Summary comparison of health plans
This chart compares New York City health plans for in-service employees and retirees not yet eligible for Medicare and is best viewed on a desktop computer. View the PDF Version of this chart
Rates as of January 2026. Subject to change.
| TYPE OF PLAN | PPO | HMO | HMO | POS | EPO | GATED EPO | OPEN ACCESS EPO | HMO | HMO | HMO | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NAME OF PLAN | NYCE PPO | HIP HMO Gold Preferred Plan (Grandfathered) | HIP HMO Gold Preferred Plan (Standard) | HIP PRIME POS | ANTHEM EPO | ANTHEM BLUE ACCESS GATED EPO | AETNA INC. EPO | VYTRA | *GHI/HMO | *METROPLUSHEALTH GOLD | ||||||||||
| MONTHLY COST Rates Effective 1/1/26 (subject to change) | - Basic coverage: $0; - Retiree optional prescription rider*: • Individual: $123.86 • Family: $227.09 Due to the NYCE PPO nationwide network expansion, the employee optional out-of-network reimbursement rider is no longer offered. | Basic coverage: $0 | Closed to new enrollment Retiree option*: •Individual: $448.51 •Family: $1,098.85 | Basic coverage: $0 | Basic with retiree option: •Individual: $149.50 •Family: $274.08 | Basic only*: •Individual: $1,467.89 •Family: $3,596.05 | Basic with retiree option: •Individual: $2,058.66 •Family: $5,043.73 | Basic only: •Individual: $1,327.22 •Family: $3,374.92 | Basic with retiree option: •Individual: $1,968.72 •Family: $4,947.58 | Basic only: •Individual: $455.89 •Family: $1,352.92 | Basic with retiree option: •Individual: $1,097.39 •Family: $2,925.58 | Basic only: •Individual: $869.93 •Family: $3,026.90 | Basic with retiree option: •Individual: $3,975.64 •Family: $12,033.42 | Basic only: •Individual: $321.67 •Family: $1,049.71 | Basic with retiree option: •Individual: $848.41 •Family: $2,420.08 | Basic only: •Individual: $396.28 •Family: $1,120.65 | Basic with retiree option: •Individual: $1,014.04 •Family: $2,696.07 | Basic only: •Individual: $0 •Family: $0 | Basic with retiree option: •Individual: $131.50 •Family: 251.20 | |
| Phone Number | 212-501-4444 | 833-CNY-GOLD / 833‑269‑4653 | 800-244-6224 | 800-447-8255 | 800-767-8672 | 833-924-1055 | 800-445-8742 | 866-409-0999 | 877-244-4466 | 877-475-3795 | ||||||||||
| WEBSITE | www.nyceppo.com | www.emblemhealth.com/city | www.emblemhealth.com/city | www.emblemhealth.com/city | www.anthem.com | www.aetna.com | www.emblemhealth.com | www.emblemhealth.com/city | www.metroplus.org/plans/city-employees/gold | |||||||||||
| Overview | ||||||||||||||||||||
| MEDICAL/SURGICAL — In-Network or Participating Provider | Preferred - $0 copay (ACPNY & H&H). Participating - $15 for primary care/$30 specialist/$50 urgent care. $100 copay at CityMD & ProHealth, $25 copay at NYC Health & Hospital locations. | Preferred provider, no copay. Nonpreferred, $10 copay. Urgent care, $50 copay. | Preferred provider, no copay. Nonpreferred, $10 copay. Urgent care, $50 copay. | $10 copay primary care/$15 copay specialist. Urgent care, $15 copay. | $15 copay. Urgent care: $15 copay. Includes doctor services. Additional charges may apply depending on the care provided. Out-of-network covered as in-network. | $15 copay. Urgent care: $15 copay. Includes doctor services. Additional charges may apply depending on the care provided. Out-of-network covered as in-network. | Covered in full minus copays as specified below. | $5 copay for PCP and specialist. Urgent care $5 per visit when using a participating provider. If you visit an urgent care center that is not in Vytra's network, the service is not covered. | $15 copay for PCP and specialist. Urgent care $50 copay. $100 copay applies specifically to CityMD and ProHEALTH Urgent Care centers. | Participating providers' services are provided at no cost. Urgent care copay: $25. | ||||||||||
| MEDICAL/SURGICAL — Out-of-Network or Non-Participating Provider Deductible | $200 individual/$500 family per calendar year. | Not applicable. | Not applicable. | $750 annual deductible per person, $2,250 for a family. | In-network benefits only. | In-network benefits only. | Not applicable. | Not applicable. | Not applicable. | Non-participating provider services are not covered except for emergency care. | ||||||||||
