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 (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 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