NYC Employee Health Plans and Adult ADHD Coverage

Written by the practice's editorial team. Published October 13, 2026; updated October 19, 2026. Part of the New York Adult ADHD Guide, weigh your options section. Medically reviewed by John C. Shershow, M.D. on October 19, 2026. Editorial policy

Key points

All GHI-CBP members were moved automatically into the new NYCE PPO on January 1, 2026, according to the Office of Labor Relations.
The NYCE PPO summary lists outpatient mental and behavioral health visits at $0 with a preferred provider and $15 with a participating provider, and NYC Health + Hospitals is a preferred provider.
Out of network, the NYCE PPO pays its plan allowance after a $200 individual deductible, and you pay the difference between the allowance and the clinician's fee.
The HIP HMO summary lists outpatient mental health visits at $0 or $10 and does not cover non-participating providers.
OLR tells employees to contact their union or welfare fund about prescription drug coverage, and the plans' own drug benefits come through an optional rider.

If you work for the City of New York, your health plan is chosen through the NYC Health Benefits Program, which the Office of Labor Relations (OLR) runs. The program changed in 2026, and the details that matter most for adult ADHD care, mental health visits and prescription drugs, sit in different places. This article shows where to find them, using OLR's plan summaries as of October 2026. It covers active employees and non-Medicare retirees; Medicare retirees have separate plans.

The 2026 change: NYCE PPO replaced GHI-CBP

OLR's plan list shows the GHI-CBP plan as discontinued as of January 1, 2026, and says all current GHI-CBP members were automatically enrolled in the new NYC Employees PPO (NYCE PPO) on that date. If you were in GHI-CBP and have not looked at your coverage since, your network, copays and claims address have changed.

OLR lists these plans for employees and non-Medicare retirees: Aetna EPO, Anthem EPO, Anthem Blue Access Gated EPO, DC 37 Med-Team (DC 37 members only), GHI HMO, HIP HMO Preferred, HIP Prime POS, MetroPlusHealth Gold, NYCE PPO and Vytra Health Plans. Each has a one-page summary and a federal Summary of Benefits and Coverage on OLR's website.

Mental health visits in the two largest plans

Plan	Outpatient mental health visit	Out of network	Referral to a specialist
NYCE PPO	$0 with a preferred provider; $15 with a participating provider	Covered after a $200 individual deductible; you pay the difference between the plan allowance and the fee	Not required
HIP HMO Preferred	$0 with a preferred primary care provider; $10 with a non-preferred one	Not covered for non-participating providers	The summary says written approval is required to see a specialist; ask whether that applies to a psychiatrist

The NYCE PPO summary names NYC Health + Hospitals, Advance Care Physicians (ACPNY), Memorial Sloan Kettering and the Hospital for Special Surgery as preferred, alongside the plan's own preferred providers. It says the plan's EmblemHealth network covers 13 downstate counties and that it uses the UnitedHealthcare Choice Plus network elsewhere in the country. The summary also lists a $10 copay for Teladoc Health visits, but describes that service for conditions such as colds, sinus problems and allergies, not psychiatric care.

Going out of network with the NYCE PPO

If the psychiatrist you want to see is not in the plan's network, this rule decides what you get back. The NYCE PPO summary says out-of-network services are paid at a "plan allowance" after the $200 deductible, and you pay the difference between the allowance and the provider's fee. The allowance can be set in several ways, one of which is 100 percent of Medicare's published rate for the service in your area. The summary also lists an unlimited out-of-network total out-of-pocket maximum.

Before you book, ask the plan two questions: what allowance it pays for the specific billing codes the clinician will use, and whether any preauthorization is needed. Then compare that with the clinician's fee. How out-of-network reimbursement works and in-network or private-pay walk through the math.

Prescription drugs: rider or welfare fund

This is where City employees most often get surprised. The NYCE PPO's base drug benefit covers ACA-mandated preventive drugs, insulin, diabetic supplies and opioid withdrawal medication. Other drugs are covered through an optional drug rider. In the NYCE PPO summary the rider charges, at retail:

generics (Tier 1): 20 percent coinsurance, minimum $5;
preferred brands (Tier 2): 40 percent coinsurance, minimum $25;
non-preferred brands (Tier 3): 50 percent coinsurance, minimum $40.

