New York Plans

MVP Health Care plans for , part of MVP’s suite of Premier plans offered on New York State of Health.

View all MVP NY Individual & Family Plans

MVP Premier Bronze 1 HDHP FRNY-HMOH-DB-001-S (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $6,100 / $12,200
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $6,900 / $13,800
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 50% coinsurance
Specialist Visit 50% coinsurance
ER 50% coinsurance Deductible applies.
Urgent Care 50% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) $10 copay Deductible applies. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $35 copay Deductible applies. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $70 copay Deductible applies. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, 20% discount on CVS health brand-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Bronze 2 FRNY-HMO-DB-002-S (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $4,700 / $9,400
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $8,550 / $17,100
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $50 copay (First 3 visits no Deductible)
Specialist Visit $75 copay (First 3 visits no Deductible)
ER 50% coinsurance Deductible applies.
Urgent Care 50% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) $10 copay Deductible applies. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $35 copay Deductible applies. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $70 copay Deductible applies. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, 20% discount on CVS health brand-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Bronze 1 FRNY-HMO-DB-001-N (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $6,600 / $13,200
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $8,100 / $16,200
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $40 copay
Specialist Visit $80 copay
ER $500 copay Deductible applies.
Urgent Care $80 copay Deductible applies.
Generic Rx Coverage (Tier 1) $10 copay Deductible waived. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $45 copay Deductible applies. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $90 copay Deductible applies. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Bronze 2 FRNY-HMO-DB-002-N (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $6,100 / $12,200
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $8,400 / $16,800
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 40% coinsurance ($0 copay first 3 visits)
Specialist Visit 40% coinsurance
ER 40% coinsurance Deductible applies.
Urgent Care 40% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) $5 copay Deductible applies. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $60 copay Deductible applies. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $80 copay Deductible applies. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Bronze 3 HDHP FRNY-HMOH-DB-003-N (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $6,200 / $12,400
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $6,900 / $13,800
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $30 copay
Specialist Visit $50 copay
ER $500 copay Deductible applies.
Urgent Care $50 copay Deductible applies.
Generic Rx Coverage (Tier 1) $10 copay Deductible applies. 30 day retail/90 day mail order; preventive drugs deductible waived.
Preferred Rx Coverage (Tier 2) $45 copay Deductible applies. 30 day retail/90 day mail order; preventive drugs deductible waived.
Non Preferred Rx Coverage (Tier 3) $90 copay Deductible applies. 30 day retail/90 day mail order; preventive drugs deductible waived.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Silver 11 FRNY-HMO-DS-011-N (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $3,000 / $6,000
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $7,800 / $15,600
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $60 copay ($0 copay first 3 visits)
Specialist Visit $70 copay
ER $500 copay Deductible applies.
Urgent Care $70 copay Deductible waived.
Generic Rx Coverage (Tier 1) $15 copay Deductible waived. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $45 copay Deductible applies. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $90 copay Deductible applies. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Silver 2 FRNY-HMO-DS-002-N (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $2,650 / $5,300
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $6,900 / $13,800
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $40 copay ($0 copay first 3 visits)
Specialist Visit $70 copay
ER $500 copay Deductible waived.
Urgent Care $70 copay Deductible waived.
Generic Rx Coverage (Tier 1) $15 copay Deductible applies. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $40 copay Deductible applies. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $70 copay Deductible applies. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Silver 3 HDHP FRNY-HMOH-DS-003-N (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $2,500 / $5,000
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $5,700 / $11,400
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $30 copay
Specialist Visit $60 copay
ER $300 copay Deductible applies.
Urgent Care $60 copay Deductible applies.
Generic Rx Coverage (Tier 1) $10 copay Deductible applies. 30 day retail/90 day mail order; preventive drugs deductible waived.
Preferred Rx Coverage (Tier 2) $45 copay Deductible applies. 30 day retail/90 day mail order; preventive drugs deductible waived.
Non Preferred Rx Coverage (Tier 3) $90 copay Deductible applies. 30 day retail/90 day mail order; preventive drugs deductible waived.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Silver 1 FRNY-HMO-DS-001-S (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $1,300 / $2,600
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $8,500 / $17,000
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $30 copay
Specialist Visit $50 copay
ER $300 copay Deductible applies.
Urgent Care $70 copay Deductible applies.
Generic Rx Coverage (Tier 1) $10 copay Deductible waived. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $35 copay Deductible waived. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $70 copay Deductible waived. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, 20% discount on CVS health brand-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Gold 1 FRNY-HMO-DG-001-S (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $600 / $1,200
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $4,000 / $8,000
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $25 copay
Specialist Visit $40 copay
ER $150 copay Deductible applies.
Urgent Care $60 copay Deductible applies.
Generic Rx Coverage (Tier 1) $10 copay Deductible waived. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $35 copay Deductible waived. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $70 copay Deductible waived. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, 20% discount on CVS health brand-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Gold 1 FRNY-HMO-DG-001-N (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $1,200 / $2,400
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $5,900 / $11,800
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $15 copay ($0 copay first 3 visits)
Specialist Visit $50 copay
ER $350 copay Deductible waived.
Urgent Care $50 copay Deductible waived.
Generic Rx Coverage (Tier 1) $10 copay Deductible waived. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $40 copay Deductible applies. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $60 copay Deductible applies. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Gold 2 HDHP FRNY-HMOH-DG-002-N (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $1,400 / $2,800
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $6,900 / $13,800
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $5 copay
Specialist Visit $25 copay
ER $75 copay Deductible applies.
Urgent Care $25 copay Deductible applies.
Generic Rx Coverage (Tier 1) $5 copay Deductible applies. 30 day retail/90 day mail order; preventive drugs deductible waived.
Preferred Rx Coverage (Tier 2) $15 copay Deductible applies. 30 day retail/90 day mail order; preventive drugs deductible waived.
Non Preferred Rx Coverage (Tier 3) $25 copay Deductible applies. 30 day retail/90 day mail order; preventive drugs deductible waived.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Platinum 1 FRNY-HMO-DP-001-S (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Platinum
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $2,000 / $4,000
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $15 copay
Specialist Visit $35 copay
ER $100 copay No Deductible.
Urgent Care $55 copay No Deductible.
Generic Rx Coverage (Tier 1) $10 copay No Deductible. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $30 copay No Deductible. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $60 copay No Deductible. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, 20% discount on CVS health brand-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

