New York Essential Plan

Health care is about you. So are we.

Empire is proud to serve New York Essential Plan members. We’ll help you get the benefits you need to stay healthy.

What You Get with Empire Essential Plan

We’re here to help you get the care you need. Get free or low-cost New York State-sponsored health insurance for you.

Designed with your needs in mind, Empire gives you access to local providers through New York Essential Plan.You choose your provider from hundreds of quality providers in our network.

Get:

  • Immunizations and wellness visits
  • Vision and dental care for select plans
  • Prescription drug coverage and over-the-counter medicines prescribed by your provider
  • Specialist physician care, X-rays and lab tests
  • Emergency hospital visits and inpatient hospital, medical and surgical care
  • Hospitalization care
  • Care without staying in the hospital, including diagnostic tests and treatments.
  • Mental Health and Substance Use services, including Behaviorial Health treatment
  • Maternity Services
  • Chronic Disease Management
  • Guided help with choosing your health plan. You can enroll or renew at our Community Service Centers. Our Marketplace Facilitated Enrollers can even come to you!
  • Gym membership and other healthy lifestyle rewards

Preapproval

Some Empire services and benefits require preapproval. This means that you and/or your doctor must ask Empire to approve those services or benefits before you get them. Empire requires preapproval for these services:

  • Ambulance transportation (emergency air and nonemergency)
  • Chiropractic services
  • Diagnostic testing
  • Durable medical equipment
  • End-stage renal disease services
  • Eye/vision care and services for people age 20 and younger
  • Home health extended services for people age 20 and younger
  • Home health services for people age 21 and over: registered/skilled nurse, physical therapy, occupational therapy, speech therapy, home health aide and IV therapy
  • Hospice services: inpatient, home and hospice facility
  • Inpatient acute care hospitalization
  • Medicines (See the Empire Preferred Drug List. Low copays for over-the-counter medicine require a prescription from your doctor.)
  • Mental health rehab services: family therapy, crisis stabilization, assertive community treatment
  • Nurse-midwifery services
  • Organ transplant services
  • Outpatient hospital services: physical therapy, occupational therapy, speech therapy and surgical procedures
  • Pediatric Day Health Care (PDHC) for people ages 20 and older
  • Personal Care Services (PCS) for people ages 20 and older
  • Physician services: medical assessments, treatments and surgical services (includes behavioral health physicians)
  • Podiatry services
  • Post-stabilization care services: from doctors inside or outside the Empire plan
  • Radiology services
  • Rehabilitation services: physical therapy, occupational therapy and speech therapy
  • Transportation services
  • If you live in NYC, nonemergency transportation is provided through the state’s vendor, Medical Answering Services (MAS). To set up a ride, please call MAS at 1-800-850-5340.
  • For members who live in Nassau, please call LogistiCare at 1-844-678-1103 (TTY 1-866-288-3133).
  • All other counties, please call Medical Answering Services at 1-800-850-5340.
Vision and Dental Plans

See your way to a happier, healthier you with vision and dental coverage through your New York Essential Plan.


Vision Coverage – Insight to your health

Your eyes can offer clues about your overall health. That’s why it’s important to get annual eye exams. As an Empire member, we want to help you get the best care with these vision benefits:

Preventive and routine care:

  • Eye exam once a year
  • Other diagnostic procedures performed by an eye doctor

Prescribed lenses and frames:

  • Lenses or contacts once a year unless medically necessary
  • Frames once a year unless medically necessary

Take advantage of these benefits from Empire, a company with 80 years of health care experience. Enroll in the Essential Plan from Empire today.

Dental Benefits – Something to smile about!

With Essential Plan coverage through Empire BlueCross BlueShield HealthPlus, we give you these oral care benefits:

Preventive care:

Teeth cleaning twice a year

Routine care:

  • Oral exams
  • X-rays
  • Extractions
  • Fillings

And more…

  • Emergency care
  • Dentures (removable or partial)
  • Fixed bridges, if required
  • Orthodontics
Prescription Drugs

Empire works with Express Scripts to provide your pharmacy benefit. We cover a wide range of prescriptions and many over-the-counter medicines. Starting May 1, Rite Aid is no longer a pharmacy in your plan. Go to Express Scripts to find a plan pharmacy near you.

Preferred Drug List

To see if your Empire benefits cover your prescriptions, please see the Preferred Drug List (also known as a “formulary”). Your plan has three levels (tiers) and includes many different categories and classes of drugs. You can also use the Searchable Formulary tool below to find out a drug’s level, but certain exceptions may apply. This list of covered prescriptions may change at any time without notice.