The HIP HMO summary describes a similar optional rider. Many employees do not buy a rider, because their drug benefit comes from somewhere else: OLR tells active employees to contact their union or welfare fund for information about "prescription drug coverage (if applicable)." So the first question for ADHD medication is which one covers you, the health plan's rider or your welfare fund. Ask the one that covers you for its formulary listing for your medication.

One caution. The NYCE PPO rider describes retail fills as a 30-day supply with two refills before home delivery is required. ADHD stimulants are Schedule II drugs and cannot be refilled under New York law, so each fill needs a new prescription. How the rider's retail and mail rules apply to stimulants was not stated in the summary; ask the plan's pharmacy benefit manager. See New York's ADHD medication rules and what ADHD medication costs in New York.

The Employee Assistance Program

The NYC Employee Assistance Program offers free, confidential short-term counseling, education and individualized referrals for employees and family members. It covers non-uniformed mayoral agencies, the Department of Correction, NYCHA, the Department of Education and NYC Health + Hospitals. Uniformed agencies and some unions run their own programs; OLR lists, for example, the NYPD Counseling Unit, the FDNY Counseling Services Unit, POPPA, the DC 37 Personal Services Unit and the UFT Member Assistance Program.

The EAP does not describe diagnosing ADHD or prescribing. Its FAQ says that, working with your health plan, it can help you receive treatment, and that information is not released without your written permission except in certain extreme situations. It can be a useful first call if you are not sure where to start.

Where to find answers

Which plan you are in, enrollment and premiums: your agency's health benefits or payroll office, or NYCAPS Central at (212) 487-0500. Department of Education employees contact HR Connect at (718) 935-4000.
Covered services, claims and allowances: the health plan itself, using the number on your ID card.
Prescription drug, dental and vision benefits: your union or welfare fund.
Plan documents: the summaries, Summaries of Benefits and Coverage and the full Summary Plan Description on OLR's website.

Time off for appointments

The city's Protected Time Off Law does not cover government employees, according to the Department of Consumer and Worker Protection. City employees' leave comes from their own agency rules and union contracts, so ask your agency's human resources office. The law that does apply to private employees is explained in using NYC protected time off for ADHD appointments. If you work for New York State rather than the City, see Empire Plan coverage for adult ADHD.

If you are looking for an adult ADHD psychiatrist

Dr. Shershow is a psychiatrist who focuses on adult ADHD and sees adults located in New York or New Jersey. Whether he participates in any City plan network is a question to ask the office, which can tell you the current fees and how insurance works with the practice. Adult ADHD care in New York City explains how evaluation and follow-up work, and ADHD treatment for professionals covers privacy questions many public employees ask.

Questions

Does the NYCE PPO cover an out-of-network ADHD psychiatrist?

It has out-of-network benefits. Its 2026 summary says that after the $200 individual deductible, you pay the difference between the plan allowance and the provider's fee. The allowance can be well below a private psychiatrist's fee, so ask the plan for its allowance for the specific visit codes before you start.

Who covers my ADHD medication as a City employee?

It depends on your union. OLR's guidance says to contact your union or welfare fund about prescription drug coverage, if applicable. If you buy the optional drug rider with your health plan, the rider covers drugs at the coinsurance listed in the plan summary. Check which applies to you before your first fill.

Can the City EAP diagnose ADHD?

The NYC Employee Assistance Program offers free, confidential short-term counseling, education and referrals. It does not describe diagnosing ADHD or prescribing medication, but it says it can work with your health plan to help you get treatment.

Does NYC's Protected Time Off Law apply to City employees?

No. The city's Department of Consumer and Worker Protection says the law does not cover federal, State or City government employees. City workers' time off for appointments comes from their own leave rules and union contracts.

Sources

This article is general information, not medical or legal advice. Rules and coverage change; check the linked sources for the current position, and speak with a clinician or attorney about your own situation.

NYC employee health plans and adult ADHD coverage