Metal Level
Annual Deductibles
Purchase Via
Plan Type
MVP VT Secure FRVT-HMOC-001-N (2023)
HMONA
Special Eligibility:
Under age 30, catastrophic coverage
Annual In-Network Deductible:
$9,100 person / $18,200 family
Annual In-Network Out-of-Pocket Limits:
$9,100 person / $18,200 family
Primary Care Visit:
0% coinsurance (First 3 PCP or MH, SA Visits Not Subject to DD)
Specialist Visit:
0% coinsurance
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
0% coinsurance / 0% coinsurance / 0% coinsurance
MVP VT Plus Bronze 1 FRVT-HMO-B-001-N (2023)
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
MVP VT Plus Bronze 1 AI-AN U300% FRVT-HMO-BA1-001-N (2023)
HMOBronze
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$0 person / $0 family
Annual In-Network Out-of-Pocket Limits:
N/A
Primary Care Visit:
$0 copay
Specialist Visit:
$0 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$0 copay / $0 copay / $0 copay
MVP VT Plus Bronze 1 AI-AN FRVT-HMO-BA2-001-N (2023)
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
MVP VT Bronze 2 FRVT-HMO-B-002-S (2023)
HMOBronze
Annual In-Network Deductible:
$6,450 person / $12,900 family
Annual In-Network Out-of-Pocket Limits:
$9,100 person / $18,200 family
Primary Care Visit:
$35 copay
Specialist Visit:
$90 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$15 copay / $85 copay / 60% coinsurance
MVP VT Bronze 2 AI-AN U300% FRVT-HMO-BA1-002-S (2023)
HMOBronze
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$0 person / $0 family
Annual In-Network Out-of-Pocket Limits:
N/A
Primary Care Visit:
$0 copay
Specialist Visit:
$0 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$0 copay / $0 copay / $0 copay
MVP VT Bronze 2 AI-AN FRVT-HMO-BA2-002-S (2023)
HMOBronze
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$6,450 person / $12,900 family
Annual In-Network Out-of-Pocket Limits:
$9,100 person / $18,200 family
Primary Care Visit:
$35 copay
Specialist Visit:
$90 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$15 copay / $85 copay / 60% coinsurance
MVP VT Plus Bronze 5 FRVT-HMO-B-005-N (2023)
HMOBronze
Annual In-Network Deductible:
$9,100 person / $18,200 family
Annual In-Network Out-of-Pocket Limits:
$9,100 person / $18,200 family
Primary Care Visit:
0% coinsurance (First 3 PCP or MH, SA Visits Not Subject to DD)
Specialist Visit:
0% coinsurance
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$35 copay / 0% coinsurance / 0% coinsurance
MVP VT Plus Bronze 5 AI-AN U300% FRVT-HMO-BA1-005-N (2023)
HMOBronze
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$0 person / $0 family
Annual In-Network Out-of-Pocket Limits:
N/A
Primary Care Visit:
$0 copay
Specialist Visit:
$0 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$0 copay / $0 copay / $0 copay
MVP VT Plus Bronze 5 AI-AN FRVT-HMO-BA2-005-N (2023)
HMOBronze
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$9,100 person / $18,200 family
Annual In-Network Out-of-Pocket Limits:
$9,100 person / $18,200 family
Primary Care Visit:
0% coinsurance (First 3 PCP or MH, SA Visits Not Subject to DD)
Specialist Visit:
0% coinsurance
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$35 copay / 0% coinsurance / 0% coinsurance
MVP VT Bronze 3 HDHP FRVT-HMOH-B-003-S (2023)
HMO HDBronze
Compatibility:
This plan is a qualified high-deductible health plan and is compatible with an HSA
Annual In-Network Deductible:
$5,800 person / $11,600 family (aggregate)
Annual In-Network Out-of-Pocket Limits:
$7,100 person / $14,200 family (Max $9,100 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
MVP VT Bronze 3 AI-AN U300% FRVT-HMOH-BA1-003-S (2023)
HMOBronze
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$0 person / $0 family
Annual In-Network Out-of-Pocket Limits:
N/A
Primary Care Visit:
$0 copay
Specialist Visit:
$0 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$0 copay / $0 copay / $0 copay
MVP VT Bronze 3 HDHP AI-AN FRVT-HMOH-BA2-003-S (2023)
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:
$5,800 person / $11,600 family (aggregate)
Annual In-Network Out-of-Pocket Limits:
$7,100 person / $14,200 family (Max $9,100 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
MVP VT Bronze 4 FRVT-HMO-B-004-S (2023)
HMOBronze
Annual In-Network Deductible:
$9,000 person / $18,000 family
Annual In-Network Out-of-Pocket Limits:
$9,000 person / $18,000 family
Primary Care Visit:
$40 copay (First 3 PCP or MH, SA Visits Covered in Full)
Specialist Visit:
$100 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$30 copay / 0% coinsurance / 0% coinsurance
MVP VT Bronze 4 AI-AN U300% FRVT-HMO-BA1-004-S (2023)
HMOBronze
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$0 person / $0 family
Annual In-Network Out-of-Pocket Limits:
N/A
Primary Care Visit:
$0 copay
Specialist Visit:
$0 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$0 copay / $0 copay / $0 copay
MVP VT Bronze 4 AI-AN FRVT-HMO-BA2-004-S (2023)
HMOBronze
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$9,000 person / $18,000 family
Annual In-Network Out-of-Pocket Limits:
$9,000 person / $18,000 family
Primary Care Visit:
$40 copay (First 3 PCP or MH, SA Visits Covered in Full)
Specialist Visit:
$100 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$30 copay / 0% coinsurance / 0% coinsurance
MVP VT Plus Reflective Silver 1 VT-HMO-S-001-N II (2023)
HMOSilver
Annual In-Network Deductible:
$2,100 person / $4,200 family
Annual In-Network Out-of-Pocket Limits:
$7,000 person / $14,000 family
Primary Care Visit:
$30 copay (First 3 PCP or MH, SA Visits Not Subject to DD)
Specialist Visit:
$60 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$5 copay / 50% coinsurance / 50% coinsurance
MVP VT Reflective Silver 3 VT-HMO-S-003-S II (2023)
HMOSilver
Annual In-Network Deductible:
$4,000 person / $8,000 family
Annual In-Network Out-of-Pocket Limits:
$9,100 person / $18,200 family
Primary Care Visit:
$40 copay (First 3 PCP or MH, SA Visits Covered in Full)
Specialist Visit:
$90 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$20 copay / $70 copay / 50% coinsurance
MVP VT Reflective Silver 4 HDHP VT-HMOH-S-004-S II (2023)
HMO HDSilver
Compatibility:
This plan is a qualified high-deductible health plan and is compatible with an HSA
Annual In-Network Deductible:
$2,100 person / $4,200 family (aggregate)
Annual In-Network Out-of-Pocket Limits:
$7,050 person / $14,100 family (Max $9,100 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
MVP VT Plus Reflective Silver 2 HDHP VT-HMOH-S-002-N II (2023)
HMO HDSilver
Compatibility:
This plan is a qualified high-deductible health plan and is compatible with an HSA
Annual In-Network Deductible:
$5,525 person / $11,050 family
Annual In-Network Out-of-Pocket Limits:
$5,525 person / $11,050 family
Primary Care Visit:
0% coinsurance
Specialist Visit:
0% coinsurance
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
0% coinsurance / 0% coinsurance / 0% coinsurance
MVP VT Plus Silver 1 FRVT-HMO-S-001-N (2023)
HMOSilver
Annual In-Network Deductible:
$2,100 person / $4,200 family
Annual In-Network Out-of-Pocket Limits:
$7,000 person / $14,000 family
Primary Care Visit:
$30 copay (First 3 PCP or MH, SA Visits Not Subject to DD)
Specialist Visit:
$60 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$5 copay / 50% coinsurance / 50% coinsurance
MVP VT Plus Silver 1 AI-AN U300% FRVT-HMO-SA1-001-N (2023)
HMOSilver
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$0 person / $0 family
Annual In-Network Out-of-Pocket Limits:
N/A
Primary Care Visit:
$0 copay
Specialist Visit:
$0 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$0 copay / $0 copay / $0 copay
MVP VT Plus Silver 1 AI-AN FRVT-HMO-SA2-001-N (2023)
HMOSilver
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$2,100 person / $4,200 family
Annual In-Network Out-of-Pocket Limits:
$7,000 person / $14,000 family
Primary Care Visit:
$30 copay (First 3 PCP or MH, SA Visits Not Subject to DD)
Specialist Visit:
$60 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$5 copay / 50% coinsurance / 50% coinsurance
