Metal Level
Annual Deductibles
Purchase Via
Special Eligibility
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