MVP Prescription Benefits Rider
Please check with your employer to find out if this benefit is
part of your plan.
New York State HMO Rx Options
NY $5/$20/$40
NY $10/$15/$40
NY $10/$30/$50
NY $10/30%/50%
NY 50%
NY $10 Generic
New York State MVP PPO Rx Options
NY $5/$15/$25
NY $10/$20/$30
NY $10/$25/$50
NY $10/30%/50%
New York State MVP EPO Rx Options
$5/$15/$25
$10/$20/$30
$10/$25/$50
$10/30%/50%
New York State MVP Preferred EPO/PPO Rx Options
NY Rx 500 $10 Tier 1
NY Rx 503 $0/$0/$0 $1,000 Annual Max
NY Rx 508 $10/$25/$40 $2,500 Annual Max
NY Rx 510 $10/$30/$50 $4,000 Annual Max
NY Rx 515 $10/$30/$50
NY Rx 517 $10/$25/$40
Vermont HMO Rx Options
VT 50%
VT $5/$20/$40
VT $10/$30/$50
Vermont MVP PPO Rx Options
VT $5/$20/$40
VT $10/$30/$50
New Hampshire HMO Rx Options
NH $10/$15/$40
NH $10/$15/$40 with $100 Deductible
NH $10/$25/$45
NH $10/$25/$45 with $250 Deductible
