Non Standard Individual Plans

MVP VT Plus (non-standard) plans for Vermont individuals offered on Vermont Health Connect.

View all MVP VT Individual & Family Plans

MVP VT Plus Bronze 1 FRVT-HMO-B-001-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $7,250 / $14,500
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $8,400 / $16,800
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $40 copay
Specialist Visit $100 copay
ER 50% coinsurance Deductible applies.
Urgent Care $100 copay Deductible applies.
Generic Rx Coverage (Tier 1) $25 copay Deductible waived. VBID 30 day supply $3/90 day supply $7.50
Preferred Rx Coverage (Tier 2) $100 copay Deductible applies. VBID 30 day supply $3/90 day supply $7.50. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 60% coinsurance Deductible applies. VBID 30 day supply $3/90 day supply $7.50. Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Bronze 5 FRVT-HMO-B-005-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $9,100 / $18,200
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $9,100 / $18,200
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 0% coinsurance (First 3 PCP or MH, SA Visits Not Subject to DD)
Specialist Visit 0% coinsurance
ER 0% coinsurance Deductible applies.
Urgent Care 0% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) $35 copay Deductible waived. VBID 30 day supply $3/90 day supply $7.50
Preferred Rx Coverage (Tier 2) 0% coinsurance Deductible applies. VBID 30 day supply $3/90 day supply $7.50. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 0% coinsurance Deductible applies. VBID 30 day supply $3/90 day supply $7.50. Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Silver 1 FRVT-HMO-S-001-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $2,100 / $4,200
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $7,000 / $14,000
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $30 copay (First 3 PCP or MH, SA Visits Not Subject to DD)
Specialist Visit $60 copay
ER $400 copay Deductible applies.
Urgent Care $60 copay Deductible applies.
Generic Rx Coverage (Tier 1) $5 copay Deductible applies. VBID 30 day supply $1/90 day supply $2.50
Preferred Rx Coverage (Tier 2) 50% coinsurance Deductible applies. VBID 30 day supply $1/90 day supply $2.50. Prior authorization required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 50% coinsurance Deductible applies. VBID 30 day supply $1/90 day supply $2.50. Prior authorization required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Silver 2 HDHP FRVT-HMOH-S-002-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $5,500 / $11,000
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $5,500 / $11,000
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 0% coinsurance
Specialist Visit 0% coinsurance
ER 0% coinsurance Deductible applies.
Urgent Care 0% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) 0% coinsurance Deductible applies. Preventive drugs deductible waived
Preferred Rx Coverage (Tier 2) 0% coinsurance Deductible applies. Preventive drugs deductible waived. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 0% coinsurance Deductible applies. Preventive drugs deductible waived. Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Gold 2 FRVT-HMO-G-002-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $850 / $1,700
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $6,600 / $13,200
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $20 copay
Specialist Visit $45 copay
ER $250 copay Deductible applies.
Urgent Care $30 copay Deductible waived.
Generic Rx Coverage (Tier 1) $15 copay Deductible waived. VBID 30 day supply $1/90 day supply $2.50
Preferred Rx Coverage (Tier 2) $40 copay Deductible applies. VBID 30 day supply $1/90 day supply $2.50. Prior authorization required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 50% coinsurance Deductible applies. VBID 30 day supply $1/90 day supply $2.50. Prior authorization required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Gold 3 HDHP FRVT-HMOH-G-003-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $3,200 / $6,400
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $3,200 / $6,400 (aggregate)
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 0% coinsurance
Specialist Visit 0% coinsurance
ER 0% coinsurance Deductible applies.
Urgent Care 0% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) 0% coinsurance Deductible applies. Preventive drugs 30 day supply $10; 90 day supply $25, deductible waived
Preferred Rx Coverage (Tier 2) 0% coinsurance Deductible applies. Preventive drugs 30 day supply $15; 90 day supply $37.50, DD Waived. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 0% coinsurance Deductible applies. Preventive drugs 30 day/90 supply 5% deductible waived. Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Secure FRVT-HMOC-001-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level NA
Annual In-Network Deductible (Single/Family) $9,100 / $18,200
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $9,100 / $18,200
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 0% coinsurance (First 3 PCP or MH, SA Visits Not Subject to DD)
Specialist Visit 0% coinsurance
ER 0% coinsurance Deductible applies.
