Non-Standard Individual Bronze Plans

MVP Health Care non-standard plans for individuals, 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 (2022)

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. $100 max out of pocket on 30 day supply of Insulin
Non Preferred Rx Coverage (Tier 3) $90 copay Deductible applies. 30 day retail/90 day mail order.
Rx Formulary 2022 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 WellBeing Rewards
Availability January 1, 2022

MVP Premier Plus Bronze 2 FRNY-HMO-DB-002-N (2022)

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. $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 2022 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 WellBeing Rewards
Availability January 1, 2022

MVP Premier Plus Bronze 3 HDHP FRNY-HMOH-DB-003-N (2022)

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. $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 2022 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 WellBeing Rewards
Availability January 1, 2022

MVP Premier Plus Bronze 1 AI-AN FRNY-HMO-DBA1-001-N (2022)

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 (Single/Family) $0 / $0
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. $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 2022 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 WellBeing Rewards
Availability January 1, 2022

MVP Premier Plus Bronze 2 AI-AN FRNY-HMO-DBA1-002-N (2022)

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 (Single/Family) $0 / $0
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. $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 2022 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 WellBeing Rewards
Availability January 1, 2022

MVP Premier Plus Bronze 3 AI-AN FRNY-HMOH-DBA1-003-N (2022)

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 (Single/Family) $0 / $0
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. $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 2022 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 WellBeing Rewards
Availability January 1, 2022