Standard Individual Plans
MVP Health Care standard individual plans, part of MVP's suite of Premier plans offered on New York State of Health.
View all MVP NY Individual & Family Plans
MVP Premier Bronze 1 HDHP FRNY-HMOH-DB-001-S (2022) |
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State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | Bronze |
Annual In-Network Deductible (Single/Family) | $6,100 / $12,200 |
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 | 50% coinsurance |
Specialist Visit | 50% coinsurance |
ER | 50% coinsurance Deductible applies. |
Urgent Care | 50% coinsurance Deductible applies. |
Generic Rx Coverage (Tier 1) | $10 copay Deductible applies. 30 day retail/90 day mail order. |
Preferred Rx Coverage (Tier 2) | $35 copay Deductible applies. 30 day retail/90 day mail order. $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 | 2022 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 | 20% discount on CVS brand health-related items |
Well-Being Features | $600 WellBeing Rewards |
Availability | January 1, 2022 |
MVP Premier Bronze 2 FRNY-HMO-DB-002-S (2022) |
|
---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | Bronze |
Annual In-Network Deductible (Single/Family) | $4,700 / $9,400 |
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 | $50 copay (First 3 visits no Deductible) |
Specialist Visit | $75 copay (First 3 visits no Deductible) |
ER | $500 copay Deductible applies. |
Urgent Care | $75 copay Deductible applies. |
Generic Rx Coverage (Tier 1) | $10 copay Deductible applies. 30 day retail/90 day mail order. |
Preferred Rx Coverage (Tier 2) | $35 copay Deductible applies. 30 day retail/90 day mail order. $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 | 2022 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 | 20% discount on CVS brand health-related items |
Well-Being Features | $600 WellBeing Rewards |
Availability | January 1, 2022 |
MVP Premier Silver 1 FRNY-HMO-DS-001-S (2022) |
|
---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | Silver |
Annual In-Network Deductible (Single/Family) | $1,300 / $2,600 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit (Single/Family) | $8,500 / $17,000 |
Annual Out-of-Network Out-of-Pocket Limit | N/A |
Primary Care Visit | $30 copay |
Specialist Visit | $50 copay |
ER | $300 copay Deductible applies. |
Urgent Care | $70 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. 30 day retail/90 day mail order.; $100 max out of pocket on 30 day supply of Insulin |
Non Preferred Rx Coverage (Tier 3) | $70 copay Deductible waived. 30 day retail/90 day mail order. |
Rx Formulary | 2022 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 | 20% discount on CVS brand health-related items |
Well-Being Features | $600 WellBeing Rewards |
Availability | January 1, 2022 |
MVP Premier Gold 1 FRNY-HMO-DG-001-S (2022) |
|
---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
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) | $4,000 / $8,000 |
Annual Out-of-Network Out-of-Pocket Limit | N/A |
Primary Care Visit | $25 copay |
Specialist Visit | $40 copay |
ER | $150 copay Deductible applies. |
Urgent Care | $60 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. 30 day retail/90 day mail order. $100 max out of pocket on 30 day supply of Insulin |
Non Preferred Rx Coverage (Tier 3) | $70 copay Deductible waived. 30 day retail/90 day mail order. |
Rx Formulary | 2022 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 | 20% discount on CVS brand health-related items |
Well-Being Features | $600 WellBeing Rewards |
Availability | January 1, 2022 |
MVP Premier Platinum 1 FRNY-HMO-DP-001-S (2022) |
|
---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | Platinum |
Annual In-Network Deductible (Single/Family) | $0 / $0 |
Annual Out-of-Network Deductible | N/A |
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 | $15 copay |
Specialist Visit | $35 copay |
ER | $100 copay No Deductible. |
Urgent Care | $55 copay No Deductible. |
Generic Rx Coverage (Tier 1) | $10 copay No Deductible. 30 day retail/90 day mail order. |
Preferred Rx Coverage (Tier 2) | $30 copay No Deductible. 30 day retail/90 day mail order. $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 | 2022 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 | 20% discount on CVS brand health-related items |
Well-Being Features | $600 WellBeing Rewards |
Availability | January 1, 2022 |
Essential Plan 1 FRNY-EP-D-001 (2022) |
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---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | NA |
Annual In-Network Deductible (Single/Family) | $0 / $0 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit | $2,000 / N/A None |
Annual Out-of-Network Out-of-Pocket Limit | N/A |
Primary Care Visit | $15 copay |
Specialist Visit | $25 copay |
ER | $75 copay No Deductible. |
Urgent Care | $25 copay No Deductible. |
Generic Rx Coverage (Tier 1) | $6 copay No Deductible. 30 day supply retail. |
Preferred Rx Coverage (Tier 2) | $15 copay No Deductible. 30 day supply retail. |
Non Preferred Rx Coverage (Tier 3) | $30 copay No Deductible. 30 day supply retail. |
