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NYC Health Benefits Program
Prescription Drug Update for GHI/Anthem Senior Care and HIP VIP Members
If you have questions or are experiencing issues with your pharmacy benefits, please contact Express Scripts at 866-325-5236 or Prime Therapeutics directly at 833.998.5351.
Effective January 1, 2026, EmblemHealth pharmacy benefits under GHI/Anthem Senior Care and HIP VIP was transitioned from Express Scripts to Prime Therapeutics. Your retail pharmacy options remain the same. You will still be able to pick up your prescriptions, including 30-day supplies of acute medication prescriptions and 90-day supplies of maintenance medication, at retail pharmacy networks.
If you had Express Scripts Home Delivery/Mail Order prior to the transition, you can continue receiving your prescriptions through Express Scripts Home Delivery/Mail Order. As of January 1, 2026, you also have the option to use Amazon Pharmacy for Home Delivery/Mail Order.
Summary of changes:
- Retail: No action is needed. You can still receive your prescriptions the same way you do now through retail pharmacies.
- Mail Order: You can still receive your prescriptions the same way you do now through Express Scripts. The only change is that you now also have the option to receive mail-order prescriptions through Amazon Pharmacy.
- Mail Order through Express Scripts - This is the same home delivery service that you have had, and no change or action is needed.
- Mail Order through Amazon Pharmacy - If you would like to use Amazon Pharmacy for home delivery instead of Express Scripts, you can request your doctor to send your prescriptions to Amazon Pharmacy. You can also create an online Amazon Pharmacy account or call 844-536-4074. However, there is no need to create an Amazon Pharmacy account to use this service. Your doctor can just send your prescriptions to Amazon Pharmacy for you.
*Please Note: You do not need to create an Amazon account or have an Amazon Prime membership to utilize Amazon Pharmacy Mail Order.
IMPORTANT: You will still be able to receive all your prescriptions without establishing an online account. Having an account with Express Scripts or Amazon Pharmacy is just an option that is available if you would like to view or manage your prescriptions online.
Visit EmblemHealth to learn more about the your pharmacy benefits, including a video which explains how to access your pharmacy benefits online.
Information and update regarding the Medicare Advantage Plan - June 20, 2025
Mayor Adams stated that the City has found other ways to address health care costs while providing quality health care coverage for city workers, and the City has decided not to move forward with the Medicare Advantage plan at this time.
Please refer to Mayor Adams' June 20, 2025 statement on the future of Medicare Advantage.
Information and Update: $15 copays to resume January 1, 2025 for the EmblemHealth-GHI portion of the GHI/Anthem Senior Care Plan
Senior Care members—As you may know, $15 copays for the EmblemHealth-GHI portion of the GHI/Anthem Senior Care Plan were previously suspended by court order. Now, in accordance with a more recent court order, $15 copays will resume on January 1, 2025.
Senior Care members will receive a new ID card before January 1, 2025.
Clarification in response to questions from GHI/Anthem Senior Care members with respect to the October 18, 2024 letter sent by EmblemHealth to Senior Care members:
As set forth in the updated letter, the copays are limited to one copay of $15 per provider per date of service. See November 2024 letter from EmblemHealth and the Health Benefits Summary Program Description reflecting this information.
As of January 1, 2025, Senior Care members will be required to pay a $15 copayment each time they use the health services listed below:
- Primary Care Physician Office Visits: $15 Copayment per visit
- Specialist Office Visit: $15 Copayment per visit
- Allergy testing/injections: $15 Copayment per visit
- X-rays: $15 Copayment per visit
- Laboratory tests: $15 Copayment per test
- Complex diagnostic and radiology services: $15 Copayment per visit
- Radiation therapy: $15 Copayment per visit
- Urgent Care Services: $15 Copayment per visit
- Emergency Care (Professional Component): $15 Copayment per visit
- Mental Health Care (Outpatient): $15 Copayment per visit
- Substance Use Disorder Services (Outpatient): $15 Copayment per visit
- Physical, Occupational, and Speech Therapy: $15 Copayment per visit
- Cardiac Rehabilitation: $15 Copayment per visit
- Pulmonary Rehabilitation: $15 Copayment per visit
- Chiropractic Care: $15 Copayment per visit
- Podiatry Care: $15 Copayment per visit
- Vision Care: $15 Copayment per visit
Please note, that Senior Care members are responsible for the annual Medicare Part B deductible and $50 GHI Senior Care deductible.
For questions, please call the EmblemHealth Customer Service phone number on the Senior Care member ID card.
Visit the Plans & Rates page of the Health Benefits Program wesbite to review other City’s health plan options for Medicare eligible retirees and their Medicare eligible dependents.
Retiree Responsibilities and Assistance
Medicare Part B and IRMAA Reimbursement
Information about Medicare and IRMAA Reimbursement Learn More
Medicare Part B Reimbursement
The City reimburses retirees and their eligible dependents for Medicare Part B premiums paid, excluding any penalties. You must be receiving a City pension check and be enrolled as the contract holder for City health benefits in order to receive reimbursement for Part B premiums.
For most retirees, the refund is issued automatically by the Health Benefits Program. The reimbursement amount is based on the standard Medicare Part B premiums.
Medicare Part B reimbursements are issued to eligible retirees annually during the month of April. If you are currently receiving your pension check through Electronic Fund Transfer (EFT) or direct deposit, your reimbursement will be deposited directly into your bank account. This will be separate from your pension payment. If you don’t have EFT or direct deposit, you will receive a check in the mail.
What is IRMAA?
The Income-Related Monthly Adjustment Amount (IRMAA) is an additional amount that you are required to pay for your monthly Medicare premiums if you have higher annual earnings.
Medicare-eligible retirees and their Medicare-eligible dependents can submit an IRMAA application if they paid above the standard amount per month. If you did not pay more than the standard amount then you are not eligible for IRMAA. Please do NOT submit an IRMAA application if you are not eligible for reimbursement.
IRMAA reimbursements are issued to eligible retirees annually during the 3rd week of October. If you are currently receiving your pension check through Electronic Fund Transfer (EFT) or direct deposit, your reimbursement is deposited directly into your bank account. This is separate from your pension payment. If you don’t have EFT or direct deposit, you will receive a check in the mail.
The Medicare Part B Reimbursement Program video provides information about the different types of Medicare Part B reimbursements that the City provides, as well as information to help you to see whether you qualify to receive these payments, and how to apply.
Your Responsibilities
It is important that you know how your health plan works and what is required of you. Learn More
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
Who you should contact for assistance and when you should contact them Learn More
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 and Telephone Number
Complete Social Security Number
Pension Number
Inquiries and questions can be emailed to: healthbenefits@olr.nyc.gov
Who Do I Contact After Retirement?
Find out who you should contact after retirement. Learn More
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
When Should I Contact My Health Plan?
Find out when you should contact your Health Plan. Learn More
(Refer to your health plan identification card or plan booklet for telephone numbers.)
- 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.
When Should I Contact My Union/Welfare Fund?
Find out when you should contact your Union/Welfare Fund. Learn More
For information about:
- Prescription drug coverage (if applicable)
- Vision benefits
- Dental benefits
- Life Insurance (if applicable)
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 and Telephone Number
Complete Social Security Number
Pension Number
Inquiries and questions can be emailed to healthbenefits@olr.nyc.gov