Essential Plan 1 FRNY-EP-D-001 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level NA
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit $2,000 / N/A None
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $15 copay
Specialist Visit $25 copay
ER $75 copay No Deductible.
Urgent Care $25 copay No Deductible.
Generic Rx Coverage (Tier 1) $6 copay No Deductible. 30 day supply retail.
Preferred Rx Coverage (Tier 2) $15 copay No Deductible. 30 day supply retail.
Non Preferred Rx Coverage (Tier 3) $30 copay No Deductible. 30 day supply retail.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights Dental and vision coverage, $0 telemedicine services, 20% discount on CVS brand health-related items
Well-Being Features $125 WellBeing Rewards
Availability January 1, 2021

Essential Plan 2 FRNY-EP-D-002 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level NA
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit $200 / N/A None
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $1 copay No Deductible. 30 day supply retail.
Preferred Rx Coverage (Tier 2) $3 copay No Deductible. 30 day supply retail.
Non Preferred Rx Coverage (Tier 3) $3 copay No Deductible. 30 day supply retail.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights Dental and vision coverage, $0 telemedicine services, 20% discount on CVS brand health-related items
Well-Being Features $125 WellBeing Rewards
Availability January 1, 2021

Essential Plan 3 FRNY-EPA-D-003 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level NA
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit $200 / N/A None
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $1 copay No Deductible. For covered prescription drugs, the Maximum Out-of- Pocket Limit is $50 per calendar quarter.
Preferred Rx Coverage (Tier 2) $3 copay No Deductible. For covered prescription drugs, the Maximum Out-of- Pocket Limit is $50 per calendar quarter.
Non Preferred Rx Coverage (Tier 3) $3 copay No Deductible. For covered prescription drugs, the Maximum Out-of- Pocket Limit is $50 per calendar quarter.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights Dental and vision coverage, $0 telemedicine services, 20% discount on CVS brand health-related items
Well-Being Features $125 WellBeing Rewards
Availability January 1, 2021