MVP VT Silver 3 FRVT-HMO-S-003-S (2023)
HMOSilver
Annual In-Network Deductible:
$4,000 person / $8,000 family
Annual In-Network Out-of-Pocket Limits:
$9,100 person / $18,200 family
Primary Care Visit:
$40 copay (First 3 PCP or MH, SA Visits Covered in Full)
Specialist Visit:
$90 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$20 copay / $70 copay / 50% coinsurance
MVP VT Silver 3 AI-AN U300% FRVT-HMO-SA1-003-S (2023)
HMOSilver
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$0 person / $0 family
Annual In-Network Out-of-Pocket Limits:
N/A
Primary Care Visit:
$0 copay
Specialist Visit:
$0 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$0 copay / $0 copay / $0 copay
MVP VT Silver 3 AI-AN FRVT-HMO-SA2-003-S (2023)
HMOSilver
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$4,000 person / $8,000 family
Annual In-Network Out-of-Pocket Limits:
$9,100 person / $18,200 family
Primary Care Visit:
$40 copay (First 3 PCP or MH, SA Visits Covered in Full)
Specialist Visit:
$90 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$20 copay / $70 copay / 50% coinsurance
MVP VT Silver 4 HDHP FRVT-HMOH-S-004-S (2023)
HMO HDSilver
Compatibility:
This plan is a qualified high-deductible health plan and is compatible with an HSA
Annual In-Network Deductible:
$2,100 person / $4,200 family (aggregate)
Annual In-Network Out-of-Pocket Limits:
$7,050 person / $14,100 family (Max $9,100 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
MVP VT Silver 4 AI-AN U300% FRVT-HMOH-SA1-004-S (2023)
HMOSilver
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$0 person / $0 family
Annual In-Network Out-of-Pocket Limits:
N/A
Primary Care Visit:
$0 copay
Specialist Visit:
$0 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$0 copay / $0 copay / $0 copay
MVP VT Silver 4 HDHP AI-AN FRVT-HMOH-SA2-004-S (2023)
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:
$2,100 person / $4,200 family (aggregate)
Annual In-Network Out-of-Pocket Limits:
$7,050 person / $14,100 family (Max $9,100 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
MVP VT Plus Silver 2 HDHP FRVT-HMOH-S-002-N (2023)
HMO HDSilver
Compatibility:
This plan is a qualified high-deductible health plan and is compatible with an HSA
Annual In-Network Deductible:
$5,500 person / $11,000 family
Annual In-Network Out-of-Pocket Limits:
$5,500 person / $11,000 family
Primary Care Visit:
0% coinsurance
Specialist Visit:
0% coinsurance
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
0% coinsurance / 0% coinsurance / 0% coinsurance
MVP VT Plus Silver 2 AI-AN U300% FRVT-HMOH-SA1-002-N (2023)
HMOSilver
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$0 person / $0 family
Annual In-Network Out-of-Pocket Limits:
N/A
Primary Care Visit:
$0 copay
Specialist Visit:
$0 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$0 copay / $0 copay / $0 copay
MVP VT Plus Silver 2 HDHP AI-AN FRVT-HMOH-SA2-002-N (2023)
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:
$5,500 person / $11,000 family
Annual In-Network Out-of-Pocket Limits:
$5,500 person / $11,000 family
Primary Care Visit:
0% coinsurance
Specialist Visit:
0% coinsurance
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
0% coinsurance / 0% coinsurance / 0% coinsurance
MVP VT Gold 1 FRVT-HMO-G-001-S (2023)
HMOGold
Annual In-Network Deductible:
$1,400 person / $2,800 family
Annual In-Network Out-of-Pocket Limits:
$5,600 person / $11,200 family
Primary Care Visit:
$20 copay (First 3 PCP or MH, SA Visits Covered in Full)
Specialist Visit:
$50 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$12 copay / $55 copay / 50% coinsurance
MVP VT Gold 1 AI-AN U300% FRVT-HMO-GA1-001-S (2023)
HMOGold
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$0 person / $0 family
Annual In-Network Out-of-Pocket Limits:
N/A
Primary Care Visit:
$0 copay
Specialist Visit:
$0 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$0 copay / $0 copay / $0 copay
MVP VT Gold 1 AI-AN FRVT-HMO-GA2-001-S (2023)
