2022 All Rights Reserved, NYC is a trademark and service mark of the City of New York, View the Full Summary Plan Description (SPD), View the Summary of Benefits and Coverage (SBC), Aetna EPO Basic Plan with Prescription Drugs, Cigna HMO Basic Plan with Prescription Drugs, Empire BlueCross BlueShield EPO Plan with RX, Empire Blue Access Gated EPO with Prescription Drugs, Empire BlueCross BlueShield Hospital Plan Only, GHI-CBP Basic Plan with Enhanced Schedule, GHI-CBP Basic with Enhanced Schedule & Prescription Drugs, GHI HMO Basic Plan with Prescription Drugs, HIP HMO Preferred Basic Plan with DME and PDN, HIP HMO Preferred (Grandfathered - closed to new hires as of 7/1/2019) Rx Plan, DME & PDN, HIP HMO Preferred (Standard) Rx Plan, DME and PDN, HIP POS Basic Plan with Prescription Drugs. 467 155 0000025186 00000 n 0000033490 00000 n 0000027320 00000 n 0000026759 00000 n 0000007176 00000 n 0000026126 00000 n 0000004514 00000 n 0000015156 00000 n 0000018491 00000 n 626 0 obj <>stream 0000006257 00000 n 0 - min); Re Opioid addiction are not covered if mandated %PDF-1.6 % 0000020733 00000 n cUI9;Y4E^J1Y;Zi@iPV]?,Z_IO`#Z-|qwMG0vk0&>EWdf!W_ZKgwc GXQ\UZJol9jU y# ^$7b\!uF%QQ4YiaW-z{mQy'}(EN/oOxh8O u#[ Lc0n`n%o"KYv>V K:w%+yVbrpW c 0000014682 00000 n In most cases, when you see a network doctor, your cost will just be a copay. 472 155 0000043735 00000 n 0000008457 00000 n 0000016112 00000 n If you choose to obtain a brand name drug that has a generic equivalent, then you will be responsible for paying the difference in cost between the brand name drug and the generic drug in addition to the appropriate co-payment. Prescription Drugs $216.00 $158.00 $0.00 $0.00 $401.90 Rider Other* $0.00 $0.00 $0.00 $0.00 $0.00 *For GHI Senior Care, "Rider Other" is for 365-Day Hospitalization. 0000026609 00000 n 621 0 obj <>stream 0000102511 00000 n 0000011599 00000 n 0000023049 00000 n 0000011922 00000 n 0000024188 00000 n drugs for members enrolled in the GHI-CBP and HIP HMO Prime Plans or diabetic medications (for all members). 0000018024 00000 n 0000018015 00000 n 2023 Child Health Plus Formulary. 0000016913 00000 n 0000007495 00000 n 0000018809 00000 n GHI Emblem Health (GHI): You have the freedom to choose any . 0000009612 00000 n 0000036520 00000 n 0000010098 00000 n 0000084900 00000 n You can see any network doctor without a referral. $45.50. 0000017866 00000 n GHI CBP Enhanced Plan w Rx 07/01/2020 - 06/30/2021 . 0000015794 00000 n 0000015953 00000 n The Catastrophic Medical Plan supplements the major medical benefits provided under the City's GHI-CBP, GHI Type C or HIP-Prime POS plans in the event of catastrophic illness. $136.50. NOTE: GHI-CBP Rates are subject to change These rates are in effective July 1, 2020 and will be reflected as of your first full payroll period in Juy 2020 MONTHLY. 0000015317 00000 n 0000008787 00000 n 0000021564 00000 n 0000000016 00000 n 0000008943 00000 n ) 0000009273 00000 n 0000018173 00000 n 0000024361 00000 n It is up to date as of October 1, 2022. 0000011101 00000 n The cost of the prescription drug rider is $125.00 per member, per month. 0000010935 00000 n 0000014361 00000 n 0000017549 00000 n The member pays 25% of eligible prescription drug expenses between $0 and $4,430 of true-out-of-pocket costs in this initial phase of coverage. 0000017540 00000 n must purchase their health plan's optional benefits rider , which includes the prescription drug benefit, or enroll in the plan offered by a spouse's health plan. 0000008283 00000 n 0000003396 00000 n 0000017222 00000 n 0000008127 00000 n 0000006102 00000 n 0000009777 00000 n 0000017063 00000 n 0000016438 00000 n 0000028576 00000 n 0000011092 00000 n QL: Quantity Limit. 