| Coinsurance/Schedule | For out-of-network only: After deductible is met, NYCE PPO pays 100% of the allowed amount. | Preferred provider, no copay. Nonpreferred PCP, $10 copay. No out-of-network benefits. | Preferred provider, no copay. Nonpreferred PCP, $10 copay. No out-of-network benefits. | For out-of-network only, 70% of the customary charges as determined by HIP. Customary charges are based on nationally recognized fee schedule. Patient responsible for 30% plus charges in excess of customary charge. | Not applicable. In-network benefits only. | Not applicable. In-network benefits only. | Not applicable. | $5 copay for PCP and specialist in-network only | $15 copay for PCP and specialists | in-network only Not applicable. In-network benefits only. | ||||||||||
| Stop Loss/Catastrophic | Maximum out-of-pocket: $7,150 individual/$14,300 family (this is combined medical and hospital). Once total out-of-pocket maximum is reached, member cost share will be waived for the remainder of the calendar year. | No limit in-network. | No limit in-network. | After $3,000 coinsurance per person, $9,000 for family, payment at 100% of customary charges. Charges in excess of covered charges remain the patient's responsibility. | Not applicable. In-network benefits only. | Not applicable. In-network benefits only. | Not applicable. | Not applicable. | Not applicable. | In-network benefits only. | ||||||||||
| Maximums | Unlimited. | Unlimited. | Unlimited. | Unlimited. | Unlimited. | Unlimited. | None. | Unlimited. | Unlimited. | Unlimited. | ||||||||||
| Notification and/or Approval | No referrals needed. Preauthorization for some services required. | Referrals needed for specialists. Preferred provider: no copay. Nonpreferred PCP: $10 copay. | Referrals needed for specialists. Preferred provider: no copay. Nonpreferred PCP: $10 copay. | Referrals needed for in-network specialists. | Precertification required for inpatient admission, home health care, home infusion therapy, physical therapy, occupational therapy, hospice, skilled nursing, speech therapy, cardiac rehab, MRI, MRA, durable medical equipment, inpatient and outpatient surgery, maternity, air ambulance. | PCP referral required for specialist visit. Precertification by PCP required for inpatient admission, home health care, home infusion therapy, physical therapy, occupational therapy, hospice, skilled nursing, speech therapy, cardiac rehab, MRI, MRA, durable medical equipment, inpatient and outpatient surgery, maternity, air ambulance. | None. | Written approval is required to see specialist. | Written approval is required to see specialist. | No written referral required for specialist visits. | ||||||||||
| Sample Restrictions (POS Plan) | Not applicable. | Not applicable. | Not applicable. | There are in- and out-of-network benefits on this plan. | In-network benefits only. | In-network benefits only. | None. | Not applicable. | Not applicable. | Not applicable. | ||||||||||
| HOSPITALIZATION — In-Network or Participating Provider | $300 copay per admission up to $750 per calendar year maximum. | $100 copay. Centers of Excellence, Hospital for Special Surgery and Memorial Sloan Kettering Cancer Center, $0 copay. Not applicable. | $100 copay. Centers of Excellence, Hospital for Special Surgery and Memorial Sloan Kettering Cancer Center, $0 copay. Not applicable. | In-network, $100 copay per admission. Out-of-network, covered 70% after deductible. | As many days as medically necessary, semiprivate room and board covered in full with prior precertification from Anthem's Medical Management Program and subject to copay of $250 individual/maximum $625 per calendar year per contract. | As many days as medically necessary. Semiprivate room and board. $300 copay per admission. | $300 hospitalization copay. | No copay. | No copay. | $0 covered in full. | ||||||||||
| HOSPITALIZATION — Out-of-Network or Non-Participating Provider | $500 copay per visit per admission and 20% coinsurance and balance billing. | Not applicable. | Not applicable. | In-network benefits only. | In-network benefits only. | Not covered. | Emergency services only. | $35 copay emergency room care out- of-network. Urgent care not covered out-of-network. | Not covered. | |||||||||||