HMOGold
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$1,400 person / $2,800 family
Annual In-Network Out-of-Pocket Limits:
$5,600 person / $11,200 family
Primary Care Visit:
$20 copay (First 3 PCP or MH, SA Visits Covered in Full)
Specialist Visit:
$50 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$12 copay / $55 copay / 50% coinsurance
MVP VT Plus Gold 3 HDHP FRVT-HMOH-G-003-N (2023)
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 (aggregate)
Annual In-Network Out-of-Pocket Limits:
$3,200 person / $6,400 family (aggregate)
Primary Care Visit:
0% coinsurance
Specialist Visit:
0% coinsurance
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
0% coinsurance / 0% coinsurance / 0% coinsurance
MVP VT Plus Gold 3 AI-AN U300% FRVT-HMOH-GA1-003-N (2023)
HMOGold
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$0 person / $0 family
Annual In-Network Out-of-Pocket Limits:
N/A
Primary Care Visit:
$0 copay
Specialist Visit:
$0 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$0 copay / $0 copay / $0 copay
MVP VT Plus Gold 3 HDHP AI-AN FRVT-HMOH-GA2-003-N (2023)
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 (aggregate)
Annual In-Network Out-of-Pocket Limits:
$3,200 person / $6,400 family (aggregate)
Primary Care Visit:
0% coinsurance
Specialist Visit:
0% coinsurance
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
0% coinsurance / 0% coinsurance / 0% coinsurance
MVP VT Plus Gold 2 FRVT-HMO-G-002-N (2023)
HMOGold
Annual In-Network Deductible:
$850 person / $1,700 family
Annual In-Network Out-of-Pocket Limits:
$6,600 person / $13,200 family
Primary Care Visit:
$20 copay
Specialist Visit:
$45 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$15 copay / $40 copay / 50% coinsurance
MVP VT Plus Gold 2 AI-AN U300% FRVT-HMO-GA1-002-N (2023)
HMOGold
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$0 person / $0 family
Annual In-Network Out-of-Pocket Limits:
N/A
Primary Care Visit:
$0 copay
Specialist Visit:
$0 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$0 copay / $0 copay / $0 copay
MVP VT Plus Gold 2 AI-AN FRVT-HMO-GA2-002-N (2023)
HMOGold
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$850 person / $1,700 family
Annual In-Network Out-of-Pocket Limits:
$6,600 person / $13,200 family
Primary Care Visit:
$20 copay
Specialist Visit:
$45 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$15 copay / $40 copay / 50% coinsurance
MVP VT Platinum 1 FRVT-HMO-P-001-S (2023)
HMOPlatinum
Annual In-Network Deductible:
$425 person / $850 family
Annual In-Network Out-of-Pocket Limits:
$1,500 person / $3,000 family
Primary Care Visit:
$15 copay (First 3 PCP or MH, SA Visits Covered in Full)
Specialist Visit:
$40 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$10 copay / $50 copay / 50% coinsurance
MVP VT Platinum 1 AI-AN U300% FRVT-HMO-PA1-001-S (2023)
HMOPlatinum
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$0 person / $0 family
Annual In-Network Out-of-Pocket Limits:
N/A
Primary Care Visit:
$0 copay
Specialist Visit:
$0 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$0 copay / $0 copay / $0 copay
MVP VT Platinum 1 AI-AN FRVT-HMO-PA2-001-S (2023)
HMOPlatinum
Special Eligibility:
American Indian/Alaska Native
Annual In-Network Deductible:
$425 person / $850 family
Annual In-Network Out-of-Pocket Limits:
$1,500 person / $3,000 family
Primary Care Visit:
$15 copay (First 3 PCP or MH, SA Visits Covered in Full)
Specialist Visit:
$40 copay
Rx Coverage (Tier 1 / Tier 2 / Tier 3):
$10 copay / $50 copay / 50% coinsurance
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 Marketplace representative.
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.
MVP virtual care services through Gia are available at no cost-share for most members, except those enrolled in a qualified high-deductible health plan (QHDHP). QHDHP members must meet the annual deductible before Gia services are covered in full. In-person visits and referrals are subject to cost-share per plan.