Find benefit summaries, formularies (list of covered drugs), and all necessary forms to get the most out of your EmblemHealth coverage.
Authorization, Verification and Certification Forms Authorization to Use and Disclose Protected Health Information A written authorization is required for your plan to share a member's protected health information with anyone, except as required or permitted by law.
Use this form if you are a plan member or the child of a plan member who is now a young adult and wants to be covered under your parent's plan. Members who have an On Exchange plan must contact NYSOH at 1‑855‑355‑5777 to elect coverage under the Young Adult rider.
Use this form if you are a plan member or the child of a plan member who is now a young adult and wants to be covered under your parent's plan.
Use this form to maintain coverage for your dependent who has not married, is disabled, and became disabled before reaching the age at which dependent coverage would otherwise end. NYSHIP members must obtain the Statement of Disability form (PS-451) from their health benefits administrator.
When members are changing their primary care physicians (PCPs) from different medical centers or private physician offices, this form should be used.
This form assists you in the coordination of benefits received under more than one health insurance program by you or any dependent.
This form assists you in the coordination of benefits received under more than one health insurance program by you or any dependent.
This form assists you in the coordination of benefits received under more than one health insurance program by you or any dependent.
If your benefit plan includes the ExerciseRewardsTM Program, use this form to verify you are a member at a fitness facility.
With the ExerciseRewardsTM program, you can enjoy the benefits of exercise and get paid back for your dues.
If your benefit plan includes the ExerciseRewardsTM Program, use this form to get back up to $200 of your membership dues.
Your member handbook tells you how your plan coverage works to get the medical care you need and avoid out-of-pocket costs. Some sections of your member handbook have been updated. For information about the changes refer to the inserts at the end of the member handbook.
Enhanced Care (Medicaid) Enhanced Care Plus (HARP) See All See AllWant to see if your procedure requires a preauthorization? We have a resource for that.
It’s a quick form that tells you whether a preauthorization is needed for specific services.
You will need your member ID and the following details from your provider before you can use the tool:
Click the button below to launch the tool and enter the requested information to see if you need to get a preauthorization ahead of your procedure.
Remember, you never have to get a preauthorization for emergency services.
If you have any questions, please contact us here or at the number on your ID card.
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Any information provided on this website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office. Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.
