Non-Standard Individual Silver 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 HDHP Silver 3 FRNY-HMOH-DS-003-N (2019) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $2,500 / $5,000 |
| Annual Out-of-Network Deductible (Single/Family) | $0 / $0 |
| 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 supply retail; preventive drugs deductible waived |
| Preferred Rx Coverage (Tier 2) | $45 copay Deductible applies. 30 day supply retail; preventive drugs deductible waived |
| Non Preferred Rx Coverage (Tier 3) | $90 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 Silver 11 FRNY-HMO-DS-011-N (2019) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $5,850 / $11,700 |
| Annual Out-of-Network Deductible (Single/Family) | $0 / $0 |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $5,850 / $11,700 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $35 copay $0 copay first 3 visits |
| Specialist Visit | $55 copay |
| ER | $0 copay Deductible applies. |
| Urgent Care | $55 copay Deductible waived. |
| Generic Rx Coverage (Tier 1) | $10 copay Deductible waived. 30 day supply retail |
| Preferred Rx Coverage (Tier 2) | $0 copay Deductible applies. 30 day supply retail |
| Non Preferred Rx Coverage (Tier 3) | $0 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 Silver 2 FRNY-HMO-DS-002-N (2019) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $2,645 / $5,290 |
| Annual Out-of-Network Deductible (Single/Family) | $0 / $0 |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $6,350 / $12,700 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $40 copay $0 copay first 3 visits |
| Specialist Visit | $70 copay |
| ER | $500 copay Deductible waived. |
| Urgent Care | $70 copay Deductible waived. |
| Generic Rx Coverage (Tier 1) | $15 copay Deductible applies. 30 day supply retail |
| Preferred Rx Coverage (Tier 2) | $40 copay Deductible applies. 30 day supply retail |
| Non Preferred Rx Coverage (Tier 3) | $70 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 Silver 3, 73 FRNY-HMOH-DS1-003-N-73 (2019) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $1,700 / $3,400 |
| Annual Out-of-Network Deductible (Single/Family) | $0 / $0 |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $4,500 / $9,000 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $25 copay |
| Specialist Visit | $50 copay |
| ER | $200 copay Deductible applies. |
| Urgent Care | $50 copay 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) | $70 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 |
| Special Eligibility | Must 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 | 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 Silver 3, 87 FRNY-HMOH-DS1-003-N-87 (2019) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $400 / $800 |
| Annual Out-of-Network Deductible (Single/Family) | $0 / $0 |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $2,000 / $4,000 |
| 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 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 |
| Special Eligibility | Must 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 | 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 Silver 3, 94 FRNY-HMOH-DS1-003-N-94 (2019) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $200 / $400 |
| Annual Out-of-Network Deductible (Single/Family) | $0 / $0 |
| 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 supply retail |
| Preferred Rx Coverage (Tier 2) | $15 copay Deductible applies. 30 day supply retail |
| Non Preferred Rx Coverage (Tier 3) | $35 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 |
| Special Eligibility | Must 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 | 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 Silver 11 FRNY-HMO-DSA1-011-N (2019) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| 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 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 | 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 Silver 11, 73 FRNY-HMO-DS1-011-N-73 (2019) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $5,100 / $10,200 |
| Annual Out-of-Network Deductible (Single/Family) | $0 / $0 |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $5,100 / $10,200 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $35 copay $0 copay first 3 visits |
| Specialist Visit | $55 copay |
| ER | $0 copay Deductible applies. |
| Urgent Care | $55 copay Deductible waived. |
| Generic Rx Coverage (Tier 1) | $10 copay Deductible waived. 30 day supply retail |
| Preferred Rx Coverage (Tier 2) | $0 copay Deductible applies. 30 day supply retail |
| Non Preferred Rx Coverage (Tier 3) | $0 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 |
| Special Eligibility | Must 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 | 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 Silver 11, 87 FRNY-HMO-DS1-011-N-87 (2019) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $1,500 / $3,000 |
| Annual Out-of-Network Deductible (Single/Family) | $0 / $0 |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $1,500 / $3,000 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $25 copay $0 copay first 3 visits |
| Specialist Visit | $35 copay |
| ER | $0 copay Deductible applies. |
| Urgent Care | $35 copay Deductible waived. |
| Generic Rx Coverage (Tier 1) | $10 copay Deductible waived. 30 day supply retail |
| Preferred Rx Coverage (Tier 2) | $0 copay Deductible applies. 30 day supply retail |
| Non Preferred Rx Coverage (Tier 3) | $0 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 |
| Special Eligibility | Must 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 | 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 Silver 11, 94 FRNY-HMO-DS1-011-N-94 (2019) |
|
|---|---|
| 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 (Single/Family) | $0 / $0 |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $500 / $1,000 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $25 copay $0 copay first 3 visits |
| Specialist Visit | $35 copay |
| ER | $0 copay Deductible applies. |
| Urgent Care | $35 copay Deductible waived. |
| Generic Rx Coverage (Tier 1) | $10 copay Deductible waived. 30 day supply retail |
| Preferred Rx Coverage (Tier 2) | $0 copay Deductible applies. 30 day supply retail |
| Non Preferred Rx Coverage (Tier 3) | $0 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 |
| Special Eligibility | Must 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 | 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 Silver 2 FRNY-HMO-DSA1-002-N (2019) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| 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 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 | 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 Silver 2, 73 FRNY-HMO-DS1-002-N-73 (2019) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $1,900 / $3,800 |
| Annual Out-of-Network Deductible (Single/Family) | $0 / $0 |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $4,800 / $9,600 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $40 copay $0 copay first 3 visits |
| Specialist Visit | $70 copay |
| ER | $500 copay Deductible waived. |
| Urgent Care | $70 copay Deductible waived. |
| Generic Rx Coverage (Tier 1) | $15 copay Deductible applies. 30 day supply retail |
| Preferred Rx Coverage (Tier 2) | $40 copay Deductible applies. 30 day supply retail |
| Non Preferred Rx Coverage (Tier 3) | $70 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 |
| Special Eligibility | Must 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 | 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 Silver 2, 87 FRNY-HMO-DS1-002-N-87 (2019) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $350 / $700 |
| Annual Out-of-Network Deductible (Single/Family) | $0 / $0 |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $2,100 / $4,200 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $5 copay $0 copay first 3 visits |
| Specialist Visit | $25 copay |
| ER | $200 copay Deductible waived. |
| Urgent Care | $25 copay Deductible waived. |
| Generic Rx Coverage (Tier 1) | $15 copay Deductible applies. 30 day supply retail |
| Preferred Rx Coverage (Tier 2) | $40 copay Deductible applies. 30 day supply retail |
| Non Preferred Rx Coverage (Tier 3) | $70 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 |
| Special Eligibility | Must 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 | 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 Silver 2, 94 FRNY-HMO-DS1-002-N-94 (2019) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $50 / $100 |
| Annual Out-of-Network Deductible (Single/Family) | $0 / $0 |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $1,300 / $2,600 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $5 copay $0 copay first 3 visits |
| Specialist Visit | $15 copay |
| ER | $150 copay Deductible waived. |
| Urgent Care | $15 copay Deductible waived. |
| Generic Rx Coverage (Tier 1) | $5 copay Deductible applies. 30 day supply retail |
| Preferred Rx Coverage (Tier 2) | $15 copay Deductible applies. 30 day supply retail |
| Non Preferred Rx Coverage (Tier 3) | $35 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 |
| Special Eligibility | Must 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 | 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 |