Transition of Care form. If you need help, call Customer Service at 212-501-4444 (TTY: 711). You will need to provide all the required information when calling.
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