Metal Level
Annual Deductibles
Purchase Via
Plan Type
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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 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.
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.