Rx Formulary | 2022 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 | Dental and vision benefits included at no cost, 20% discount on CVS brand health-related items. Visit mvphealthcare.com/essential for more information. |
Well-Being Features | $125 WellBeing Rewards |
Availability | January 1, 2022 |
Essential Plan 2 FRNY-EP-D-002 (2022) |
|
---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | NA |
Annual In-Network Deductible (Single/Family) | $0 / $0 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit | $200 / N/A None |
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) | $1 copay No Deductible. 30 day supply retail. |
Preferred Rx Coverage (Tier 2) | $3 copay No Deductible. 30 day supply retail. |
Non Preferred Rx Coverage (Tier 3) | $3 copay No Deductible. 30 day supply retail. |
Rx Formulary | 2022 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 | Dental and vision benefits included at no cost, 20% discount on CVS brand health-related items. Visit mvphealthcare.com/essential for more information. |
Well-Being Features | $125 WellBeing Rewards |
Availability | January 1, 2022 |
Essential Plan 3 FRNY-EPA-D-003 (2022) |
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---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | NA |
Annual In-Network Deductible (Single/Family) | $0 / $0 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit | $200 / N/A None |
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) | $1 copay No Deductible. For covered prescription drugs, the Maximum Out-of-Pocket Limit is $50 per calendar quarter. |
Preferred Rx Coverage (Tier 2) | $3 copay No Deductible. For covered prescription drugs, the Maximum Out-of- Pocket Limit is $50 per calendar quarter. |
Non Preferred Rx Coverage (Tier 3) | $3 copay No Deductible. For covered prescription drugs, the Maximum Out-of- Pocket Limit is $50 per calendar quarter. |
Rx Formulary | 2022 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 | Dental and vision benefits included at no cost, 20% discount on CVS brand health-related items. Visit mvphealthcare.com/essential for more information. |
Well-Being Features | $125 WellBeing Rewards |
Availability | January 1, 2022 |
Essential Plan 4 FRNY-EPA-D-004 (2022) |
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---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | NA |
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 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 | 2022 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 | Dental and vision benefits included at no cost, 20% discount on CVS brand health-related items. Visit mvphealthcare.com/essential for more information. |
Well-Being Features | $125 WellBeing Rewards |
Availability | January 1, 2022 |
MVP Secure FRNY-HMO-DC-001-S (2022) |
|
---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | NA |
Annual In-Network Deductible (Single/Family) | $8,700 / $17,400 |
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 | 0% coinsurance (First 3 visits no Deductible) |
Specialist Visit | 0% coinsurance |
ER | 0% coinsurance Deductible applies. |
Urgent Care | 0% coinsurance Deductible applies. |
Generic Rx Coverage (Tier 1) | 0% coinsurance Deductible applies. 30 day retail/90 day mail order. |
Preferred Rx Coverage (Tier 2) | 0% coinsurance Deductible applies. 30 day retail/90 day mail order.; $100 max out of pocket on 30 day supply of Insulin |
Non Preferred Rx Coverage (Tier 3) | 0% coinsurance Deductible applies. 30 day retail/90 day mail order. |
Rx Formulary | 2022 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 | 20% discount on CVS brand health-related items |
Well-Being Features | $600 WellBeing Rewards |
Availability | January 1, 2022 |
MVP Premier Bronze 1 AI-AN FRNY-HMOH-DBA1-001-S (2022) |
|
---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | Bronze |
Annual In-Network Deductible (Single/Family) | $0 / $0 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit (Single/Family) | $0 / $0 |
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. 30 day retail/90 day mail order. $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 | 2022 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 | 20% discount on CVS brand health-related items |
Well-Being Features | $600 WellBeing Rewards |
Availability | January 1, 2022 |
MVP Premier Bronze 2 AI-AN FRNY-HMO-DBA1-002-S (2022) |
|
---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | Bronze |
Annual In-Network Deductible (Single/Family) | $0 / $0 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit (Single/Family) | $0 / $0 |
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. 30 day retail/90 day mail order. $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 | 2022 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 | 20% discount on CVS brand health-related items |
Well-Being Features | $600 WellBeing Rewards |
Availability | January 1, 2022 |
MVP Premier Silver 1 73 FRNY-HMO-DS1-001-S-73 (2022) |
|
---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | Silver |
Annual In-Network Deductible (Single/Family) | $1,100 / $2,200 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit (Single/Family) | $6,500 / $13,000 |
Annual Out-of-Network Out-of-Pocket Limit | N/A |
Primary Care Visit | $30 copay |
Specialist Visit | $50 copay |
