The GHI Comprehensive Benefits Plan (CBP) gives you the freedom to choose in-network or out-of-network doctors. You can see any network doctor without a referral. In most cases, when you see a network doctor, your cost will just be a copay.

Using an Out-of-Network Health Care Professional

When you choose to use out-of-network doctors, payment for covered services will be made under the NYC Non-Participating Provider Schedule of Allowable Charges. The reimbursement rates 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, in addition to deductibles and coinsurance; therefore, you may have a substantial out-of-pocket expense. This plan is offered to employees and non-Medicare eligible retirees and covers medical and surgical services. Hospitalization benefits are provided to you by Empire BlueCross BlueShield.

Some services may need a prior approval. If you do not get a required prior approval, you may not get reimbursed.

If you choose to get services outside of our network, you can use the GHI CBP Allowance Calculator at or call 800-624-2414 to estimate how much EmblemHealth will reimburse you for the service. Ask your doctor for the medical procedure codes (CPT Codes) of the services you need. This can help you make a decision.

Using a health care professional in our network is a cost-effective way to use this plan. This chart shows the estimated cost of seeing a doctor outside of our network.

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Established Patient Office Visit (typically 15 minutes) — CPT Code 99213
Estimated charge for a doctor in Manhattan $215
Reimbursement under the schedule – $36
Member out-of-pocket responsibility $179
Routine Maternity Care and Delivery — CPT Code 59400
Estimated charge for a doctor in Manhattan $9,500
Reimbursement under the schedule – $1,379
Member out-of-pocket responsibility $8,121
Total Hip Replacement Surgery — CPT Code 27130
Estimated charge for a doctor in Manhattan $20,000
Reimbursement under the schedule – $3,011
Member out-of-pocket responsibility $16,989

Plan Details

GHI CBP offers great coverage everyone can afford. You get:

  • Coverage for in-network services
  • No required primary care physician (PCP)
  • Coverage of out-of-network services
  • Low copays for in-network services
  • No payroll deduction for base coverage
  • No referrals for in-network doctors
  • $0 copay at an AdvantageCare Physicians provider or Montefiore faculty-based center

Current in-network costs

  • ACPNY PCP: $0 copay
  • ACPNY Specialist: $0 copay
  • All Other PCPs: $15 copay
  • All other specialty providers: $30 copay
  • Urgent Care: $50 copay
  • Diagnostic/Lab: $20 copay
  • MRI/CAT/Hi-Tech Radiology: $50 copay
  • Physical Therapy: $20 copay
  • Emergency Room: $150 copay

Out-of-network costs

There will be no changes to your current out-of-pocket costs. You will still pay any applicable out-of-network cost-sharing plus the difference between the provider’s fee and GHI’s reimbursement (which may be substantial).

Benefits are subject to approval by the New York State Department of Financial Services.

MOOP refers to the maximum amount of in-network cost-sharing expenses that you will pay in each calendar year for covered services received from Participating Providers under the GHI/Empire BlueCross BlueShield plans combined. MOOP includes deductibles, coinsurance and copay charge amounts that you must pay for covered in-network services and any applicable riders in a calendar year. Cost-sharing amounts attributable to services received from Non-Participating Providers generally do not count toward MOOP. Amounts incurred for non-covered services and other non-covered expenses, such as amounts in excess of plan allowances as well as any financial penalties do not count toward MOOP. Premiums and/or premium contributions also do not count toward MOOP. The MOOP amount may change from calendar year to calendar year.**

For calendar years beginning January 1, 2019 – December 31, 2019** (Subject to indexing by the federal government)

Individual MOOP

  • GHI Medical MOOP: $4,550
  • EBCBS Hospital MOOP: $2,600

Family MOOP

  • GHI Medical MOOP: $9,100
  • EBCBS Hospital MOOP: $5,200

Drugs Covered

For City of New York employees who have prescription drug coverage:

  • 2020 CNY PPO Preferred Plan Full Rx Formulary

  • 2020 CNY PPO Preferred Plan Base Benefit Formulary

  • 2020 Medicare Part D Drug Formulary: Covered Medication List

    For City of New York employees who have EmblemHealth Medicare PDP coverage.

  • 2020 Step Therapy Criteria

    The drugs on this list require step therapy pre-approval. This means that your doctor must have you first try a different drug to treat your medical condition before we will cover a drug that needs step therapy pre-approval.

  • 2020 Prior Authorization Criteria

  • Recent Changes to the 2020 Medicare Part D Drug Formulary

Provider Coverage

With our robust network of quality doctors, you can get care from many of the region’s leading doctors, clinicians and facilities, including hospitals and urgent care centers.

A partner in wellness

The Right Care, in the Right Neighborhood

AdvantageCare Physicians are the newest addition to the EmblemHealth family and are now one of the largest primary and specialty care practices in New York City. With 37 locations throughout New York City and Long Island, you can find a convenient location near home or work.

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