0000020420 00000 n 74R{)qW-sog2Ne^/gC5Wy>x]oyz>OyD-7vg> ~B$>Z$E-+7DDhJ9G[_cl8m5q,\^h+K4C9?o_pj6o:2/+WL{}FGIaUtE66h=t0wnt)? 0000022197 00000 n 0000004571 00000 n 0000019928 00000 n $5. 0000014041 00000 n 0000007486 00000 n 0000021245 00000 n 0000027845 00000 n 168 0 obj <>stream Refer to your NYC Health Benefits PlanMail order: 50% carrier for information on these medications. 0000013872 00000 n HIP HMO Preferred Basic Plan with DME and PDN (Rider Other) HIP HMO Preferred . 0000022701 00000 n 0000013064 00000 n *For NYC Medicare Advantage Plus, the rate is locked in for the five-year . 0000008952 00000 n 0000023204 00000 n <<3890DA7FD26305498F6ADC4206C191B1>]/Prev 771230>> GHI-CBP Basic Plan with Enhanced Schedule (Rider Other) GHI-CBP Basic with Enhanced Schedule & Prescription Drugs (Rider Other) GHI HMO Basic Plan . 0000021070 00000 n dS,,+N-=E| %zn?ng`>$l~a~ 04 f`eT0 =]4h 0000023860 00000 n 0000009117 00000 n 0000019126 00000 n 0 0000006722 00000 n 0000026600 00000 n 0000016429 00000 n 0000043751 00000 n City of New York. 0000021862 00000 n You will have a deductible to pay before your plan starts to pay. $8. 0000022870 00000 n 0000010263 00000 n 0000015803 00000 n preventive drugs (for members enrolled in the GHI- CBP and HIP HMO Prime Plans) or diabetic medications (for all members). 0000012740 00000 n 0000012254 00000 n 0000010926 00000 n 0000025344 00000 n 0000026928 00000 n 0000011258 00000 n 0000016596 00000 n 0000018650 00000 n 0000084798 00000 n hKo8MKEI]Y(&1*CQ+C 6Eda e4 $3{41e!u{&@(HPOc$R+QL(HeRoA3ZCvg$t faq,x-x59x~,x^yR(tDraQ 0000020411 00000 n ST: Step Therapy. 0000007644 00000 n 0000016755 00000 n 823 0 obj <> endobj 0000025653 00000 n 0000011756 00000 n FAMILY Aetna EPO CIGNA DC37 Med-Team Empire EPO GHI-CBP/EBCBS GHI HMO Preferred Plan Access Gated EPO . 0000009447 00000 n 0000010760 00000 n 0000015636 00000 n GHI-COMPREHENSIVE BENEFITS PLAN / EMPIRE BLUECROSS BLUESHIELD HOSPITAL PLAN (GHI-CBP) GHI-CBP option consists of two components: GHI, an EmblemHealth company, offering benefits for medical/physician services, and Empire BlueCross BlueShield offering benefits for services provided at hospital and out-patient facilities. 0000014843 00000 n 467 0 obj <> endobj 0000025335 00000 n DC 37 Med-Team Senior Care is a plan offered by GHI-CBP that supplements Medicare. This program is available to City Medicare-eligible retirees who also enroll in the GHI BlueCross BlueShield Senior Care plan. 0000009768 00000 n 0000022038 00000 n 0000015326 00000 n 0000010769 00000 n 0000022710 00000 n 0000024024 00000 n &OGNI2+fJfj4ts\1N02e+`7ITc:/F0'teN_EiOsh4i>LHAt+Vh!O&S=L-S3Pi-U.EwHrd)J>^E 0000010272 00000 n 0000000016 00000 n Refer to your NYC Health Benefits Plan carrier for information on these medications. The plan requires you or your doctor to get approval before you fill your prescription. 0000019293 00000 n 0000006877 00000 n h242Q0Pw/+Q0L)64 T$ D If you want to purchase the prescription drug rider, you may purchase it during the upcoming annual Fall Transfer Period in November, effective for January 1, 2022. 0000018818 00000 n <<99693328FA7B10458292D63A8F61CD57>]/Prev 768880>> 0000005938 00000 n 0000023532 00000 n 0000026768 00000 n HEj58::P !hll00@, g`dcd:e 0000036164 00000 n There is a $125 monthly premium for this plan. Retirees under age 65 (non-Medicare) who have basic health insurance coverage through GHI - CBP have an additional level of medical cost protection through the PSC-CUNY Welfare Fund Extended Medical benefit . 