These services help prevent health problems and help find problems before they get serious. Care includes routine and sick visits to your primary care physician (PCP) and other network providers for:

• Regular checkups
• Eye and hearing exams
• Eyeglasses and other medically needed vision aids
• Regular gynecological exams
• Breast exams (including mammography)
• Allergy testing and treatment
• HIV counseling and testing services
• Smoking Cessation counseling (all members are eligible for six sessions in a
  calendar year)
• Child/Teen Health Plan Services (C/THP) for Family Health Plus members
  19 and 20 years old, including transportation to obtain these services.

When medically needed, your doctor will refer you for:

• Lab work
• X-rays
• Specialty care

Maternity care

• Prenatal care
• Childbirth classes
• Doctor/midwife services
• Hospital delivery
• Newborn nursery care

Note: Medical supplies, other than diabetic supplies and smoking cessation products, are not covered.

You must use pharmacies that participate in our pharmacy network to fill all of your new drug prescriptions and other covered over-the-counter medications, diabetic supplies, select durable medical equipment and medical supplies.

We offer a large network of well-known pharmacies as well as many independent pharmacies. Ask your pharmacy if they are a network pharmacy. If they are, you can continue to use that pharmacy. If not, you will need to switch pharmacies to one in our network. This is easy to do; and it's important for getting your prescriptions filled in a timely manner and for avoiding out-of-pocket costs. To search for a list of participating pharmacies, click here.

Please make sure to use your new FHPlus ID card when filling a prescription or obtaining other covered pharmacy benefits at a network pharmacy. To locate a network pharmacy near you, go to www.emblemhealth.com/ssp-rx and click on “Pharmacy Locator.” You can also call our Pharmacy Customer Service at 1-888-447-7364.

Our Medicaid/FHPlus Formulary is a list of medications that our network doctors and other medical experts have approved for treating disease and for maintaining the health of our members. The main purpose of our Medicaid/FHPlus Formulary is to promote the use of safe, effective and affordable drugs and treatments while providing quality care. Your doctors will prescribe medications listed on our Medicaid/FHPlus Formulary unless there is a medical need to prescribe a drug that is not on the list. s there is a medical need to prescribe a drug that is not on the list. To see a list of drugs covered for Medicaid members, To see a list of drugs covered for FHPlus members, click here.

You may get home delivery of your maintenance drugs through our mail order pharmacy partner Express Scripts, Inc. (ESI). Maintenance drugs are used to treat chronic conditions and are usually prescribed in quantities greater than 30-day supplies. All you need to do is get a new written prescription from your doctor or other licensed health care provider, and mail it to ESI along with the completed order form. You may request an ESI order form to be mailed to you by calling our Pharmacy Customer Service at 1-888-447-7364. Mail the form and the original prescription(s) along with the required copayment to ESI as directed on the form. You may include multiple new prescriptions in your order.

If you prefer, your doctor or other licensed health care professional can assist you. You can bring your order form to them and they can fax it to ESI directly with your prescription. Or they can submit your prescription via the Web. In both cases, they must have your member ID number. Only doctors or other licensed health care providers may submit new prescriptions via fax or Web.

To use the Home Delivery tool, go to myEmblemHealth and register if you haven't already. After you sign in, click on “Pharmacy Services” and then select “Home Delivery”. You will be able to do things like check order status and request refills to existing prescriptions. You will need to register the first time you use the tool, and you will need your member ID to create an account. You or your doctor will still need to send ESI the actual written prescription when using the online option. Please allow 7 to 10 days for delivery from the day ESI receives the prescription(s) to receive your home delivery.

You can easily check the status of your order via the EmblemHealth/Express Scripts pharmacy benefits tool on this page. You will need to sign in using your member ID and password. You can also call ESI at 1-877-866-4165. If you have a hearing or speech impairment, and use a TDD, you can call 1-800-899-2114. You will need your member ID number and your prescription number(s) to access this information.

Specialty drugs are usually injectable, oral or inhaled drugs. They are used to treat chronic conditions such as multiple sclerosis, growth deficiencies, hepatitis C and cancer. They also require special storage and/or handling. You must have your specialty drug prescriptions filled through our select Specialty Pharmacy program. You cannot fill specialty drug prescriptions at a network retail pharmacy or through the ESI mail order program. Your doctor or other licensed health care provider will submit the prescription through our Specialty Pharmacy program. And similar to home delivery, your specialty prescriptions will be filled and sent directly to you at home.

For questions, please call EmblemHealth's Specialty Pharmacy program at 1-888-447-0295.

This kind of care includes:

• Inpatient care
• Outpatient care
• Emergency care
• Lab work and other tests
• X-rays
• Nursing services
• Inpatient and outpatient surgery, including dental surgery
• Inpatient detoxification services

• Emergency care services are procedures, treatments or services needed to evaluate or stabilize an emergency condition.
• Care you need after you have received emergency care to make sure you remain in stable condition. Depending on the need, you may be treated in the emergency room, in an inpatient hospital room, or in another setting. These are called Post Stabilization Services.

