MVP VT Secure FRVT-HMOC-001-N (2022)

HMONA

Special Eligibility:

Under age 30, catastrophic coverage

Annual In-Network Deductible:

$8,700 person / $17,400 family

Annual In-Network Out-of-Pocket Limits:

$8,700 person / $17,400 family

Primary Care Visit:

0% coinsurance

Specialist Visit:

0% coinsurance

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

0% coinsurance / 0% coinsurance / 0% coinsurance

Plan Details

MVP VT Plus Bronze 1 FRVT-HMO-B-001-N (2022)

HMOBronze

Annual In-Network Deductible:

$7,250 person / $14,500 family

Annual In-Network Out-of-Pocket Limits:

$8,400 person / $16,800 family

Primary Care Visit:

$40 copay

Specialist Visit:

$100 copay

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

$25 copay / $100 copay / 60% coinsurance

Plan Details

MVP VT Plus Bronze 1 AI-AN U300 FRVT-HMO-BA1-001-N (2022)

HMOBronze

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$0 person / $0 family

Annual In-Network Out-of-Pocket Limits:

$0 person / $0 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 Details

MVP VT Plus Bronze 1 AI-AN FRVT-HMO-BA2-001-N (2022)

HMOBronze

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$7,250 person / $14,500 family

Annual In-Network Out-of-Pocket Limits:

$8,400 person / $16,800 family

Primary Care Visit:

$40 copay

Specialist Visit:

$100 copay

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

$25 copay / $100 copay / 60% coinsurance

Plan Details

MVP VT Bronze 2 FRVT-HMO-B-002-S (2022)

HMOBronze

Annual In-Network Deductible:

$6,450 person / $12,900 family

Annual In-Network Out-of-Pocket Limits:

$8,700 person / $17,400 family

Primary Care Visit:

$35 copay

Specialist Visit:

$90 copay

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

$15 copay / $85 copay / 60% coinsurance

Plan Details

MVP VT Bronze 2 AI-AN U300 FRVT-HMO-BA1-002-S (2022)

HMOBronze

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$0 person / $0 family

Annual In-Network Out-of-Pocket Limits:

$0 person / $0 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 Details

MVP VT Bronze 2 AI-AN FRVT-HMO-BA2-002-S (2022)

HMOBronze

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$6,450 person / $12,900 family

Annual In-Network Out-of-Pocket Limits:

$8,700 person / $17,400 family

Primary Care Visit:

$35 copay

Specialist Visit:

$90 copay

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

$15 copay / $85 copay / 60% coinsurance

Plan Details

MVP VT Bronze 3 HDHP FRVT-HMOH-B-003-S (2022)

HMO HDBronze

Compatibility:

This plan is a qualified high-deductible health plan and is compatible with an HSA

Annual In-Network Deductible:

$5,700 person / $11,400 family

Annual In-Network Out-of-Pocket Limits:

$7,050 person / $14,100 family (Max $8,700 per family member)

Primary Care Visit:

50% coinsurance

Specialist Visit:

50% coinsurance

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

$12 copay / 40% coinsurance / 60% coinsurance

Plan Details

MVP VT Bronze 3 AI-AN U300 FRVT-HMOH-BA1-003-S (2022)

HMOBronze

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$0 person / $0 family

Annual In-Network Out-of-Pocket Limits:

$0 person / $0 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 Details

MVP VT Bronze 3 HDHP AI-AN FRVT-HMOH-BA2-003-S (2022)

HMO HDBronze

Compatibility:

This plan is a qualified high-deductible health plan and is compatible with an HSA

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$5,700 person / $11,400 family

Annual In-Network Out-of-Pocket Limits:

$7,050 person / $14,100 family (Max $8,700 per family member)

Primary Care Visit:

50% coinsurance

Specialist Visit:

50% coinsurance

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

$12 copay / 40% coinsurance / 60% coinsurance

Plan Details

MVP VT Plus Bronze 5 FRVT-HMO-B-005-N (2022)

HMOBronze

Annual In-Network Deductible:

$7,850 person / $15,700 family

Annual In-Network Out-of-Pocket Limits:

$7,850 person / $15,700 family

Primary Care Visit:

0% coinsurance (First 3 visits no Deductible)

Specialist Visit:

0% coinsurance

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

$35 copay / 0% coinsurance / 0% coinsurance

Plan Details

MVP VT Plus Bronze 5 AI-AN U300 FRVT-HMO-BA1-005-N (2022)