| IN-HOSPITAL SPECIALIST CONSULTATION | Payment in full for participating providers. Limited to one per specialty per confinement for each condition. Covered only upon referral of your provider. | $100 copay; Centers of Excellence, Hospital for Special Surgery and Memorial Sloan Kettering Cancer Center, $0 copay. | $100 copay; Centers of Excellence, Hospital for Special Surgery and Memorial Sloan Kettering Cancer Center, $0 copay. | In-network: included in hospital admission copay. Out-of-network: covered 70% after deductible. | All services covered in full with prior precertification from Anthem's Medical Management Program and subject to copay of $250 individual/ maximum $625 per calendar year per contract for any inpatient admission. | All services covered in full with prior precertification from your PCP by Anthem's Medical Management Program and subject to copay of $250 individual/ maximum $625 per calendar year per contract for any inpatient admission. | Covered in full. | Covered in full. | Covered in full. | $0 covered in full. | ||||||||||
| SURGERY (In or out of hospital) | Inpatient: In-network: $300 copay per admission up to $750 per calendar year combined with skilled nursing care. Out-of-network: $500 copay per admission up to $1,250 per calendar year; 20% coinsurance up to $2,000 per calendar year. You pay the difference between the plan allowance and the provider's fee. | $150 at hospital and $50 at other facilities. | $150 at hospital and $50 at other facilities. | In-network: $100 copay ambulatory surgery. Out-of-network: covered 70% after deductible. | Covered in full. Outpatient surgery center copay $75. | $0 copay for ambulatory surgery, inpatient covered in full. | Covered in full. | $0 covered in full. | ||||||||||||
| ASSISTANT AT SURGERY | Schedule of allowances. | Covered in full. | Covered in full. | In-network: included in hospital admission copay. Out-of-network: covered 70% after deductible. | Covered in full. | Covered in full when medically necessary. | Covered in full. | $0 covered in full. | ||||||||||||
| IN-HOSPITAL ANESTHESIA | Payment in full for participating providers. | Covered in full. | Covered in full. | Covered in full after $300 copay. | Covered in full. | Covered in full. | $0 covered in full. | |||||||||||||
| MATERNITY AND RELATED CARE | $300 copay for mother's hospital stay. For most other charges, payment in full for participating providers. | Covered in full. | Covered in full. | In-network: $15 copay for first OB visit only. $300 hospitalization copay. | $0 copay. | In-network: First visit $15 copay OB/GYN visits. Hospital covered in full. | $0 covered in full. | |||||||||||||
| NEWBORN WELL-BABY NURSERY CHARGES | Initial in-hospital pediatric visit payment in full for participating providers. | Covered in full. | Covered in full. | Covered in full. | Covered in full. | Covered in full if added to plan/contract within 30 days. | $0 covered in full. | |||||||||||||
| NEWBORN WELL-BABY MEDICAL CARE | We cover well-baby and well-child care which consists of routine physical examinations including vision screenings and hearing screenings, developmental assessment, anticipatory guidance and laboratory tests ordered at the time of visit as recommended by the American Academy of Pediatrics. We also cover preventive care and screenings as provided for in the comprehensive guidelines supported by HRSA and items or services with an "A" or "B" rating from USPSTF. If the schedule of well-child visits referenced above permits one (1) well-child visit per calendar year, we will not deny a well-child visit if 365 days have not passed since the previous well-child visit. Immunizations and boosters as required by ACIP are also covered. This benefit is provided to members from birth through attainment of age 19 and is not subject to copays, deductibles or coinsurance when provided by a preferred or participating provider. | Covered in full. | Covered in full. | In-network: no copay. Out-of-network: covered 70% after deductible. | No copay. | Covered in full. | Covered in full. | $0 covered in full. | ||||||||||||
