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 $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 $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 $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 $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 $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 $0 telemedicine services, 20% discount on CVS brand health-related items
Well-Being Features $125 WellBeing Rewards
Availability January 1, 2021