HMOBronze

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$0 person / $0 family

Annual In-Network Out-of-Pocket Limits:

$0 person / $0 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 Details

MVP VT Plus Bronze 5 AI-AN FRVT-HMO-BA2-005-N (2022)

HMOBronze

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$7,850 person / $15,700 family

Annual In-Network Out-of-Pocket Limits:

$7,850 person / $15,700 family

Primary Care Visit:

0% coinsurance (First 3 visits no Deductible)

Specialist Visit:

0% coinsurance

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

$35 copay / 0% coinsurance / 0% coinsurance

Plan Details

MVP VT Bronze 4 FRVT-HMO-B-004-S (2022)

HMOBronze

Annual In-Network Deductible:

$8,700 person / $17,400 family

Annual In-Network Out-of-Pocket Limits:

$8,700 person / $17,400 family

Primary Care Visit:

$40 copay

Specialist Visit:

$100 copay

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

$30 copay / 0% coinsurance / 0% coinsurance

Plan Details

MVP VT Bronze 4 AI-AN U300 FRVT-HMO-BA1-004-S (2022)

HMOBronze

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$0 person / $0 family

Annual In-Network Out-of-Pocket Limits:

$0 person / $0 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 Details

MVP VT Bronze 4 AI-AN FRVT-HMO-BA2-004-S (2022)

HMOBronze

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$8,700 person / $17,400 family

Annual In-Network Out-of-Pocket Limits:

$8,700 person / $17,400 family

Primary Care Visit:

$40 copay

Specialist Visit:

$100 copay

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

$30 copay / 0% coinsurance / 0% coinsurance

Plan Details

MVP VT Plus Reflective Silver 1 VT-HMO-S-001-N II (2022)

HMOSilver

Annual In-Network Deductible:

$1,750 person / $3,500 family

Annual In-Network Out-of-Pocket Limits:

$6,950 person / $13,900 family

Primary Care Visit:

$30 copay (First 3 visits no Deductible)

Specialist Visit:

$60 copay

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

$5 copay / 50% coinsurance / 50% coinsurance

Plan Details

MVP VT Reflective Silver 4 HDHP VT-HMOH-S-004-S II (2022)

HMO HDSilver

Compatibility:

This plan is a qualified high-deductible health plan and is compatible with an HSA

Annual In-Network Deductible:

$1,850 person / $3,700 family

Annual In-Network Out-of-Pocket Limits:

$6,900 person / $13,800 family (Max $8,700 per family member)

Primary Care Visit:

10% coinsurance

Specialist Visit:

30% coinsurance

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

$10 copay / $40 copay / 50% coinsurance

Plan Details

MVP VT Plus Reflective Silver 2 HDHP VT-HMOH-S-002-N II (2022)

HMO HDSilver

Compatibility:

This plan is a qualified high-deductible health plan and is compatible with an HSA

Annual In-Network Deductible:

$5,100 person / $10,200 family

Annual In-Network Out-of-Pocket Limits:

$5,100 person / $10,200 family

Primary Care Visit:

0% coinsurance

Specialist Visit:

0% coinsurance

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

0% coinsurance / 0% coinsurance / 0% coinsurance

Plan Details

MVP VT Reflective Silver 3 VT-HMO-S-003-S II (2022)

HMOSilver

Annual In-Network Deductible:

$3,400 person / $6,800 family

Annual In-Network Out-of-Pocket Limits:

$8,550 person / $17,100 family

Primary Care Visit:

$35 copay

Specialist Visit:

$80 copay

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

$15 copay / $60 copay / 50% coinsurance

Plan Details

MVP VT Plus Silver 1 FRVT-HMO-S-001-N (2022)

HMOSilver

Annual In-Network Deductible:

$1,750 person / $3,500 family

Annual In-Network Out-of-Pocket Limits:

$6,950 person / $13,900 family

Primary Care Visit:

$30 copay (First 3 visits no Deductible)

Specialist Visit:

$60 copay

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

$5 copay / 50% coinsurance / 50% coinsurance

Plan Details

MVP VT Plus Silver 1 AI-AN U300 FRVT-HMO-SA1-001-N (2022)

HMOSilver

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$0 person / $0 family

Annual In-Network Out-of-Pocket Limits:

