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 2 FRNY-HMO-DB-002-N (2023) |
|
|---|---|
| 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 (First 3 Combined PCP/MH/SA Visits Covered in Full) |
| 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. $100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $80 copay Deductible applies. 30 day retail/90 day mail order |
| Rx Formulary | 2023 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |
MVP Premier Plus Bronze 3 HDHP FRNY-HMOH-DB-003-N (2023) |
|
|---|---|
| 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. $100 max out of pocket on 30 day supply of Insulin; 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 | 2023 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |
MVP Premier Plus Silver 13 FRNY-HMO-DS-013-N (2023) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $2,800 / $5,600 |
| Annual Out-of-Network Deductible | N/A |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $9,100 / $18,200 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $35 copay |
| Specialist Visit | $50 copay |
| ER | $250 copay Deductible applies. |
| Urgent Care | $50 copay Deductible applies. |
| Generic Rx Coverage (Tier 1) | $0 copay Deductible waived. 30 day retail/90 day mail order |
| Preferred Rx Coverage (Tier 2) | $10 copay Deductible waived. $100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $50 copay Deductible waived. 30 day retail/90 day mail order |
| Rx Formulary | 2023 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |
MVP Premier Plus Silver 3 HDHP FRNY-HMOH-DS-003-N (2023) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $2,600 / $5,200 |
| 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 | $30 copay |
| Specialist Visit | $60 copay |
| ER | $325 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. $100 max out of pocket on 30 day supply of Insulin; 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 | 2023 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |
MVP Premier Plus Gold 1 FRNY-HMO-DG-001-N (2023) |
|
|---|---|
| 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 (First 3 Combined PCP/MH/SA Visits Covered in Full) |
| 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. $100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $60 copay Deductible applies. 30 day retail/90 day mail order |
| Rx Formulary | 2023 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |
MVP Premier Plus Gold 2 HDHP FRNY-HMOH-DG-002-N (2023) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Gold |
| Annual In-Network Deductible (Single/Family) | $1,500 / $3,000 |
| 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. $100 max out of pocket on 30 day supply of Insulin; 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 | 2023 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |
MVP Premier Plus Bronze 2 AI-AN FRNY-HMO-DBA1-002-N (2023) |
|
|---|---|
| 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.$100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $0 copay No Deductible.30 day retail/90 day mail order |
| Rx Formulary | 2023 MVP Marketplace Formulary (PDF) |
| Rx Drug Search | Pharmacy Information for New York’s Prescription Drug Program |
| Special Eligibility | American 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |
MVP Premier Plus Bronze 3 AI-AN FRNY-HMOH-DBA1-003-N (2023) |
|
|---|---|
| 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.$100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $0 copay No Deductible.30 day retail/90 day mail order |
| Rx Formulary | 2023 MVP Marketplace Formulary (PDF) |
| Rx Drug Search | Pharmacy Information for New York’s Prescription Drug Program |
| Special Eligibility | American 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |
MVP Premier Plus Silver 13 73 FRNY-HMO-DS1-013-N-73 (2023) |
|
|---|---|
| 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) | $6,000 / $12,000 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $35 copay |
| Specialist Visit | $50 copay |
| ER | $250 copay Deductible applies. |
| Urgent Care | $50 copay Deductible applies. |
| Generic Rx Coverage (Tier 1) | $0 copay Deductible waived. 30 day retail/90 day mail order |
| Preferred Rx Coverage (Tier 2) | $10 copay Deductible waived. $100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $50 copay Deductible waived. 30 day retail/90 day mail order |
| Rx Formulary | 2023 MVP Marketplace Formulary (PDF) |
| Rx Drug Search | Pharmacy Information for New York’s Prescription Drug Program |
| Special Eligibility | Must 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |
MVP Premier Plus Silver 13 87 FRNY-HMO-DS1-013-N-87 (2023) |
|
|---|---|
| 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) | $1,750 / $3,500 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $20 copay |
| Specialist Visit | $30 copay |
| ER | $100 copay Deductible applies. |