In certain situations, you may need a drug that is not on the Preferred Drug List. You may be able to get the noncovered drug for an additional copay. For more information about how your prescription benefits work, please see the Prescription Drug Coverage section of your Member Handbook.

If you have any questions about your pharmacy benefit, please call our Member Services department at 1-800-300-8181 (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 9 a.m. to 5 p.m.

Searchable Formulary

Search for name brand and generic drugs that are on the formulary. You can search for your drug by:

  • Typing the name (at least first three letters) of the drug in the search box
  • Using the A-Z list to search by the first letter of your drug
    • OR
  • Clicking on therapeutic class of the drug
Searchable Formulary

Drug Interactions and Side Effects

Learn more about drug interactions or side effects on the ESI Drug Information website.

Getting your prescription filled is easy!

Simply present the written prescription from your doctor to a participating network pharmacy. Or your doctor can call in the prescription to your local participating pharmacy. You will also need to show the pharmacy your Empire ID card to have a prescription filled.
It is good to use the same pharmacy each time. This way, your pharmacist will know about problems that may occur when you are taking more than one prescription. If you use another pharmacy, you should tell the pharmacist about any medicines you are taking.

You can use the links below to get more pharmacy information:

ESI Member Reimbursement

ESI Online Registration Instructions

ESI Mail Order Form

Prescription Drug List

Gym Benefit

It pays to stay healthy. With Empire BlueCross BlueShield HealthPlus Essential Plan, you can receive up to $400 per year to exercise!

With our Exercise Rewards program, you can get reimbursed $200 for your gym membership dues every six months. Simply work out at one of our many participating gyms or fitness centers at least 50 times in a six-month period. Then submit your fitness log and proof of your fitness center membership payment (see forms below) and you’ll receive your check!

Activate your ExerciseRewards® now!

Note: The gym reimbursement applies to Essential Plan members only.

You can learn more about the program in these brochures:

Use these forms to request your reimbursement:

Eligibility

Get the benefits you need — doctor care, hospital care, health screenings, prescription coverage and more. Find out if you’re eligible and how to choose Empire.

Empire BlueCross BlueShield HealthPlus is a Managed Care Organization (MCO) that participates with the New York State-sponsored New York Essential Plan program. We help manage health care benefits for adults 19 years of age and up who don’t have health insurance and don’t qualify for Medicaid.

With Essential Plan coverage through Empire, adults can get benefits like:

  • A 24/7 NurseLine to answer health questions
  • A personal provider for primary care and to coordinate all of your health care
  • Medically necessary health care and medical services, including vision care and eyeglasses, dental services, drugs and pharmacy items prescribed by a qualified Empire provider

You are eligible to join the Essential Plan through Empire if:

  • You are below age 64 and over the age of 19
  • You are not eligible for Medicaid or Child Health Plus
  • You are not eligible for minimum essential coverage
  • You live in Brooklyn, Bronx, Queens, Manhattan, Staten Island, Nassau, or Putnam counties

You do not have to be a citizen or legal resident to qualify for the Essential Plan. Participation in this program will not affect any future immigration status.

Find out more about income and resources limitations by contacting the New York State of Health, The Official Health Plan Marketplace at 1-855-355-5777 or TTY:1-800-662-1220

For help with enrolling or if you have questions, call us at 1-888-809-8009 (TTY 711). You can also visit one of our office locations.

Already a member, and have questions?

Call Member Services at 1-800-300-8181 (TTY 711). Member Services is open Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 9 a.m. to 5 p.m. We are happy to help you with your health care!

Summary of Benefits

If you qualify for Essential Plan coverage through Empire, you’ll receive many benefits as well as a health plan that has nearly 80 years’ experience in health care. We speak your language. And we are 100% committed to you and to the communities we serve. Maybe that’s why over 400,000 New Yorkers call Empire their plan of choice.

Your benefits include:

  • A personal primary care provider (PCP) to manage all of your health care needs
  • No limits on the number of provider visits when medically necessary
  • A large network of providers, including hospitals, PCPs, specialists, vision providers and dentists
  • Dental care for adults, including two checkups per year*
  • A full list of prescription drugs and smoking cessation products that can be prescribed by your doctor (copays may apply)*
  • Emergency room and emergency ambulance services
  • Family planning and reproductive health
  • Drug, alcohol and mental health services
  • Home health care when medically necessary
  • Case management for those who need extra attention
  • Clinical staff who review your medical information to ensure you receive the right care in the right time and at the right setting
  • And much more

*For those who qualify. Covered only in certain plans.