Urgent Care 0% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) 0% coinsurance Deductible applies.
Preferred Rx Coverage (Tier 2) 0% coinsurance Deductible applies. Prior authorization is required for some prescriptions.
Non Preferred Rx Coverage (Tier 3) 0% coinsurance Deductible applies. Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2023

MVP VT Plus Bronze 1 AI-AN FRVT-HMO-BA2-001-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $7,250 / $14,500
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $8,400 / $16,800
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $40 copay
Specialist Visit $100 copay
ER 50% coinsurance Deductible applies.
Urgent Care $100 copay Deductible applies.
Generic Rx Coverage (Tier 1) $25 copay Deductible waived. VBID 30 day supply $3/90 day supply $7.50
Preferred Rx Coverage (Tier 2) $100 copay Deductible applies. VBID 30 day supply $3/90 day supply $7.50. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 60% coinsurance Deductible applies. VBID 30 day supply $3/90 day supply $7.50. Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Bronze 1 AI-AN U300% FRVT-HMO-BA1-001-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible.Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible.Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Bronze 5 AI-AN FRVT-HMO-BA2-005-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $9,100 / $18,200
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $9,100 / $18,200
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 0% coinsurance (First 3 PCP or MH, SA Visits Not Subject to DD)
Specialist Visit 0% coinsurance
ER 0% coinsurance Deductible applies.
Urgent Care 0% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) $35 copay Deductible waived. VBID 30 day supply $3/90 day supply $7.50
Preferred Rx Coverage (Tier 2) 0% coinsurance Deductible applies. VBID 30 day supply $3/90 day supply $7.50. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 0% coinsurance Deductible applies. VBID 30 day supply $3/90 day supply $7.50. Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Bronze 5 AI-AN U300% FRVT-HMO-BA1-005-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible.Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible.Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Silver 1 73 FRVT-HMO-S1-001-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $1,500 / $3,000
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $6,150 / $12,300
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $30 copay (First 3 PCP or MH, SA Visits Not Subject to DD)
Specialist Visit $60 copay
ER $350 copay Deductible applies.
Urgent Care $60 copay Deductible applies.
Generic Rx Coverage (Tier 1) $5 copay Deductible applies. VBID 30 day supply $1/90 day supply $2.50
Preferred Rx Coverage (Tier 2) 50% coinsurance Deductible applies. VBID 30 day supply $1/90 day supply $2.50. Prior authorization required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 50% coinsurance Deductible applies. VBID 30 day supply $1/90 day supply $2.50. Prior authorization required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Silver 1 77 FRVT-HMO-S1-004-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $750 / $1,500
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $5,750 / $11,500
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $15 copay (First 3 PCP or MH, SA Visits Not Subject to DD)
Specialist Visit $40 copay
ER $150 copay Deductible applies.
Urgent Care $40 copay Deductible applies.
Generic Rx Coverage (Tier 1) $5 copay Deductible applies. VBID 30 day supply $1/90 day supply $2.50
Preferred Rx Coverage (Tier 2) 40% coinsurance Deductible applies. VBID 30 day supply $1/90 day supply $2.50. Prior authorization required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 40% coinsurance Deductible applies. VBID 30 day supply $1/90 day supply $2.50. Prior authorization required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Silver 1 87 FRVT-HMO-S1-002-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $200 / $400
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $2,600 / $5,200
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $5 copay (First 3 PCP or MH, SA Visits Not Subject to DD)
Specialist Visit $30 copay
ER $50 copay Deductible applies.
Urgent Care $30 copay Deductible applies.
