Non-Standard Plans

MVP Health Care non-standard 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 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 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 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 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