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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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

Plan Details

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 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 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.