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