Non-Standard Individual Gold Plans

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 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

MVP Premier Plus Gold 1 FRNY-HMO-DG-001-N (2023)