Treatment Cost Calculator

Calculate Your Treatment Costs

We understand that you need the full picture in order to make health care decisions. Taking care of yourself is easier when you understand how much it costs. Our Treatment Cost Calculator can give you a general estimate of your out-of-pocket costs for many common services. Use this tool to:

  • Get a generic estimate for common treatments and services
  • Print or save estimates
  • Review past treatment cost calculations

How to Use the Treatment Cost Calculator:

  • Login or create an account
  • Visit the Treatment Cost Calculator
  • Select the member
  • Select the treatment
  • Select your provider (skip if no provider)
  • Review, print and/or save your estimate
Member Handbooks

Your member handbook is your go-to guide for health services. It tells you how you can get the most from Empire BlueCross BlueShield HealthPlus. You’ll find answers to these items:

  • Your benefits
  • How to get help after your doctor’s office closed
  • How to choose a primary care provider
  • How to renew your coverage
  • How to reach Member Services if you have a question

Essential Plan 1

Essential Plan 2

Essential Plan 1 with Dental and Vision

Essential Plan 2 with Dental and Vision

Essential Plan 3

Essential Plan 4

Notice of Privacy Practices

Frequently Asked Questions

Frequently Asked Questions


How do I get help if I need health care after my primary care provider’s (PCP) office closes?

Call your PCP for advice on how to get urgent care. The number is listed on your member ID card. You can call our Member Services department at 1-800-300-8181 (TTY 711) or our 24/7 NurseLine at the same number.

My provider says I need to see a specialist. How do I set up an appointment with the specialist?

Your PCP will refer you to a specialist. If you need specialist services that you can’t get from a doctor in the Empire network, we will work with your PCP to refer you to an out-of-network specialist.

My plan has dental benefits. How do I choose a dentist?

If you need to find a dentist or change your dentist, please call Healthplex toll free at 1-800-468-9868 (TTY 1-800-662-1220) Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 9 a.m. to 5 p.m. You can also call the Member Services department at 1-800-300-8181 (TTY 711). When you visit your dentist, you should show your plan ID card.

How do I get a copy of the Empire provider directory?

You can call the Member Services department at 1-800-300-8181 (TTY 711) and request one. You can also download a free mobile app and search for Empire on your Android or iPhone. Then simply enter the name of your PCP.

How do I see a doctor who is not in the Empire network?

Please call the Member Services department at 1-800-300-8181 (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 9 a.m. to 5 p.m. with questions.

Pharmacy Benefits: How can I find out what pharmacies are in the Empire network?

You can look in your new member enrollment package for a list of pharmacies in our network, or you can search our list of network pharmacies. You can also call Member Services at 1-800-300-8181 (TTY 711) or ask your local pharmacy for help.

Are over-the-counter (OTC) products covered, and do I need a prescription?

We cover many OTC products, including pain relievers, antacids, contraceptives and some vitamins. All OTC products require a written prescription from your doctor and can be filled at any network pharmacy.

How does my doctor request prior authorization?

Your doctor can request prior authorization on medicines by calling our Pharmacy department at 1-800-450-8753.

How do I get my medicine if I am traveling?

We have network pharmacies in all 50 states. Most chain pharmacies as well as many independent and grocery store pharmacies participate. If you need a refill while on vacation, contact your doctor for a new prescription to take with you or fax it to the closest network pharmacy where you are.

What happens if my medicines are lost or stolen?

If your medicines are lost or stolen, you should contact your doctor to authorize the pharmacy to refill your prescription early. The pharmacy may have to contact us for prior approval. Replacement of lost or stolen medicines will be reviewed on a case-by-case basis.

What if I paid out of pocket for a medicine and want to be reimbursed?

If you had to pay for a medicine, you may submit a request for reimbursement. You’ll need to mail a completed reimbursement request form along with any receipts to:

Express Scripts
P.O. Box 14711
Lexington, KY 40512

Will I be able to receive my enteral nutrition, diapers and medical supplies through a pharmacy?

Enteral nutrition, diapers and durable medical equipment can be obtained through your Durable Medical Equipment (DME) benefit. Some medical supplies can be obtained from your local pharmacy, like bandages, insulin syringes and diabetic glucose test strips.

*For qualifying applicants

Empire BlueCross BlueShield HealthPlus is the trade name of HealthPlus HP, LLC, an independent licensee of the Blue Cross and Blue Shield Association.

The Essential Plan from Empire BlueCross BlueShield HealthPlus is available on the NY State of Health, The Official Health Plan Marketplace, at nystateofhealth.ny.gov or by phone at 1-855-355-5777.