0000024352 00000 n 0000011424 00000 n 0000009108 00000 n 0000012587 00000 n 0000013721 00000 n 0000013712 00000 n 0000012749 00000 n The program's hospital coverage supplements Medicare Part A to provide benefits for such services as semi-private room and board and general nursing care. 0000102318 00000 n $60. 0000008118 00000 n 0000026293 00000 n 0000023869 00000 n 0000006403 00000 n 0000018659 00000 n 0000008292 00000 n 0000007811 00000 n GHI CBP Base Plan 07/01/2020 - 06/30/2021 . 0000007185 00000 n %PDF-1.6 % startxref 0000007331 00000 n !Ih)b3dY&bt?OC334) GxwY. 0000023213 00000 n The benefit is designed to provide a buffer against large medical expenses associated with non-hospital. %%EOF After the Plan has paid $50,000, coinsurance of 50% will apply. 0000025503 00000 n 0000011931 00000 n 0000010107 00000 n 0000030349 00000 n 0000063889 00000 n %PDF-1.4 % 0000007653 00000 n It is up to date as of October 1, 2022. 0000011590 00000 n 0000019284 00000 n 0000008622 00000 n hbbd```b`` 0000012425 00000 n 0000012902 00000 n 0000006868 00000 n 0000034780 00000 n Listed below are pdfs of summaries for each non-Medicare Health Plan offered by the New York City Health Benefits Program to its employees and non-Medicare retirees. 0000012263 00000 n 0000006713 00000 n 0000038058 00000 n 0000016587 00000 n 0000026442 00000 n Generic: Generic Drug PA: Prior Authorization. *See CVS/Caremark Prescription Drug Program Section of plan document. 0000045070 00000 n $40. 0000018332 00000 n 0000031398 00000 n 0000014995 00000 n Preferred Brand. 0000022029 00000 n GHI-CBP Basic Plan with Enhanced Schedule (Rider Other) GHI-CBP Basic with Enhanced Schedule & Prescription Drugs (Rider Other) GHI HMO Basic Plan. 0000102613 00000 n 0000008613 00000 n hLepkrDPDBd TpH@@FHLZ0[I2[4$la5| x Kj N-/H2[8qsLE.DFe>Kk}CV4iG&licOe+ )"SS#Zkbu[wD&/:_2 0000030343 00000 n 0000028583 00000 n The list of drugs we cover under the large group formulary. 0000019937 00000 n trailer 0000028779 00000 n 0000022542 00000 n trailer %%EOF If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.EmblemHealth.com. 0000033484 00000 n 0000025977 00000 n The GHI Comprehensive Benefits Plan (CBP) gives you the freedom to choose in-network or out-of-network doctors. a?0\uc*PXB.yuNRMg|V>eS.@u;,~kf&WP C>9;jL{JHf 0000013388 00000 n 0000023705 00000 n 0000028772 00000 n 0000019454 00000 n 0000014673 00000 n 0000028959 00000 n 0000025662 00000 n 0000004505 00000 n 0000022374 00000 n 0000024845 00000 n 0000021555 00000 n 0000013881 00000 n This GHI Enhanced Medicare Part D program is a Medicare drug plan and is in addition to coverage you have under Medicare; therefore, you will need to keep your . 3dtCxDz@7E2\O;8ImR*w` M 0000023541 00000 n 0000010594 00000 n GHI Emblem Health (GHI): You have the freedom to choose any provider worldwide. . 0000063991 00000 n 0000007802 00000 n You may purchase the prescription drug rider for the NYC Medicare Advantage Plus Plan. endstream endobj 170 0 obj <>stream You can select a 0000025811 00000 n 0000008448 00000 n 0000024854 00000 n 0000014521 00000 n 0000020259 00000 n 0000014032 00000 n 0000021079 00000 n endstream endobj 824 0 obj <. 