Non-Standard Individual Gold 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 Gold 1 FRNY-HMO-DG-001-N (2019)

State New York
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $950 / $1,900
Annual Out-of-Network Deductible (Single/Family) $0 / $0
Annual In-Network Out-of-Pocket Limit (Single/Family) $5,500 / $11,000
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $15 copay $0 copay first 3 visits
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 supply retail
Preferred Rx Coverage (Tier 2) $40 copay Deductible applies. 30 day supply retail
Non Preferred Rx Coverage (Tier 3) $60 copay Deductible applies. 30 day supply retail
Rx Formulary 2019 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 Acupuncture, Telemedicine, 3 $0 PCP visits w/ no ded, $1,000 out of area coverage for dependents, and domestic partner coverage included.
Wellness Features MVP Wellness Program
Availability January 1, 2019

MVP Premier Plus HDHP Gold 2 FRNY-HMOH-DG-002-N (2019)

State New York
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $1,350 / $2,700
Annual Out-of-Network Deductible (Single/Family) $0 / $0
Annual In-Network Out-of-Pocket Limit (Single/Family) $4,100 / $8,200
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 supply retail; preventive drugs deductible waived
Preferred Rx Coverage (Tier 2) $15 copay Deductible applies. 30 day supply retail; preventive drugs deductible waived
Non Preferred Rx Coverage (Tier 3) $25 copay Deductible applies. 30 day supply retail; preventive drugs deductible waived
Rx Formulary 2019 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 Acupuncture, Telemedicine, Preventive drugs no ded, $1,000 out of area coverage for dependents, and domestic partner coverage included.
Wellness Features MVP Wellness Program
Availability January 1, 2019

MVP Premier Plus HDHP Gold National FRNY-HMOH-DG-001-NN (2019)

State New York
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $1,350 / $2,700
Annual Out-of-Network Deductible (Single/Family) $0 / $0
Annual In-Network Out-of-Pocket Limit (Single/Family) $5,600 / $11,200
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 20% coinsurance
Specialist Visit 20% coinsurance
ER 20% coinsurance Deductible applies.
Urgent Care 20% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) $10 copay Deductible applies. 30 day supply retail; preventive drugs deductible waived
Preferred Rx Coverage (Tier 2) $40 copay Deductible applies. 30 day supply retail; preventive drugs deductible waived
Non Preferred Rx Coverage (Tier 3) $60 copay Deductible applies. 30 day supply retail; preventive drugs deductible waived
Rx Formulary 2019 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 National Network coverage, Acupuncture, myVisitNow (Telemedicine), domestic partner coverage included, Preventive drugs no ded.
Wellness Features MVP Wellness Program
Availability January 1, 2019

MVP Premier Plus Gold 1 FRNY-HMO-DGA1-001-N (2019)

State New York
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible (Single/Family) $0 / $0
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 supply retail
Preferred Rx Coverage (Tier 2) $0 copay Deductible waived. 30 day supply retail
Non Preferred Rx Coverage (Tier 3) $0 copay Deductible waived. 30 day supply retail
Rx Formulary 2019 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 Acupuncture, Telemedicine, preventive drugs no ded, $1,000 out of area coverage for dependents, and domestic partner coverage included.
Wellness Features MVP Wellness Program
Availability January 1, 2019

MVP Premier Plus HDHP Gold 2 FRNY-HMOH-DGA1-002-N (2019)

State New York
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible (Single/Family) $0 / $0
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 supply retail
Preferred Rx Coverage (Tier 2) $0 copay No Deductible.30 day supply retail
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible.30 day supply retail
Rx Formulary 2019 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 Acupuncture, Telemedicine, preventive drugs no ded, $1,000 out of area coverage for dependents, and domestic partner coverage included.
Wellness Features MVP Wellness Program
Availability January 1, 2019

MVP Premier Plus HDHP Gold National FRNY-HMOH-DGA1-001-NN (2019)

State New York
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible (Single/Family) $0 / $0
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 supply retail
Preferred Rx Coverage (Tier 2) $0 copay No Deductible.30 day supply retail
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible.30 day supply retail
Rx Formulary 2019 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 $125 Healthy Lifestyle Credits, myVisitNow (Telemedicine)
Wellness Features MVP Wellness Program
Availability January 1, 2019