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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 Savings at preferred provider facilities, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023