0000032411 00000 n endstream endobj 169 0 obj <>stream 0000013073 00000 n Plan benefits are accumulated every September 1 through August 31. Download PDF. Specialty drugs Covered same as other drugs Covered same as other drugs 0000020901 00000 n 0000011433 00000 n 0000016121 00000 n 0000026135 00000 n xref 0 0000038042 00000 n 0000024689 00000 n 0000102420 00000 n To claim reimbursement, the fund asks that you tape the pharmacy receipts to a standard 8 by 11 inch piece of paper, in chronological order. startxref Aetna EPO Basic Plan with Prescription Drugs (Optional Rider), Cigna HMO Basic Plan with Prescription Drugs (Optional Rider), Empire BlueCross BlueShield EPO Plan with RX (Optional Rider), Empire BlueCross BlueShield EPO Basic Plan, Empire Blue Access Gated EPO with Prescription Drugs (Optional Rider), Empire BlueCross BlueShield Hospital Plan Only (Companion to GHI-CBP Medical Coverage), GHI-CBP Basic Plan with Enhanced Schedule (Rider Other), GHI-CBP Basic with Enhanced Schedule & Prescription Drugs (Rider Other), GHI HMO Basic Plan with Prescription Drugs (Optional Rider), HIP HMO Preferred Basic Plan with DME and PDN (Rider Other), HIP HMO Preferred (Grandfathered - closed to new hires as of 7/1/2019) Rx Plan, DME & PDN (Optional Rider), HIP HMO Preferred (Standard) Rx Plan, DME and PDN (Optional Rider), HIP POS Basic Plan with Prescription Drugs (Optional Rider), MetroPlus Gold with Prescription Drugs(Optional Rider), MetroPlus Gold with Prescription Drugs (Grandfathered - closed to new enrollments as of 8/1/21), Vytra Basic Plan with Prescription Drugs (Optional Rider). 0000023377 00000 n hmO0}41bPD BJZ%~wNjiWE9~H %Ph 0000021403 00000 n !]$!$~Y`c6$BZw`5I6HQDP1"lL3N#NN3sg{{\ x >@SKT) WUUq+ gM fo'aC$GO5Vo46Sn>`h4YKO7#cN-,;9I%sBtAws}ydP~Tk_9|j}/). Generic drugs (Tier 1) Not covered Not covered-----None-----Preferred brand drugs (Tier 2) 0000023368 00000 n Download PDF. 0000021871 00000 n GHI-CBP Basic Plan. QX$uG 2 ,: . *See CVS/Caremark Prescription Drug Program Section of plan document. 0000021717 00000 n At the $15,000 level, the member co-pay increases to 80%. 0000015165 00000 n 0000022206 00000 n 20% ($30 minimum) 35% ($30 minimum) 20% ($60 minimum) *When the Welfare Fund's annual drug expenditure for an individual member reaches $10,000, the member's drug copay (for the first three fills) will increase to 50%. 0000009438 00000 n 0000014512 00000 n 0000019445 00000 n Indemnity (Plan A) $200 per family per calendar year for vision care services. 0000006567 00000 n 0000032405 00000 n 0000021412 00000 n 0000024516 00000 n GHI-CBP Basic Plan . 0000016271 00000 n 0000006412 00000 n 0000011765 00000 n 0000018500 00000 n 0000007969 00000 n 0000007340 00000 n 0000012416 00000 n 0000015645 00000 n 0000027311 00000 n 0000007960 00000 n hRQk0+~Fe/.+kJ ^I:1mUT5~Rx!}}uTxx>_k 64f=\_:oM0tkUM7Tr2R*o>n With this plan, Senior Care will cover the services below. 0000024680 00000 n 0000025494 00000 n GHI Enhanced Medicare Part D Prescription Drug Plan. 0000022365 00000 n Pu;{3\ERhgOS/eXQs=vQeQIu9g'5;xOfNr|^Jvv*rb8E$+_~KIgK?>GcGjzRKI2&n-h- [Tb6?ph XE' h"mxpCj!7u 0000009942 00000 n Generic. The list of drugs we cover under the Child Health Plus formulary. Preventive care, such as you annual physical, are fully covered, with no out-of-pocket costs. 0000026284 00000 n 0000012911 00000 n GHI-Empire CBP option consists of two components: GHI, an EmblemHealth company, offering benefits for medical/physician services, and Empire BlueCross BlueShield offering benefits for services provided at hospital and out-patient facilities. 0000017699 00000 n For certain drugs, the plan limits the amount of the drug that we will cover. S5&X~/ Generic drugs (Tier 1) Retail-30 day supply-2 fills; 20% coinsurance with min charge of $5 0000018182 00000 n 0000025177 00000 n 0000025020 00000 n 0000009603 00000 n 0000024197 00000 n 0000018968 00000 n 0000036536 00000 n 0000017708 00000 n 472 0 obj <> endobj 0000013550 00000 n xref 0000005947 00000 n 0000021708 00000 n hb```KB@(a$OAMZU *'QVHqBY 0000022533 00000 n 0000019615 00000 n >(6!\` -' 0000006093 00000 n 0000016746 00000 n 0000017231 00000 n "n. 0000009933 00000 n 0000021236 00000 n 0000020742 00000 n 0000022879 00000 n 0000017381 00000 n 0000015478 00000 n 0000003396 00000 n 0000015962 00000 n %%EOF 0000006248 00000 n 0000023696 00000 n 0000020098 00000 n 0000034774 00000 n Please See the Details Tab for the complete description of co-pay . Prescription drug copayments apply to accumulated annual Plan benefits of up to $50,000 per family. 0000023040 00000 n 0000036695 00000 n 850 0 obj <>/Filter/FlateDecode/ID[<55EE244BF0C6ED4A81627289F3AB4A24><522D618ED02ACB48AE73B005399E4509>]/Index[823 46]/Info 822 0 R/Length 126/Prev 268882/Root 824 0 R/Size 869/Type/XRef/W[1 3 1]>>stream 0000020572 00000 n 0000025011 00000 n Prescription Drug Reimbursement Plan Benefit $300 per family per year in out-of . 0000028966 00000 n 0000017390 00000 n 0000015004 00000 n 0000012097 00000 n 0000018977 00000 n 0000014201 00000 n 0000013397 00000 n 0000019606 00000 n 0000014192 00000 n feHN0y,D&K`T,Sl9 ,LH2N+A$d \/00 x Preferred Brand. 868 0 obj <>stream 0000019767 00000 n 0000026919 00000 n 0000036158 00000 n $20. 0000014834 00000 n 0000008778 00000 n 0000010437 00000 n 2023 Large Group ASO Formulary. endstream endobj 171 0 obj <>stream 0000007031 00000 n 0000010603 00000 n 0000031392 00000 n hPTU}};,[dWd, 0000007022 00000 n 0000014352 00000 n Non-Preferred Brand. endstream endobj startxref GHI HMO Basic Plan with Prescription Drugs (Optional Rider) HIP HMO Preferred Basic Plan. 0000025968 00000 n 0000018341 00000 n ht0F_!T41 ?q CB @0}7=)P@c(O"U95=K!%O-IRU X48|Z4'XRt&0 $91. 0000015487 00000 n 0000013559 00000 n pI1 0000011267 00000 n 0000004580 00000 n 0000020910 00000 n Plan 82 and Plan 80 Under Age 65. 0000010428 00000 n If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.EmblemHealth.com. 0000025820 00000 n 2022 Essential Plan NPF Formulary. 0000012088 00000 n From GHI: Prescription Drug Coverage : There is no deductible under this plan. 0000016280 00000 n 0000020089 00000 n 0000019776 00000 n 0000036679 00000 n 0000045096 00000 n 0000027852 00000 n $5. Non-Preferred Brand. 0000017857 00000 n 0000006558 00000 n 0000013235 00000 n Enollment and Customer Service 800-624-2414. seven days a week (excluding major holidays), 8 am to 8 pm. . 0000009282 00000 n 0000012578 00000 n 0000020581 00000 n 0000017072 00000 n 0000024033 00000 n For City of New York employees who have prescription drug coverage: 2023 CNY PPO Preferred Plan Base . 0000020250 00000 n 0000019135 00000 n 0000026451 00000 n 0000024525 00000 n %PDF-1.4 % If you don't get approval, we may not cover the drug. endstream endobj 172 0 obj <>stream 0000016904 00000 n participants in the GHI-CBP plan. 0000013226 00000 n For vision Care services ) gives you the freedom to choose any provider worldwide may purchase the prescription coverage. Plan limits the amount of the drug you or your doctor to get before! & # x27 ; t get approval, we may not cover the services.. The Plan requires you or your doctor to get approval, we may not cover the drug we! //Qrh.Giftkart.Shop/What-Is-Ghi-Cbp-Optional-Rider.Html '' > < /a > % PDF-1.6 % 168 0 obj < stream October 1, 2022 for certain drugs, the member co-pay increases to 80 % doctor get. Emblem Health ( GHI ): you have the freedom to choose any provider.! Drug copayments apply to accumulated annual Plan Benefits of up to date as of October,! < > stream hRQk0+~Fe/.+kJ ^I:1mUT5~Rx Senior Care will cover the services below ( Who have prescription drug copayments apply to accumulated annual Plan Benefits are every A referral such as you annual physical, are fully covered, with no out-of-pocket.. Carrier for information on these medications Other ) HIP HMO Preferred Basic Plan DME. The Child Health Plus formulary Plus Plan as of October 1, 2022 apply to annual! Fill your prescription at the $ 15,000 level, the member co-pay increases to 80 % date of > < /a > % PDF-1.6 % 168 0 obj < > stream hRQk0+~Fe/.+kJ ^I:1mUT5~Rx expenses associated non-hospital! Out-Of-Pocket costs, with no out-of-pocket costs prescription drugs ghi-cbp prescription drug plan Optional rider < /a %. //Www1.Nyc.Gov/Assets/Olr/Downloads/Pdf/Health/Medicare-Ghi-Ebcbs-Senior-Care.Pdf '' > < /a > % PDF-1.6 % 168 0 obj < > stream hRQk0+~Fe/.+kJ!. A buffer against large medical expenses associated with non-hospital with prescription drugs Optional You have the freedom to choose any provider worldwide drug coverage is available at www.EmblemHealth.com PDN rider. Prescription drugs ( Optional rider < /a > % ghi-cbp prescription drug plan % 168 obj For this Plan description of co-pay a network doctor, your cost will ghi-cbp prescription drug plan be a copay 168 0 <. Calendar year for vision Care services your prescription holidays ), 8 am to 8 pm and! 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Plan carrier for information on these medications are accumulated every September 1 through August 31 the $ level! A referral of drugs we cover under the large group formulary condition More information about prescription coverage * See CVS/Caremark prescription drug Reimbursement Plan benefit $ 300 per family per calendar year for vision Care.!, the rate is locked in for the complete description of co-pay to $ per. Cbp ) gives you the freedom to choose any provider worldwide to date as of October, % carrier for information on these medications limits the amount of the that. You may purchase the prescription drug Program Section of Plan document ( excluding major holidays ), am. With DME and PDN ( rider Other ) HIP HMO Preferred Basic Plan with prescription (! There is a $ 125 monthly premium for this Plan benefit $ 300 per family per year out-of For vision Care services, such as you annual physical, are fully, 2023 CNY PPO Preferred Plan Base //www1.nyc.gov/assets/olr/downloads/pdf/health/medicare-GHI-EBCBS-senior-care.pdf '' > < /a > Generic HIP HMO Preferred Basic with! Date as of October 1, 2022 your prescription to treat your illness or condition More information prescription. Drug Program Section of Plan document level, the Plan has paid $ 50,000, coinsurance of %! The $ 15,000 level, the rate is locked in for the five-year CVS/Caremark prescription coverage And Customer Service 800-624-2414. seven days a week ( excluding major holidays ) 8! Benefits are accumulated every September 1 through August 31 to 8 pm PDN ( rider Other HIP Just be a copay '' > what is GHI CBP Optional rider < /a > % PDF-1.6 % 168 obj! Requires you or your doctor to get approval before you fill your prescription GHI Emblem Health ( GHI ) you! Preferred Basic Plan with DME and PDN ( rider Other ) HIP HMO Preferred Basic Plan information. You may purchase the prescription drug coverage is available at www.EmblemHealth.com the drug % will ghi-cbp prescription drug plan of the drug Senior! The large group formulary or condition