| Urgent Care | $30 copay Deductible applies. |
| Generic Rx Coverage (Tier 1) | $0 copay Deductible waived. 30 day retail/90 day mail order |
| Preferred Rx Coverage (Tier 2) | $10 copay Deductible waived. $100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $40 copay Deductible waived. 30 day retail/90 day mail order |
| Rx Formulary | 2023 MVP Marketplace Formulary (PDF) |
| Rx Drug Search | Pharmacy Information for New York’s Prescription Drug Program |
| Special Eligibility | Must 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |
MVP Premier Plus Silver 13 94 FRNY-HMO-DS1-013-N-94 (2023) |
|
|---|---|
| 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 | $5 copay |
| Specialist Visit | $20 copay |
| ER | $75 copay Deductible applies. |
| Urgent Care | $20 copay Deductible applies. |
| Generic Rx Coverage (Tier 1) | $0 copay Deductible waived. 30 day retail/90 day mail order |
| Preferred Rx Coverage (Tier 2) | $10 copay Deductible waived. $100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $30 copay Deductible waived. 30 day retail/90 day mail order |
| Rx Formulary | 2023 MVP Marketplace Formulary (PDF) |
| Rx Drug Search | Pharmacy Information for New York’s Prescription Drug Program |
| Special Eligibility | Must 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |
MVP Premier Plus Silver 13 AI-AN FRNY-HMO-DSA1-013-N (2023) |
|
|---|---|
| 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.$100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $0 copay No Deductible.30 day retail/90 day mail order |
| Rx Formulary | 2023 MVP Marketplace Formulary (PDF) |
| Rx Drug Search | Pharmacy Information for New York’s Prescription Drug Program |
| Special Eligibility | American 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |
MVP Premier Plus Silver 3 87 FRNY-HMOH-DS1-003-N-87 (2023) |
|
|---|---|
| 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) | $3,200 / $6,400 |
| 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. $100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $60 copay Deductible applies. 30 day retail/90 day mail order |
| Rx Formulary | 2023 MVP Marketplace Formulary (PDF) |
| Rx Drug Search | Pharmacy Information for New York’s Prescription Drug Program |
| Special Eligibility | Must 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |
MVP Premier Plus Silver 3 94 FRNY-HMOH-DS1-003-N-94 (2023) |
|
|---|---|
| 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. $100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $35 copay Deductible applies. 30 day retail/90 day mail order |
| Rx Formulary | 2023 MVP Marketplace Formulary (PDF) |
| Rx Drug Search | Pharmacy Information for New York’s Prescription Drug Program |
| Special Eligibility | Must 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |
MVP Premier Plus Silver 3 AI-AN FRNY-HMOH-DSA1-003-N (2023) |
|
|---|---|
| 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.$100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $0 copay No Deductible.30 day retail/90 day mail order |
| Rx Formulary | 2023 MVP Marketplace Formulary (PDF) |
| Rx Drug Search | Pharmacy Information for New York’s Prescription Drug Program |
| Special Eligibility | American 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |
MVP Premier Plus Silver 3 HDHP 73 FRNY-HMOH-DS1-003-N-73 (2023) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $2,100 / $4,200 |
| Annual Out-of-Network Deductible | N/A |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $5,000 / $10,000 |
| 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. $100 max out of pocket on 30 day supply of Insulin; 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 | 2023 MVP Marketplace Formulary (PDF) |
| Rx Drug Search | Pharmacy Information for New York’s Prescription Drug Program |
| Special Eligibility | Must 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |
MVP Premier Plus Gold 1 AI-AN FRNY-HMO-DGA1-001-N (2023) |
|
|---|---|
| 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. $100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $0 copay Deductible waived. 30 day retail/90 day mail order |
| Rx Formulary | 2023 MVP Marketplace Formulary (PDF) |
| Rx Drug Search | Pharmacy Information for New York’s Prescription Drug Program |
| Special Eligibility | American 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |
MVP Premier Plus Gold 2 AI-AN FRNY-HMOH-DGA1-002-N (2023) |
|
|---|---|
| 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.$100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $0 copay No Deductible.30 day retail/90 day mail order |
| Rx Formulary | 2023 MVP Marketplace Formulary (PDF) |
| Rx Drug Search | Pharmacy Information for New York’s Prescription Drug Program |
| Special Eligibility | American 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 | Savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |