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 EligibilityMust 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 EligibilityMust 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 EligibilityMust 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 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 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 EligibilityMust 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 EligibilityMust 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 EligibilityMust 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 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, 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 EligibilityMust 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 EligibilityMust 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 EligibilityMust 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