MVP Premier Bronze 2 NY-HMO-DB-002-S (2020)

HMOBronze

Annual In-Network Deductible:

$4,425 person / $8,850 family

Annual In-Network Out-of-Pocket Limits:

$8,150 person / $16,300 family

Primary Care Visit:

$50% coinsurance ($0 copay first 3 visits)

Specialist Visit:

50% coinsurance

Rx Coverage (Tier 1 / Tier 2 / Tier 3):

$10 copay / $35 copay / $70 copay

Plan Rates:

$411.28 single

$822.56 double

$699.18 parent

$1,172.15 family

Estimated monthly rates to provide coverage in Schenectady County through 12/31/2020.

Plan Details

MVP Premier Plus Bronze 1 NY-HMO-DB-001-N (2020)

HMOBronze

Annual In-Network Deductible:

$6,600 person / $13,200 family

Annual In-Network Out-of-Pocket Limits:

$8,100 person / $16,200 family

Primary Care Visit:

$40 copay

Specialist Visit:

$80 copay

Rx Coverage (Tier 1 / Tier 2 / Tier 3):

$10 copay / $45 copay / $90 copay

Plan Rates:

$412.57 single

$825.14 double

$701.37 parent

$1,175.82 family

Estimated monthly rates to provide coverage in Schenectady County through 12/31/2020.

Plan Details

MVP Premier Plus Bronze 2 NY-HMO-DB-002-N (2020)

HMOBronze

Annual In-Network Deductible:

$5,100 person / $10,200 family

Annual In-Network Out-of-Pocket Limits:

$8,000 person / $16,000 family

Primary Care Visit:

$40% coinsurance ($0 copay first 3 visits)

Specialist Visit:

40% coinsurance

Rx Coverage (Tier 1 / Tier 2 / Tier 3):

$5 copay / $60 copay / $80 copay

Plan Rates:

$416.52 single

$833.04 double

$708.08 parent

$1,187.08 family

Estimated monthly rates to provide coverage in Schenectady County through 12/31/2020.

Plan Details

MVP Premier Bronze 1 HDHP NY-HMOH-DB-001-S (2020)

HMO HDBronze

Compatibility:

This plan is compatible with an HSA

Annual In-Network Deductible:

$5,500 person / $11,000 family

Annual In-Network Out-of-Pocket Limits:

$6,550 person / $13,100 family

Primary Care Visit:

50% coinsurance

Specialist Visit:

50% coinsurance

Rx Coverage (Tier 1 / Tier 2 / Tier 3):

$10 copay / $35 copay / $70 copay

Plan Rates:

$418.46 single

$836.92 double

$711.38 parent

$1,192.61 family

Estimated monthly rates to provide coverage in Schenectady County through 12/31/2020.

Plan Details

MVP Premier Plus Bronze 3 HDHP NY-HMOH-DB-003-N (2020)

HMO HDBronze

Compatibility:

This plan is compatible with an HSA

Annual In-Network Deductible:

$5,900 person / $11,800 family

Annual In-Network Out-of-Pocket Limits:

$6,750 person / $13,500 family

Primary Care Visit:

$30 copay

Specialist Visit:

$50 copay

Rx Coverage (Tier 1 / Tier 2 / Tier 3):

$10 copay / $45 copay / $90 copay

Plan Rates:

$433.40 single

$866.80 double

$736.78 parent

$1,235.19 family

Estimated monthly rates to provide coverage in Schenectady County through 12/31/2020.

Plan Details

MVP Premier Plus Bronze 6 HDHP NY-HMOH-DB-006-N (2020)

HMO HDBronze

Compatibility:

This plan is compatible with an HSA

Annual In-Network Deductible:

$6,750 person / $13,500 family

Annual In-Network Out-of-Pocket Limits:

$6,750 person / $13,500 family

Primary Care Visit:

$0 copay

Specialist Visit:

$0 copay

Rx Coverage (Tier 1 / Tier 2 / Tier 3):

$0 copay / $0 copay / $0 copay

Plan Rates:

$448.55 single

$897.10 double

$762.54 parent

$1,278.37 family

Estimated monthly rates to provide coverage in Schenectady County through 12/31/2020.

Plan Details

MVP Premier Plus Bronze 1 HDHP National NY-HMOH-DB-001-NN (2020)

HMO HDBronze

Compatibility:

This plan is compatible with an HSA

Annual In-Network Deductible:

$4,200 person / $8,400 family

Annual In-Network Out-of-Pocket Limits:

$6,750 person / $13,500 family

Primary Care Visit:

30% coinsurance

Specialist Visit:

30% coinsurance

Rx Coverage (Tier 1 / Tier 2 / Tier 3):

$10 copay / $50 copay / $80 copay

Plan Rates:

$522.22 single

$1,044.44 double

$887.77 parent

$1,488.33 family

Estimated monthly rates to provide coverage in Schenectady County through 12/31/2020.

Plan Details

MVP Premier Plus Silver 3 HDHP NY-HMOH-DS-003-N (2020)

HMO HDSilver

Compatibility:

This plan is compatible with an HSA

Annual In-Network Deductible:

$2,500 person / $5,000 family

Annual In-Network Out-of-Pocket Limits:

$5,700 person / $11,400 family

Primary Care Visit:

$30 copay

Specialist Visit:

$60 copay

Rx Coverage (Tier 1 / Tier 2 / Tier 3):

$10 copay / $45 copay / $90 copay

Plan Rates:

$573.98 single

$1,147.96 double

$975.77 parent

$1,635.84 family

Estimated monthly rates to provide coverage in Schenectady County through 12/31/2020.