| PREVENTIVE CARE (Including Well-Child Care & Immunization) | $0 copay. | Covered in full, including routine physicals. | Covered in full, including routine physicals. | In-network: no copay. Out-of-network: subject to deductible and coinsurance. | Covered in full. No copay. | Covered in full. No copay. | In-network routine physicals, routine GYN exams, mammograms, well-child care covered in full. | No copay. | No copay, applies to well-child visits, adult annual physical exam, well- woman exams, bone-density testing. | $0 covered in full, including routine physicals. | ||||||||||
| OFFICE VISIT | Preferred - $0 copay (ACPNY & H&H). Participating - $15 for primary care/$30 specialist. | Preferred PCP, no copay. Nonpreferred PCP, $10 copay. | Preferred PCP, no copay. Nonpreferred PCP, $10 copay. | In-network: $10 copay PCP office visit/$15 specialist office visit. Out-of-network: covered 70% after deductible. | Covered in full in-network with $15 copay. | Covered in full in-network with $15 copay for PCP and specialist. | $15 copay for PCP, $20 specialists. | $5 copay. | $15 copay. | $0 covered in full. | ||||||||||
| SPECIALIST CONSULTATION — OUT-OF-HOSPITAL | Payment in full for preferred providers, $30 copay for all other participating specialists. | Preferred PCP, no copay. Nonpreferred PCP, $10 copay. | Preferred PCP, no copay. Nonpreferred PCP, $10 copay. | In-network: $10 copay PCP office visit/$15 specialist office visit. Out-of-network: covered 70% after deductible. | Covered in full in-network with $15 copay. | Covered in full in-network with $15 copay and PCP referral. | Covered in full with $20 copay. | Covered in full with $5 copay with referral from PCP. | Covered in full — $15 copay with a referral from PCP. | $0 covered in full. | ||||||||||
| X-RAYS/IMAGING & LABORATORY TESTS | X-RAYS & LABS Preferred - $0 copay (ACPNY & H&H) Participating - $20 copay ADVANCED IMAGING: $25 copay for preferred (H&H) $50 copay for participating RadNet facilities, Memorial Sloan Kettering and Hospital for Special Surgery $100 copay for all other out-of-state facilities | Preferred PCP, no copay. Nonpreferred PCP, $10 copay. $100 at hospital. | Preferred PCP, no copay. Nonpreferred PCP, $10 copay. $100 at hospital. | In-network: $10 copay PCP office visit/$15 specialist office visit. Out-of-network: covered 70% after deductible. | Covered in full in-network with no copay. | Covered in full in-network with no copay. | Covered in full. $20 copay may apply. | No copay. Prior approval required for high-tech radiology. | Diagnostic lab: $0 copay. X-ray: $15 copay. | $0 covered in full. | ||||||||||
| PRIVATE DUTY NURSING | PRIVATE DUTY NURSING Private duty nursing is rendered at home or in a hospital after you have met a separate deductible for private nursing. | Covered through HIP HMO Optional Rider. Supplemental Welfare Fund benefit for employees. No coverage first 72 hours. Reimbursed at 80% for up to 504 subsequent hours in hospital.** | Covered through HIP HMO Optional Rider. Supplemental Welfare Fund benefit for employees. No coverage first 72 hours. Reimbursed at 80% for up to 504 subsequent hours in hospital.* | In-network, covered in full. Not covered out-of- network. Supplemental Welfare Fund benefit for employees, as described under HIP Prime.** | Not covered. | Not covered. | Covered in full when medically necessary and approved and coordinated through Aetna. | Not covered. | Not covered. | Not covered. | ||||||||||
| AMBULANCE SERVICE | No copay for emergency to hospital. | No copay for emergency to hospital. | No copay for emergency to hospital. | In-network: no copay. Out-of-network: same as in-network coverage. | No copay up to allowed amount. You pay difference between allowed amount and total charge. | No copay up to allowed amount. You pay difference between allowed amount and total charge. | Covered in full when medically necessary. | No copay. | Covered in full when medically necessary. | $0 covered in full. | ||||||||||
| EMERGENCY SERVICE | $150 copay per visit. Copay waived if admitted within 24 hours. | $150 copay waived if admitted. | $150 copay waived if admitted. | In-network: $100 copay. Waived if admitted. Out-of-network: same as in-network coverage. | $35 copay waived if admitted within 24 hours. | $35 copay waived if admitted within 24 hours. | Covered anytime, anywhere in the world, 24 hours a day, 7 days a week. $75 copay for emergency room visit (waived if admitted). $300 hospitalization copay. | ER copay: $25, waived if admitted. Urgent care: $5 copay. | $35 copay. Waived if admitted. Must notify GHI/HMO within 48 hours. | $100 (waived if admitted to hospital). | ||||||||||
| OUT-OF-AREA CARE AND/OR TRAVEL COVERAGE | Benefits are paid without regard to any geographical limitations. | Out-of-area care applies to emergency service only. | Out-of-area care applies to emergency service only. | Subject to deductible and coinsurance. | Access to over 668,000 providers and 8,500 hospitals nationwide participating in the Blue Card® PPO Program. BlueCard® Worldwide provides health care coverage for members traveling in Europe, Caribbean, Latin America, Asia, South Pacific, Africa and the Middle East. | Urgent and emergency care is available to members nationwide through Anthem's BlueCard® program's traditional provider network. Guest membership is available to HMO members living in another city for at least 90 days through local Anthem plans. Guest membership is available to Blue Access Gated EPO members living in another city for at least 90 days through local Anthem plans. | Worldwide emergency care coverage as described above. | Not covered. | Emergency room care as previously described. Emergency hospitalization is covered. | Not covered except for emergency care. | ||||||||||
| SKILLED NURSING FACILITY | In-network: $300 copay per admission not to exceed $750 per calendar year combined with inpatient hospital. Out-of-network: $500 copay per admission up to $1,250 per calendar year; 20% coinsurance up to $2,000 per calendar year. You pay the difference between the plan allowance and the provider's fee. | Covered in full, unlimited days. No copay. Authorization required. | Covered in full, unlimited days. No copay. Authorization required. | In-network: no copay, unlimited days per calendar year. Out-of-network: not covered. Authorization required. | Covered in full up to 60 days per calendar year. Precertification by Anthem's Medical Management Program is required. | Up to 60 days per calendar year. $100 copay per admission. | Covered in full when medically necessary in lieu of hospitalization and when coordinated through Aetna after $300 copay. | No copay. 45 days per calendar year. Authorization required. | Covered in full 120 days per year. Authorization required. | $0 covered in full – 200 day limit. | ||||||||||
| ROUTINE PODIATRIC CARE | Not covered except as prescribed for metabolic diseases, such as diabetes; office copay applies. | Not covered. | Not covered. | Not covered. | Not covered. | Not covered. | Covered in full with $20 copay, for diabetics only. | Routine foot care not covered except when patient is diabetic. | Routine care of the feet not covered. | Not covered except as prescribed for conditions which result in circulatory deficits or areas of decreased sensation in your feet, and then covered in full. | ||||||||||
| ALLERGY TESTING AND ALLERGY TREATMENTS | Allergy testing: $20 copay per visit. Allergy treatment: $15 copay for treatment performed in a PCP office, $30 copay for treatment performed in specialist office. | Preferred PCP, no copay. Nonpreferred PCP, $10 copay. | Preferred PCP, no copay. Nonpreferred PCP, $10 copay. | In-network: $15 copay. Out-of-network: covered 70% after deductible. | Covered in full in-network with $15 copay (waived for treatments). | Covered in full in-network with $15 copay (waived for treatments). | Covered in full with $20 copay. | Allergy testing and treatment covered in full with $5 copay. | $15 copay with PCP referral. | $0 covered in full. | ||||||||||
| CHIROPRACTIC CARE | Preferred: $0 copay (ACPNY & H&H). Participating: $15 copay per visit. | Preferred PCP, no copay. Nonpreferred PCP, $10 copay. | Preferred PCP, no copay. Nonpreferred PCP, $10 copay. | In-network: $15 copay. Out-of-network: covered 70% after deductible. | Covered in full in-network with $15 copay (when medically necessary). | Covered in full in-network with $15 copay (when medically necessary). PCP referral required. | Covered in full with $20 copay. Also, access to Choose Healthy™ Program, which provides negotiated discounted fees for chiropractic manipulation. | Not covered. | $15 copay with PCP referral when medically necessary. | $0 covered in full. | ||||||||||
