New York Small Group Gold Plans
MVP Health Care non-standard plans for small businesses, part of MVP’s suite of Premier plans offered on New York State of Health.
MVP EPO Gold 1 NY-EPO-SG-001 (2023) |
|
|---|---|
| State | New York |
| Plan Type | EPO |
| Exchange | Off |
| Metal Level | Gold |
| Annual In-Network Deductible (Single/Family) | $850 / $1,700 |
| Annual Out-of-Network Deductible | N/A |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $7,000 / $14,000 |
| 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 | $300 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) | $35 copay Deductible applies. $100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $70 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 | Cigna national network, pediatric dental, 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 EPO Gold 11 NY-EPO-SG-011 (2023) |
|
|---|---|
| State | New York |
| Plan Type | EPO |
| Exchange | Off |
| Metal Level | Gold |
| Annual In-Network Deductible (Single/Family) | $750 / $1,500 |
| Annual Out-of-Network Deductible | N/A |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $8,700 / $17,400 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $35 copay ($0 copay to age 26) |
| Specialist Visit | $50 copay |
| ER | $250 copay Deductible applies. |
| Urgent Care | $50 copay Deductible waived. |
| Generic Rx Coverage (Tier 1) | $10 copay Deductible waived. $0 copay to age 26; 30 day retail/90 day mail order |
| Preferred Rx Coverage (Tier 2) | $45 copay Deductible applies. $100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $90 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 | Cigna national network, pediatric dental, 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 EPO Gold 2 HDHP NY-EPOH-SG-002 (2023) |
|
|---|---|
| State | New York |
| Plan Type | EPO |
| Exchange | Off |
| Metal Level | Gold |
| Annual In-Network Deductible (Single/Family) | $1,600 / $3,200 |
| Annual Out-of-Network Deductible | N/A |
| 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 | $10 copay |
| Specialist Visit | $20 copay |
| ER | $75 copay Deductible applies. |
| Urgent Care | $20 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) | $30 copay Deductible applies. $100 max out of pocket on 30 day supply of Insulin; preventive drugs deductible waived |
| Non Preferred Rx Coverage (Tier 3) | $50 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 | Cigna national network, pediatric dental, 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 EPO Gold 3 NY-EPO-SG-003 (2023) |
|
|---|---|
| State | New York |
| Plan Type | EPO |
| Exchange | Off |
| Metal Level | Gold |
| Annual In-Network Deductible (Single/Family) | $1,000 / $2,000 |
| Annual Out-of-Network Deductible | N/A |
| 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 | $20 copay |
| Specialist Visit | $40 copay |
| ER | $300 copay Deductible applies. |
| Urgent Care | $40 copay Deductible applies. |
| Generic Rx Coverage (Tier 1) | $10 copay Deductible waived. 30 day retail/90 day mail order |
| Preferred Rx Coverage (Tier 2) | $35 copay Deductible waived. $100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | 50% coinsurance 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 |
| 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 | Cigna national network, pediatric dental, 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 EPO Gold 4 NY-EPO-SG-004 (2023) |
|
|---|---|
| State | New York |
| Plan Type | EPO |
| Exchange | Off |
| 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 (Single/Family) | $6,750 / $13,500 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $40 copay |
| Specialist Visit | $60 copay |
| ER | $500 copay No Deductible. |
| Urgent Care | $60 copay No Deductible. |
| Generic Rx Coverage (Tier 1) | $10 copay No Deductible.30 day retail/90 day mail order |
| Preferred Rx Coverage (Tier 2) | $40 copay No Deductible.$100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $60 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 |
| 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 | Cigna national network, pediatric dental, 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 EPO Gold 6 NY-EPO-SG-006 (2023) |
|
|---|---|
| State | New York |
| Plan Type | EPO |
| Exchange | Off |
| Metal Level | Gold |
| Annual In-Network Deductible (Single/Family) | $350 / $700 |
| Annual Out-of-Network Deductible | N/A |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $6,550 / $13,100 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $30 copay |
| Specialist Visit | $50 copay |
| ER | $100 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 waived. $100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $60 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 |
| 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 | Cigna national network, pediatric dental, 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 EPO Gold 8 NY-EPO-SG-008 (2023) |
|
|---|---|
| State | New York |
| Plan Type | EPO |
| Exchange | Off |
| Metal Level | Gold |
| Annual In-Network Deductible (Single/Family) | $4,000 / $8,000 |
| Annual Out-of-Network Deductible | N/A |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $8,000 / $16,000 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $40 copay |
| Specialist Visit | $60 copay |
| ER | $300 copay Deductible waived. |
| Urgent Care | $60 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 waived. $100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $60 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 |
| 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 | Cigna national network, pediatric dental, 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 HMO Gold 1 NY-HMO-SG-001 (2023) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | Off |
| Metal Level | Gold |
| Annual In-Network Deductible (Single/Family) | $850 / $1,700 |
| Annual Out-of-Network Deductible | N/A |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $7,000 / $14,000 |
| 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 | $300 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) | $35 copay Deductible applies. $100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $70 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 | Cigna national network, pediatric dental, 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 HMO Gold 10 NY-HMO-SG-010 (2023) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | Off |
| Metal Level | Gold |
| Annual In-Network Deductible (Single/Family) | $600 / $1,200 |
| Annual Out-of-Network Deductible | N/A |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $4,200 / $8,400 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $25 copay |
| Specialist Visit | $40 copay |
| ER | $300 copay Deductible applies. |
| Urgent Care | $40 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 waived. $100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $90 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 |
| 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 | Cigna national network, pediatric dental, 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 HMO Gold 11 NY-HMO-SG-011 (2023) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | Off |
| Metal Level | Gold |
| Annual In-Network Deductible (Single/Family) | $750 / $1,500 |
| Annual Out-of-Network Deductible | N/A |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $8,700 / $17,400 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $35 copay ($0 copay to age 26) |
| Specialist Visit | $50 copay |
| ER | $250 copay Deductible applies. |
| Urgent Care | $50 copay Deductible waived. |
| Generic Rx Coverage (Tier 1) | $10 copay Deductible waived. $0 copay to age 26; 30 day retail/90 day mail order |
| Preferred Rx Coverage (Tier 2) | $45 copay Deductible applies. $100 max out of pocket on 30 day supply of Insulin |
| Non Preferred Rx Coverage (Tier 3) | $90 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 | Cigna national network, pediatric dental, 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 HMO Gold 2 HDHP NY-HMOH-SG-002 (2023) |
|
|---|---|
| State | New York |
| Plan Type | HMO |
| Exchange | Off |
| Metal Level | Gold |
| Annual In-Network Deductible (Single/Family) | $1,600 / $3,200 |
| Annual Out-of-Network Deductible | N/A |
| 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 | $10 copay |
| Specialist Visit | $20 copay |
| ER | $75 copay Deductible applies. |
| Urgent Care | $20 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) | $30 copay Deductible applies. $100 max out of pocket on 30 day supply of Insulin; preventive drugs deductible waived |
| Non Preferred Rx Coverage (Tier 3) | $50 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 | Cigna national network, pediatric dental, savings at preferred provider facilities, 20% discount on CVS brand health-related items |
| Well-Being Features | $600 Well-Being Reimbursement |
| Availability | January 1, 2023 |