Plan Details

MVP Premier Plus Silver 2 NY-HMO-DS-002-N (2020)

HMOSilver

Annual In-Network Deductible:

$2,650 person / $5,300 family

Annual In-Network Out-of-Pocket Limits:

$6,750 person / $13,500 family

Primary Care Visit:

$40 copay ($0 copay first 3 visits)

Specialist Visit:

$70 copay

Rx Coverage (Tier 1 / Tier 2 / Tier 3):

$15 copay / $40 copay / $70 copay

Plan Rates:

$594.33 single

$1,188.66 double

$1,010.36 parent

$1,693.84 family

Estimated monthly rates to provide coverage in Schenectady County through 12/31/2020.

Plan Details

MVP Premier Silver 1 NY-HMO-DS-001-S (2020)

HMOSilver

Annual In-Network Deductible:

$1,300 person / $2,600 family

Annual In-Network Out-of-Pocket Limits:

$7,900 person / $15,800 family

Primary Care Visit:

$30 copay

Specialist Visit:

$50 copay

Rx Coverage (Tier 1 / Tier 2 / Tier 3):

$10 copay / $35 copay / $70 copay

Plan Rates:

$615.10 single

$1,230.20 double

$1,045.67 parent

$1,753.04 family

Estimated monthly rates to provide coverage in Schenectady County through 12/31/2020.

Plan Details

MVP Premier Plus Silver 11 NY-HMO-DS-011-N (2020)

HMOSilver

Annual In-Network Deductible:

$5,850 person / $11,700 family

Annual In-Network Out-of-Pocket Limits:

$5,850 person / $11,700 family

Primary Care Visit:

$35 copay ($0 copay first 3 visits)

Specialist Visit:

$55 copay

Rx Coverage (Tier 1 / Tier 2 / Tier 3):

$10 copay / $0 copay / $0 copay

Plan Rates:

$615.35 single

$1,230.70 double

$1,046.10 parent

$1,753.75 family

Estimated monthly rates to provide coverage in Schenectady County through 12/31/2020.

Plan Details

MVP Premier Plus Gold 2 HDHP NY-HMOH-DG-002-N (2020)

HMO HDGold

Compatibility:

This plan is compatible with an HSA

Annual In-Network Deductible:

$1,400 person / $2,800 family

Annual In-Network Out-of-Pocket Limits:

$6,750 person / $13,500 family

Primary Care Visit:

$5 copay

Specialist Visit:

$25 copay

Rx Coverage (Tier 1 / Tier 2 / Tier 3):

$5 copay / $15 copay / $25 copay

Plan Rates:

$698.95 single

$1,397.90 double

$1,188.22 parent

$1,992.01 family

Estimated monthly rates to provide coverage in Schenectady County through 12/31/2020.

Plan Details

MVP Premier Plus Gold 1 NY-HMO-DG-001-N (2020)

HMOGold

Annual In-Network Deductible:

$1,200 person / $2,400 family

Annual In-Network Out-of-Pocket Limits:

$5,900 person / $11,800 family

Primary Care Visit:

$15 copay ($0 copay first 3 visits)

Specialist Visit:

$50 copay

Rx Coverage (Tier 1 / Tier 2 / Tier 3):

$10 copay / $40 copay / $60 copay

Plan Rates:

$716.48 single

$1,432.96 double

$1,218.02 parent

$2,041.97 family

Estimated monthly rates to provide coverage in Schenectady County through 12/31/2020.

Plan Details

MVP Premier Gold 1 NY-HMO-DG-001-S (2020)

HMOGold

Annual In-Network Deductible:

$600 person / $1,200 family

Annual In-Network Out-of-Pocket Limits:

$4,000 person / $8,000 family

Primary Care Visit:

$25 copay

Specialist Visit:

$40 copay

Rx Coverage (Tier 1 / Tier 2 / Tier 3):

$10 copay / $35 copay / $70 copay

Plan Rates:

$739.16 single

$1,478.32 double

$1,256.57 parent

$2,106.61 family

Estimated monthly rates to provide coverage in Schenectady County through 12/31/2020.

Plan Details

MVP Premier Plus Gold 4 NY-HMO-DG-004-N (2020)

HMOGold

Annual In-Network Deductible:

$0 person / $0 family

Annual In-Network Out-of-Pocket Limits:

$6,750 person / $13,500 family

Primary Care Visit:

$40 copay

Specialist Visit:

$50 copay

Rx Coverage (Tier 1 / Tier 2 / Tier 3):

$10 copay / $40 copay / $60 copay

Plan Rates:

$754.48 single

$1,508.96 double

$1,282.62 parent

$2,150.27 family

Estimated monthly rates to provide coverage in Schenectady County through 12/31/2020.

Plan Details

MVP Premier Platinum 1 NY-HMO-DP-001-S (2020)

HMOPlatinum

Annual In-Network Deductible:

$0 person / $0 family

Annual In-Network Out-of-Pocket Limits:

$2,000 person / $4,000 family

Primary Care Visit:

$15 copay

Specialist Visit:

$35 copay

Rx Coverage (Tier 1 / Tier 2 / Tier 3):

$10 copay / $30 copay / $60 copay

Plan Rates:

$911.00 single

$1,822.00 double

$1,548.70 parent

$2,596.35 family

Estimated monthly rates to provide coverage in Schenectady County through 12/31/2020.

Plan Details

Plan availability and rates are subject to change without notice. Rates may vary by region and should be verified with your authorized broker, MVP or the New York State of HealthTM Marketplace. Rates do not include pediatric dental coverage.

For the most current information on the approved plans available for individuals or families in your area, please contact your broker, navigator, or MVP representative (1-800-TALK-MVP) for assistance.