ER | $275 copay Deductible applies. |
Urgent Care | $70 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. 30 day retail/90 day mail order.; $100 max out of pocket on 30 day supply of Insulin |
Non Preferred Rx Coverage (Tier 3) | $70 copay Deductible waived. 30 day retail/90 day mail order. |
Rx Formulary | 2022 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 | 20% discount on CVS brand health-related items |
Well-Being Features | $600 WellBeing Rewards |
Availability | January 1, 2022 |
MVP Premier Silver 1 87 FRNY-HMO-DS1-001-S-87 (2022) |
|
---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | Silver |
Annual In-Network Deductible (Single/Family) | $250 / $500 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit (Single/Family) | $2,200 / $4,400 |
Annual Out-of-Network Out-of-Pocket Limit | N/A |
Primary Care Visit | $15 copay |
Specialist Visit | $35 copay |
ER | $75 copay Deductible applies. |
Urgent Care | $50 copay Deductible applies. |
Generic Rx Coverage (Tier 1) | $9 copay Deductible waived. 30 day retail/90 day mail order. |
Preferred Rx Coverage (Tier 2) | $20 copay Deductible waived. 30 day retail/90 day mail order.; $100 max out of pocket on 30 day supply of Insulin |
Non Preferred Rx Coverage (Tier 3) | $40 copay Deductible waived. 30 day retail/90 day mail order. |
Rx Formulary | 2022 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 | 20% discount on CVS brand health-related items |
Well-Being Features | $600 WellBeing Rewards |
Availability | January 1, 2022 |
MVP Premier Silver 1 94 FRNY-HMO-DS1-001-S-94 (2022) |
|
---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | Silver |
Annual In-Network Deductible (Single/Family) | $0 / $0 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit (Single/Family) | $1,000 / $2,000 |
Annual Out-of-Network Out-of-Pocket Limit | N/A |
Primary Care Visit | $10 copay |
Specialist Visit | $20 copay |
ER | $50 copay No Deductible. |
Urgent Care | $30 copay No Deductible. |
Generic Rx Coverage (Tier 1) | $6 copay No Deductible. 30 day retail/90 day mail order. |
Preferred Rx Coverage (Tier 2) | $15 copay No Deductible. 30 day retail/90 day mail order.; $100 max out of pocket on 30 day supply of Insulin |
Non Preferred Rx Coverage (Tier 3) | $30 copay No Deductible. 30 day retail/90 day mail order. |
Rx Formulary | 2022 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 | 20% discount on CVS brand health-related items |
Well-Being Features | $600 WellBeing Rewards |
Availability | January 1, 2022 |
MVP Premier Silver 1 AI-AN FRNY-HMO-DSA1-001-S (2022) |
|
---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | Silver |
Annual In-Network Deductible (Single/Family) | $0 / $0 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit (Single/Family) | $0 / $0 |
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. 30 day retail/90 day mail order.; $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 | 2022 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 | 20% discount on CVS brand health-related items |
Well-Being Features | $600 WellBeing Rewards |
Availability | January 1, 2022 |
MVP Premier Gold 1 AI-AN FRNY-HMO-DGA1-001-S (2022) |
|
---|---|
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 (Single/Family) | $0 / $0 |
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. 30 day retail/90 day mail order. $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 | 2022 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 | 20% discount on CVS brand health-related items |
Well-Being Features | $600 WellBeing Rewards |
Availability | January 1, 2022 |
MVP Premier Platinum 1 AI-AN FRNY-HMO-DPA1-001-S (2022) |
|
---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | Platinum |
Annual In-Network Deductible (Single/Family) | $0 / $0 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit (Single/Family) | $0 / $0 |
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. 30 day retail/90 day mail order. $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 | 2022 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 | 20% discount on CVS brand health-related items |
Well-Being Features | $600 WellBeing Rewards |
Availability | January 1, 2022 |
Essential Plan 5 FRNY-EP-DA1-005 (2022) |
|
---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | NA |
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 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 | 2022 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 | Dental and vision benefits included at no cost, 20% discount on CVS brand health-related items. Visit mvphealthcare.com/essential for more information. |
Well-Being Features | $125 WellBeing Rewards |
Availability | January 1, 2022 |
Essential Plan 6 FRNY-EP-DA1-006 (2022) |
|
---|---|
State | New York |
Plan Type | HMO |
Exchange | On |
Metal Level | NA |
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 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 | 2022 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 | Dental and vision benefits included at no cost, 20% discount on CVS brand health-related items. Visit mvphealthcare.com/essential for more information. |
Well-Being Features | $125 WellBeing Rewards |
Availability | January 1, 2022 |