Essential Plan 4 FRNY-EPA-D-004 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level NA
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible. 30 day supply retail.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible. 30 day supply retail.
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible. 30 day supply retail.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights Dental and vision coverage, $0 telemedicine services, 20% discount on CVS brand health-related items
Well-Being Features $125 WellBeing Rewards
Availability January 1, 2021

MVP Secure FRNY-HMO-DC-001-S (2021)

State New York
Plan Type HMO
Exchange On
Metal Level NA
Annual In-Network Deductible (Single/Family) $8,550 / $17,100
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $8,550 / $17,100
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 0% coinsurance (First 3 visits no Deductible)
Specialist Visit 0% coinsurance
ER 0% coinsurance Deductible applies.
Urgent Care 0% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) 0% coinsurance Deductible applies. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) 0% coinsurance Deductible applies. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) 0% coinsurance Deductible applies. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, 20% discount on CVS health brand-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Bronze 1 AI-AN FRNY-HMOH-DBA1-001-S (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, 20% discount on CVS health brand-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Bronze 2 AI-AN FRNY-HMO-DBA1-002-S (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, 20% discount on CVS health brand-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Bronze 1 AI-AN FRNY-HMO-DBA1-001-N (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Bronze 2 AI-AN FRNY-HMO-DBA1-002-N (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Bronze 3 AI-AN FRNY-HMOH-DBA1-003-N (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Silver 11 73 FRNY-HMO-DS1-011-N-73 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $2,250 / $4,500
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $6,950 / $13,900
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $60 copay ($0 copay first 3 visits)
Specialist Visit $70 copay
ER $500 copay Deductible applies.
Urgent Care $70 copay Deductible waived.
Generic Rx Coverage (Tier 1) $15 copay Deductible waived. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $45 copay Deductible applies. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $90 copay Deductible applies. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Silver 11 87 FRNY-HMO-DS1-011-N-87 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $500 / $1,000
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $2,850 / $5,700
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $30 copay ($0 copay first 3 visits)
Specialist Visit $30 copay
ER $100 copay Deductible applies.
Urgent Care $30 copay Deductible waived.
Generic Rx Coverage (Tier 1) $10 copay Deductible waived. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $30 copay Deductible applies. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $50 copay Deductible applies. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Silver 11 94 FRNY-HMO-DS1-011-N-94 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $300 / $600
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $600 / $1,200
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $30 copay ($0 copay first 3 visits)
Specialist Visit $30 copay
ER $100 copay Deductible applies.
Urgent Care $30 copay Deductible waived.
Generic Rx Coverage (Tier 1) $10 copay Deductible waived. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $30 copay Deductible applies. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $50 copay Deductible applies. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Silver 11 AI-AN FRNY-HMO-DSA1-011-N(2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Silver 2 73 FRNY-HMO-DS1-002-N-73 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $1,900 / $3,800
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $5,650 / $11,300
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $40 copay ($0 copay first 3 visits)
Specialist Visit $70 copay
ER $500 copay Deductible waived.
Urgent Care $70 copay Deductible waived.
Generic Rx Coverage (Tier 1) $15 copay Deductible applies. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $40 copay Deductible applies. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $70 copay Deductible applies. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Silver 2 87 FRNY-HMO-DS1-002-N-87 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $350 / $700
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $2,600 / $5,200
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $5 copay ($0 copay first 3 visits)
Specialist Visit $25 copay
ER $200 copay Deductible waived.
Urgent Care $25 copay Deductible waived.
Generic Rx Coverage (Tier 1) $15 copay Deductible applies. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $40 copay Deductible applies. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $70 copay Deductible applies. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Silver 2 94 FRNY-HMO-DS1-002-N-94 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $50 / $100
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $1,300 / $2,600
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $5 copay ($0 copay first 3 visits)
Specialist Visit $15 copay
ER $150 copay Deductible waived.
Urgent Care $15 copay Deductible waived.
Generic Rx Coverage (Tier 1) $5 copay Deductible applies. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $15 copay Deductible applies. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $35 copay Deductible applies. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Silver 2 AI-AN FRNY-HMO-DSA1-002-N (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Silver 3 87 FRNY-HMOH-DS1-003-N-87 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $400 / $800
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $2,500 / $5,000
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $5 copay
Specialist Visit $15 copay
ER $100 copay Deductible applies.
Urgent Care $15 copay Deductible applies.