This type of service includes — but is not limited to — medically needed:

• Occupational, physical and speech therapy — Limited to 20 visits per therapy per calendar year.
• Respiratory therapy
• Audiology services (hearing)
• Durable medical equipment (DME), including hearing aids, artificial limbs and orthotics
• Renal and hemodialysis
• HIV/AIDS treatment services
• Midwife services
• Cardiac Rehabilitation
• Outpatient detoxification services
• Other covered services as medically needed

These services are generally provided so that you do not have to stay in a hospital. Your doctor must agree that your medical needs can be met at home with this help and request prior approval from your plan. Coverage is for up to 40 home health care visits per year. Services include:

• One medically necessary post partum home health visit, additional visits as medically necessary for high-risk women
• Other visits as needed and ordered by your PCP/specialist.

FHPlus covers emergency vision care and the following preventive and routine vision care provided once in any twenty-four-month period:

• Services of an ophthalmic dispenser, ophthalmologist and optometrist.
• One eye exam. Members diagnosed with diabetes may self-refer for a dilated eye (retinal) examination once in any twelve (12)-month period.
• Either one pair of prescription eyeglass lenses and a frame, or prescription contact lenses when medically necessary. Scratch- and break-resistant eyeglass lenses are covered. Progressive lenses are not covered.
• One pair of medically necessary occupational eyeglasses. Occupational eyeglasses are special glasses that help you perform your job duties.
• Specialist referrals for eye diseases and defects.

• Up to 60 outpatient behavioral health visits per year. Coverage includes chemical dependence services (including alcohol and substance abuse) and mental health treatment services.
• Up to 30 inpatient mental health and chemical dependence days per year.
• Detoxification services (inpatient detoxification and inpatient or outpatient withdrawal services do not count toward the limits mentioned above).

You can choose to go either to your PCP or to the county public health agency for diagnosis and/or treatment. You do not need a referral to go to the county public health agency.

These services are covered for all children under 21 years of age and members (regardless of age) with physical conditions that pose a hazard due to the presence of localized illness, injury or symptoms involving the foot, or when performed as a necessary and integral part of otherwise covered services such as the diagnosis and treatment of diabetes, ulcers and infections.

These services include home and inpatient services that provide medical and support services for members who are terminally ill with a life expectancy of six months or less. Also includes covered curative care for members under 21 years of age.

These services include land and air ambulance transportation (just call 911 for emergency transportation).

We cover these services for our New York City (all five boroughs) members and for Nassau County and Suffolk County FHPlus members 19 and 20 years of age receiving Child/Teen Health Program (C/THP) services.

Services include public bus and train trips to and from:

• Child/teen health plan appointments.
• Appointments arranged by a network doctor in follow-up to child/teen health plan diagnoses.

They also include the following forms of transportation:

• Public bus and train trips. No prior approval is needed. At the time of the appointment, you will be reimbursed for your round-trip fare by the network medical center, dentist, PCP or OB/GYN with whom you have the appointment or who is making a referral.
• Taxi and van trips. Your network doctor (or dentist) must approve taxi or van transportation based on medical necessity. Your doctor will fill out the medical necessity form and fax it to the number on the form. You can then call Customer Service at 1-800-447-8255 to reach a customer services representative who will provide you with the phone number of a network taxi or van service so that you can schedule your trip. The network taxi or van service will bill the health plan for the trip. If we give you permission to use a non-network service, you must pay for the taxi directly and we will tell you how to get reimbursed.
• Ambulette trips. When medically needed. Prior approval is required. To obtain prior approval, your doctor (or dentist) must call 1-866-447-9717. Once the trip is approved, we will arrange the trip with the ambulette company. The ambulette company will bill us for the trip.

Our network taxi and van services are only authorized to transport to and from medical services.

Notes:

1. Requests for Taxi and Ambulette transportation must be made at least 24 to 48 hours prior to your appointment.
2. Montefiore members (except Westchester County members) must call Montefiore at 1-914-377-4400 to obtain non- emergency transportation services.
3. When you need an attendant to go with you to your dentist's or doctor's appointment, the attendant's transportation is covered. When your child is the member of the plan, transportation is covered for you or someone else who takes him/her to the appointment.
4. Members are responsible for arranging and paying for transportation when they elect to see a provider more than 30 minutes or 30 miles from where they live if there is a closer provider available. If we prior approve you to see a provider, we will pay for transportation regardless of the travel time or distance.

Includes assessment and nutritional counseling sessions with a network registered dietician. The result of the initial assessment will determine the number of sessions required. Both the assessment and the counseling sessions require a referral by your primary care physician. Members who particularly benefit from these services include those who are pregnant; newly diagnosed or living with diabetes, heart disease and/or kidney disease; have an eating disorder or other digestive problems; or have been diagnosed as overweight or obese by their doctor.

These services include the coordination of benefits and services for members who have complex or serious diseases or conditions. Members may be assigned to a case management nurse who will work with you and your doctors to ensure that you get the care and services you need when you need them. You could be in the program for weeks, months or years depending on your condition and circumstances. The purpose of case management is to get the best health care outcome.

These services include help in getting needed community services.

These services are covered on a case-by-case basis according to New York state law.

These services include any HIP FHPlus plan-covered services ordered by a judge.