$0 person / $0 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 Details

MVP VT Plus Silver 1 AI-AN FRVT-HMO-SA2-001-N (2022)

HMOSilver

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$1,750 person / $3,500 family

Annual In-Network Out-of-Pocket Limits:

$6,950 person / $13,900 family

Primary Care Visit:

$30 copay (First 3 visits no Deductible)

Specialist Visit:

$60 copay

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

$5 copay / 50% coinsurance / 50% coinsurance

Plan Details

MVP VT Silver 4 HDHP FRVT-HMOH-S-004-S (2022)

HMO HDSilver

Compatibility:

This plan is a qualified high-deductible health plan and is compatible with an HSA

Annual In-Network Deductible:

$1,850 person / $3,700 family

Annual In-Network Out-of-Pocket Limits:

$6,900 person / $13,800 family (Max $8,700 per family member)

Primary Care Visit:

10% coinsurance

Specialist Visit:

30% coinsurance

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

$10 copay / $40 copay / 50% coinsurance

Plan Details

MVP VT Silver 4 AI-AN U300 FRVT-HMOH-SA1-004-S (2022)

HMOSilver

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$0 person / $0 family

Annual In-Network Out-of-Pocket Limits:

$0 person / $0 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 Details

MVP VT Silver 4 HDHP AI-AN FRVT-HMOH-SA2-004-S (2022)

HMO HDSilver

Compatibility:

This plan is a qualified high-deductible health plan and is compatible with an HSA

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$1,850 person / $3,700 family

Annual In-Network Out-of-Pocket Limits:

$6,900 person / $13,800 family (Max $8,700 per family member)

Primary Care Visit:

10% coinsurance

Specialist Visit:

30% coinsurance

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

$10 copay / $40 copay / 50% coinsurance

Plan Details

MVP VT Plus Silver 2 HDHP FRVT-HMOH-S-002-N (2022)

HMO HDSilver

Compatibility:

This plan is a qualified high-deductible health plan and is compatible with an HSA

Annual In-Network Deductible:

$5,075 person / $10,150 family

Annual In-Network Out-of-Pocket Limits:

$5,075 person / $10,150 family

Primary Care Visit:

0% coinsurance

Specialist Visit:

0% coinsurance

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

0% coinsurance / 0% coinsurance / 0% coinsurance

Plan Details

MVP VT Plus Silver 2 AI-AN U300 FRVT-HMOH-SA1-002-N (2022)

HMOSilver

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$0 person / $0 family

Annual In-Network Out-of-Pocket Limits:

$0 person / $0 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 Details

MVP VT Plus Silver 2 HDHP AI-AN FRVT-HMOH-SA2-002-N (2022)

HMO HDSilver

Compatibility:

This plan is a qualified high-deductible health plan and is compatible with an HSA

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$5,075 person / $10,150 family

Annual In-Network Out-of-Pocket Limits:

$5,075 person / $10,150 family

Primary Care Visit:

0% coinsurance

Specialist Visit:

0% coinsurance

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

0% coinsurance / 0% coinsurance / 0% coinsurance

Plan Details

MVP VT Silver 3 FRVT-HMO-S-003-S (2022)

HMOSilver

Annual In-Network Deductible:

$3,400 person / $6,800 family

Annual In-Network Out-of-Pocket Limits:

$8,550 person / $17,100 family

Primary Care Visit:

$35 copay

Specialist Visit:

$80 copay

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

$15 copay / $60 copay / 50% coinsurance

Plan Details

MVP VT Silver 3 AI-AN U300 FRVT-HMO-SA1-003-S (2022)

HMOSilver

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$0 person / $0 family

Annual In-Network Out-of-Pocket Limits:

$0 person / $0 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 Details

MVP VT Silver 3 AI-AN FRVT-HMO-SA2-003-S (2022)

HMOSilver

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$3,400 person / $6,800 family

Annual In-Network Out-of-Pocket Limits:

$8,550 person / $17,100 family

Primary Care Visit:

$35 copay

Specialist Visit:

$80 copay

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

$15 copay / $60 copay / 50% coinsurance

Plan Details

MVP VT Gold 1 FRVT-HMO-G-001-S (2022)

HMOGold

Annual In-Network Deductible:

$1,200 person / $2,400 family

Annual In-Network Out-of-Pocket Limits:

$5,400 person / $10,800 family

Primary Care Visit:

$20 copay

Specialist Visit:

$50 copay

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

$12 copay / $55 copay / 50% coinsurance

Plan Details

MVP VT Gold 1 AI-AN U300 FRVT-HMO-GA1-001-S (2022)

HMOGold

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$0 person / $0 family

Annual In-Network Out-of-Pocket Limits:

$0 person / $0 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 Details

MVP VT Gold 1 AI-AN FRVT-HMO-GA2-001-S (2022)

HMOGold

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$1,200 person / $2,400 family

Annual In-Network Out-of-Pocket Limits:

$5,400 person / $10,800 family

Primary Care Visit:

$20 copay

Specialist Visit:

$50 copay

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

$12 copay / $55 copay / 50% coinsurance

Plan Details

MVP VT Plus Gold 3 HDHP FRVT-HMOH-G-003-N (2022)

HMO HDGold

Compatibility:

This plan is a qualified high-deductible health plan and is compatible with an HSA

Annual In-Network Deductible:

$3,200 person / $6,400 family

Annual In-Network Out-of-Pocket Limits:

$3,200 person / $6,400 family

Primary Care Visit:

0% coinsurance

Specialist Visit:

0% coinsurance

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

0% coinsurance / 0% coinsurance / 0% coinsurance

Plan Details

MVP VT Plus Gold 3 AI-AN U300 FRVT-HMOH-GA1-003-N (2022)

HMOGold

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$0 person / $0 family

Annual In-Network Out-of-Pocket Limits:

$0 person / $0 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 Details

MVP VT Plus Gold 3 HDHP AI-AN FRVT-HMOH-GA2-003-N (2022)

HMO HDGold

Compatibility:

This plan is a qualified high-deductible health plan and is compatible with an HSA

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$3,200 person / $6,400 family

Annual In-Network Out-of-Pocket Limits:

$3,200 person / $6,400 family

Primary Care Visit:

0% coinsurance

Specialist Visit:

0% coinsurance

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

0% coinsurance / 0% coinsurance / 0% coinsurance

Plan Details

MVP VT Plus Gold 2 FRVT-HMO-G-002-N (2022)

HMOGold

Annual In-Network Deductible:

$700 person / $1,400 family

Annual In-Network Out-of-Pocket Limits:

$6,500 person / $13,000 family

Primary Care Visit:

$20 copay

Specialist Visit:

$40 copay

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

$15 copay / $40 copay / 50% coinsurance

Plan Details

MVP VT Plus Gold 2 AI-AN U300 FRVT-HMO-GA1-002-N (2022)

HMOGold

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$0 person / $0 family

Annual In-Network Out-of-Pocket Limits:

$0 person / $0 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 Details

MVP VT Plus Gold 2 AI-AN FRVT-HMO-GA2-002-N (2022)

HMOGold

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$700 person / $1,400 family

Annual In-Network Out-of-Pocket Limits:

$6,500 person / $13,000 family

Primary Care Visit:

$20 copay

Specialist Visit:

$40 copay

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

$15 copay / $40 copay / 50% coinsurance

Plan Details

MVP VT Platinum 1 FRVT-HMO-P-001-S (2022)

HMOPlatinum

Annual In-Network Deductible:

$400 person / $800 family

Annual In-Network Out-of-Pocket Limits:

$1,400 person / $2,800 family

Primary Care Visit:

$15 copay

Specialist Visit:

$40 copay

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

$10 copay / $50 copay / 50% coinsurance

Plan Details

MVP VT Platinum 1 AI-AN U300 FRVT-HMO-PA1-001-S (2022)

HMOPlatinum

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$0 person / $0 family

Annual In-Network Out-of-Pocket Limits:

$0 person / $0 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 Details

MVP VT Platinum 1 AI-AN FRVT-HMO-PA2-001-S (2022)

HMOPlatinum

Special Eligibility:

American Indian/Alaska Native

Annual In-Network Deductible:

$400 person / $800 family

Annual In-Network Out-of-Pocket Limits:

$1,400 person / $2,800 family

Primary Care Visit:

$15 copay

Specialist Visit:

$40 copay

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

$10 copay / $50 copay / 50% coinsurance

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 Exchange representative. Rates do not include pediatric dental coverage.

For the most current information on the approved plans available based on your desired plan effective date, location, and number of full-time employees, please contact your broker, navigator, or MVP representative (1-800-TALK-MVP) for assistance.