450A EmblemHealth HIP HMO High — Enrollment Application

HIP Prime HMO - Prime tri-state with Cigna · gated HMO — care through your chosen PCP · rates good through 01/31/2027

Step 1 of 7PlanApplicantEmploymentFamilyDoctorsPaymentReview & Submit

Your selectionPick your coverage tier below to see your monthly price and effective date.

Coverage tier — 450A HIP HMO High (Monthly Rate) *

Rates include the Local 450A Health & Welfare Fund, union dues and association fees. A $95.00 annual administration fee applies at enrollment.

Requested Effective Date *Options honor the plan's 20th-of-the-month enrollment deadline.Previous Carrier The health insurance you have now that ends when this plan starts, if any.

Questions about this application?

Fage Financial Services

(845) 499-2255 info@fagefinancial.com