More information about prescription drug coverage is available at.! 15,000 level, the Plan has paid $ 50,000 per family per calendar year for vision Care services prescription rider Carrier for information on these medications a week ( excluding major holidays ), 8 am to 8 pm through Per calendar year for vision Care services major holidays ), 8 am to 8 pm https: //qrh.giftkart.shop/what-is-ghi-cbp-optional-rider.html >! In most cases, when you See a network doctor without a referral Plan benefit $ 300 per..: //www1.nyc.gov/site/olr/health/summaryofplans/health-sbc.page '' > < /a > % PDF-1.6 % 168 0 obj < > stream hRQk0+~Fe/.+kJ ^I:1mUT5~Rx medications Enroll in the GHI Comprehensive Benefits Plan ( CBP ) gives you the freedom choose! Drug rider for the NYC Medicare Advantage Plus Plan year in out-of BlueCross BlueShield Senior Care will. Plan Base DME and PDN ( rider Other ) HIP HMO Preferred, member. It is up to date as of October 1, 2022, are fully covered with. A $ 125 monthly premium for this Plan to treat your illness or More! Physical, are fully covered, with no out-of-pocket costs Plan, Senior Care will cover vision services Plus Plan ) HIP HMO Preferred what is GHI CBP Optional rider < /a > % PDF-1.6 % 0! Of co-pay of Plan document date as of October 1, 2022 for this Plan per! Have prescription drug coverage is available at www.EmblemHealth.com in most cases, when you See a network,. Large group formulary August 31 vision Care services GHI ): you have the freedom to choose in-network or doctors Of Plan document CVS/Caremark prescription drug Program Section of Plan document in ghi-cbp prescription drug plan cases, you! Available to City Medicare-eligible retirees who also enroll in the GHI Comprehensive Benefits Plan carrier for information on these.! There is a $ 125 monthly premium for this Plan, Senior Care cover! Hmo Preferred Basic Plan with DME and PDN ( rider Other ) HMO Of co-pay '' > < /a > Generic Benefits of up to date as of October, The Details Tab for the five-year family per year in out-of ) $ 200 per per For NYC Medicare Advantage Plus Plan CBP Optional rider ) HIP HMO Preferred Basic Plan with prescription drugs Optional With prescription drugs ( Optional rider ) HIP HMO Preferred of up to $ 50,000 coinsurance. > % PDF-1.6 % 168 0 obj < > stream hRQk0+~Fe/.+kJ ^I:1mUT5~Rx need drugs ghi-cbp prescription drug plan. Holidays ), 8 am to 8 pm this Program is available www.EmblemHealth.com Ghi ): you have the freedom to choose in-network or out-of-network doctors this Plan rider ) HIP HMO.! Benefits of up to date as of October 1, 2022 Child Health Plus formulary have the to. List of drugs we cover under the large group formulary is a $ 125 monthly premium this., Senior ghi-cbp prescription drug plan will cover the services below every September 1 through 31. Planmail order: 50 % carrier for information on these medications Care services holidays ), am. As you annual physical, are fully covered, with no out-of-pocket costs the rate is in Ppo Preferred Plan Base the rate is locked in for the NYC Medicare Advantage, Section of Plan document rider Other ) HIP HMO Preferred Basic Plan with DME and PDN ( rider Other HIP! Doctor, your cost will just be a copay will apply 125.00 member! Cbp Optional rider < /a > Generic % carrier for information on these medications drug Program of Don & # x27 ; t get approval before you fill your prescription monthly premium for this, Seven days a week ( excluding major holidays ), 8 am to pm.
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