Generic Rx Coverage (Tier 1) $5 copay Deductible applies. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $40 copay Deductible applies. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $60 copay Deductible applies. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Silver 3 94 FRNY-HMOH-DS1-003-N-94 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $200 / $400
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $800 / $1,600
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $5 copay
Specialist Visit $5 copay
ER $50 copay Deductible applies.
Urgent Care $5 copay Deductible applies.
Generic Rx Coverage (Tier 1) $5 copay Deductible applies. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $15 copay Deductible applies. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $35 copay Deductible applies. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Silver 3 AI-AN FRNY-HMOH-DSA1-003-N (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Silver 3 HDHP 73 FRNY-HMOH-DS1-003-N-73 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $1,700 / $3,400
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $4,700 / $9,400
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $30 copay
Specialist Visit $60 copay
ER $300 copay Deductible applies.
Urgent Care $60 copay Deductible applies.
Generic Rx Coverage (Tier 1) $10 copay Deductible applies. 30 day retail/90 day mail order; preventive drugs deductible waived.
Preferred Rx Coverage (Tier 2) $45 copay Deductible applies. 30 day retail/90 day mail order; preventive drugs deductible waived.
Non Preferred Rx Coverage (Tier 3) $90 copay Deductible applies. 30 day retail/90 day mail order; preventive drugs deductible waived.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Silver 1 73 FRNY-HMO-DS1-001-S-73 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $1,100 / $2,200
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $6,500 / $13,000
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $30 copay
Specialist Visit $50 copay
ER $275 copay Deductible applies.
Urgent Care $70 copay Deductible applies.
Generic Rx Coverage (Tier 1) $10 copay Deductible waived. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $35 copay Deductible waived. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $70 copay Deductible waived. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, 20% discount on CVS health brand-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Silver 1 87 FRNY-HMO-DS1-001-S-87 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $250 / $500
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $2,200 / $4,400
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $15 copay
Specialist Visit $35 copay
ER $75 copay Deductible applies.
Urgent Care $50 copay Deductible applies.
Generic Rx Coverage (Tier 1) $9 copay Deductible waived. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $20 copay Deductible waived. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $40 copay Deductible waived. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, 20% discount on CVS health brand-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Silver 1 94 FRNY-HMO-DS1-001-S-94 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $1,000 / $2,000
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $10 copay
Specialist Visit $20 copay
ER $50 copay No Deductible.
Urgent Care $30 copay No Deductible.
Generic Rx Coverage (Tier 1) $6 copay No Deductible. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $15 copay No Deductible. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $30 copay No Deductible. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, 20% discount on CVS health brand-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Silver 1 AI-AN FRNY-HMO-DSA1-001-S (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, 20% discount on CVS health brand-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Gold 1 AI-AN FRNY-HMO-DGA1-001-S (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, 20% discount on CVS health brand-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Gold 1 AI-AN FRNY-HMO-DGA1-001-N (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay Deductible waived. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $0 copay Deductible waived. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $0 copay Deductible waived. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Plus Gold 2 AI-AN FRNY-HMOH-DGA1-002-N (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

MVP Premier Platinum 1 AI-AN FRNY-HMO-DPA1-001-S (2021)

State New York
Plan Type HMO
Exchange On
Metal Level Platinum
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible. 30 day retail/90 day mail order.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible. 30 day retail/90 day mail order.
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible. 30 day retail/90 day mail order.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $0 telemedicine services, 20% discount on CVS health brand-related items
Well-Being Features $600 WellBeing Rewards
Availability January 1, 2021

Essential Plan 5 FRNY-EP-DA1-005 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level NA
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible. 30 day supply retail.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible. 30 day supply retail.
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible. 30 day supply retail.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights Dental and vision coverage, $0 telemedicine services, 20% discount on CVS brand health-related items
Well-Being Features $125 WellBeing Rewards
Availability January 1, 2021

Essential Plan 6 FRNY-EP-DA1-006 (2021)

State New York
Plan Type HMO
Exchange On
Metal Level NA
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible. 30 day supply retail.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible. 30 day supply retail.
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible. 30 day supply retail.
Rx Formulary 2021 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for New York’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights Dental and vision coverage, $0 telemedicine services, 20% discount on CVS brand health-related items
Well-Being Features $125 WellBeing Rewards
Availability January 1, 2021