| RADIATION THERAPY | Covered in full; authorization required. | Covered in full; authorization required. | Covered in full; authorization required. | In-network: included in hospital admission copay. Out-of-network: covered 70% after deductible. | Covered in full in-network. No copay. | Covered in full in-network. No copay. | Covered in full with $20 copay. | No copay (inpatient). $5 copay for initial visit only (outpatient). | Covered in full. | $0 covered in full. | ||||||||||
| VISITING NURSE SERVICE | In-network: $0. Home health care is limited to 200 visits per plan year from participating providers and 40 visits per plan year from non-participating providers. | 200 visits per calendar year. No copay. Authorization required. | 200 visits per calendar year. No copay. Authorization required. | In-network: no copay. 200 visits per calendar year. Out-of-network: covered 70% after deductible. Authorization required. | Covered in full in-network up to 200 visits per calendar year under home health care. Precertification by Anthem's Medical Management Program is required. | Covered in full in-network up to 200 visits per calendar year under home health care. Precertification by your PCP through Anthem's Medical Management Program is required. | Covered when medically necessary. Covered in full when coordinated through Aetna's Patient Management Dept. | $5 copay. 40 visits per calendar year. | 40 visits per calendar year. Preauthorization required. | $0 — home health care covered for 40 visits per plan year. | ||||||||||
| PHYSICAL THERAPY | $20 copay per visit. | Preferred PCP, no copay. Nonpreferred PCP, $10 copay. 90 visits. Speech and physical therapy are only covered following a hospital stay or surgery. Preauthorization required. | Preferred PCP, no copay. Nonpreferred PCP, $10 copay. 90 visits. Speech and physical therapy are only covered following a hospital stay or surgery. Preauthorization required. | In-network: $15 copay, 90 visits per calendar year. Out-of-network: covered 70% after deductible. | Inpatient covered in-network in full up to 30 days per calendar year. Outpatient covered in-network combined 30 visits in home, office, outpatient facility per calendar year. Precertification by Anthem's Medical Management Program is required. $15 copay home or office. | Inpatient covered in-network in full up to 30 days per calendar year. Outpatient covered in-network combined 30 visits in home, office, outpatient facility per calendar year. Precertification by Anthem's Medical Management Program is required. $15 copay home or office. | In-network inpatient covered in full under hospitalization or skilled nursing facility benefit. In-network outpatient covered in full minus $20 copay. Treatment covered over 60-day consecutive period per incident of illness or injury beginning with first day of treatment. | $5 copay (outpatient). 60 visits per calendar year combined with occupational and speech therapy. | $15 copay, 60 visits per calendar year combined with occupational and speech therapy. Authorization required. | 20 visits per condition per plan year combined therapies. | ||||||||||
| APPLIANCES | Covered in full, after $100 deductible; preauthorization is required for DME in excess of $500 for rentals or $1,500 for purchases. | Covered under HIP HMO Optional Rider. Retiree: durable medical equipment including crutches, canes, wheelchairs, commodes and walkers, through rider. In-service: additional Welfare Fund benefit reimbursed at 80% of reasonable charge, subject to $25 deductible, $1,500 annual maximum and $3,000 lifetime. ** Authorization required under Emblem- Health rider. | Covered under HIP HMO Optional Rider. Retiree: durable medical equipment including crutches, canes, wheelchairs, commodes and walkers, through rider. In-service: additional Welfare Fund benefit reimbursed at 80% of reasonable charge, subject to $25 deductible, $1,500 annual maximum and $3,000 lifetime. ** Authorization required under Emblem- Health rider. | In-network: No annual deductible. Not covered out-of-network. In-service: Supplemental Welfare Fund benefit for employees, as described under HIP Prime. Authorization required. | Durable medical equipment, medical supplies, prosthetics, orthotics covered in full. Precertification by Anthem's Medical Management Program is required. In-network provider only. | 50% coinsurance. | Covered in full. Coverage for durable medical equipment must be deemed medically necessary and is subject to the approval of and coordination through Aetna's Patient Management Dept. | $0 annual deductible (prior authorization required). | 80% covered to an annual maximum of $1,500. Preauthorization required. | $0 — durable medical equipment is covered, including standard internal/external prosthetics. | ||||||||||
| ALCOHOLISM AND DRUG ABUSE (Chemical Dependency) | Outpatient: in-network, unlimited visits subject to $15 copay; out-of-network: unlimited visits subject to plan allowances. Inpatient: $300 copay per admission. | Subject to hospital admission copay — no limit on days per calendar year. Outpatient, no copay for preferred PCP. Nonpreferred PCP, $10 copay. | Subject to hospital admission copay — no limit on days per calendar year. Outpatient, no copay for preferred PCP. Nonpreferred PCP, $10 copay. | In-network: inpatient, $100 copay. Outpatient, $10 copay, unlimited visits per calendar year. Out-of-network: covered 70% after deductible. | Outpatient visits office or facility: $15; inpatient care* (as many days as medically necessary; semiprivate room and board) $250/$625 per admission per calendar year per contract. *Preapproval and authorization required by Anthem's Behavioral Healthcare Management Program. | $15 copay in office, $0 copay outpatient visits in a facility, $300 copay per admission (as many days as medically necessary, semiprivate room and board). | Detoxification covered in full for acute phase of treatment for in-network inpatient after $300 copay. In-network outpatient covered in full with $15 copay. | Outpatient drug and alcohol treatment, $5 copay, unlimited days per calendar year. Inpatient rehabilitation covered in full, unlimited days per calendar year. Inpatient detoxification, covered in full, unlimited days per calendar year. Authorization required for inpatient except for emergency admission. | Inpatient: detox covered in full. Rehabilitation covered in full. Outpatient: $15 copay per visit. | $0 covered in full. No limit. | ||||||||||
| OUTPATIENT PSYCHIATRIC CARE | Outpatient: in-network: unlimited visits subject to a $15 copay; out-of-network: unlimited visits subject to plan allowances. | Inpatient: subject to hospital admission copay. Unlimited days per calendar year. Preferred provider, no copay. Nonpreferred PCP, $10 copay. | Inpatient: subject to hospital admission copay. Unlimited days per calendar year. Preferred provider, no copay. Nonpreferred PCP, $10 copay. | In-network: $10 copay, unlimited days per calendar year. Out-of-network: covered 70% after deductible. | Outpatient visits office or facility: $15; inpatient care* (as many days as medically necessary; semiprivate room and board) $250/$625 per admission per calendar year per contract. * Preapproval and authorization required by Anthem's Behavioral Healthcare Management Program. | $15 copay in office, $0 copay outpatient visits in a facility, $300 copay per admission (as many days as medically necessary, semiprivate room and board). | $15 copay per visit. | Inpatient: covered in full, unlimited days per calendar year; unlimited biologically-based mental illness and serious childhood emotional disorders. Outpatient: $5 copay, unlimited visits per calendar year; unlimited biologically-based mental illness and serious childhood emotional disorders. | Inpatient: covered in full. Outpatient: $15 copay. | $0 covered in full. No limit. | ||||||||||
| DEPENDENT CHILDREN | Covered to age 26. | Covered to age 26. | Covered to age 26. | Covered to age 26. | Covered to age 26. | Covered to age 26. | Covered to age 26. | Covered to age 26. | Covered to age 26. | Covered to age 26. | ||||||||||
- * Finalized for January 1, 2026.
- ** Additional Welfare Fund benefits. See Green or Red Apple.
- *** Benefits in California and Arizona may differ. See City Summary Program Description for complete details.
This chart is a general outline of benefits provided and is not the contract. Refer to appropriate booklets for contractual provisions.