Generic Rx Coverage (Tier 1) $5 copay Deductible applies. VBID 30 day supply $1/90 day supply $2.50
Preferred Rx Coverage (Tier 2) 20% coinsurance Deductible applies. VBID 30 day supply $1/90 day supply $2.50. Prior authorization required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 40% coinsurance Deductible applies. VBID 30 day supply $1/90 day supply $2.50. Prior authorization required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Silver 1 94 FRVT-HMO-S1-003-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $1,650 / $3,300
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $5 copay
Specialist Visit $10 copay
ER $25 copay No Deductible.
Urgent Care $10 copay No Deductible.
Generic Rx Coverage (Tier 1) $5 copay No Deductible.VBID 30 day supply $1/90 day supply $2.50
Preferred Rx Coverage (Tier 2) 5% coinsurance No Deductible.VBID 30 day supply $1/90 day supply $2.50. Prior authorization required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 5% coinsurance No Deductible.VBID 30 day supply $1/90 day supply $2.50. Prior authorization required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Silver 1 AI-AN FRVT-HMO-SA2-001-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $2,100 / $4,200
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $7,000 / $14,000
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $30 copay (First 3 PCP or MH, SA Visits Not Subject to DD)
Specialist Visit $60 copay
ER $400 copay Deductible applies.
Urgent Care $60 copay Deductible applies.
Generic Rx Coverage (Tier 1) $5 copay Deductible applies. VBID 30 day supply $1/90 day supply $2.50
Preferred Rx Coverage (Tier 2) 50% coinsurance Deductible applies. VBID 30 day supply $1/90 day supply $2.50. Prior authorization required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 50% coinsurance Deductible applies. VBID 30 day supply $1/90 day supply $2.50. Prior authorization required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Silver 1 AI-AN U300% FRVT-HMO-SA1-001-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible.Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible.Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Silver 2 94 FRVT-HMOH-S2-003-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $550 / $1,100
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $550 / $1,100
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 0% coinsurance
Specialist Visit 0% coinsurance
ER 0% coinsurance Deductible applies.
Urgent Care 0% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) 0% coinsurance Deductible applies. Preventive drugs deductible waived
Preferred Rx Coverage (Tier 2) 0% coinsurance Deductible applies. Preventive drugs deductible waived. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 0% coinsurance Deductible applies. Preventive drugs deductible waived. Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Silver 2 AI-AN U300% FRVT-HMOH-SA1-002-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible.Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible.Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Silver 2 HDHP 73 FRVT-HMOH-S2-001-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $4,725 / $9,450
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $4,725 / $9,450
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 0% coinsurance
Specialist Visit 0% coinsurance
ER 0% coinsurance Deductible applies.
Urgent Care 0% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) 0% coinsurance Deductible applies. Preventive drugs deductible waived
Preferred Rx Coverage (Tier 2) 0% coinsurance Deductible applies. Preventive drugs deductible waived. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 0% coinsurance Deductible applies. Preventive drugs deductible waived. Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Silver 2 HDHP 77 FRVT-HMOH-S2-004-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $3,650 / $7,300
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $3,650 / $7,300
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 0% coinsurance
Specialist Visit 0% coinsurance
ER 0% coinsurance Deductible applies.
Urgent Care 0% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) 0% coinsurance Deductible applies. Preventive drugs deductible waived
Preferred Rx Coverage (Tier 2) 0% coinsurance Deductible applies. Preventive drugs deductible waived. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 0% coinsurance Deductible applies. Preventive drugs deductible waived. Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Silver 2 HDHP 87 FRVT-HMOH-S2-002-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $1,500 / $3,000
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $1,500 / $3,000
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 0% coinsurance
Specialist Visit 0% coinsurance
ER 0% coinsurance Deductible applies.
Urgent Care 0% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) 0% coinsurance Deductible applies. Preventive drugs deductible waived
Preferred Rx Coverage (Tier 2) 0% coinsurance Deductible applies. Preventive drugs deductible waived. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 0% coinsurance Deductible applies. Preventive drugs deductible waived. Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityMust qualify for Cost-Saving Reduction (CSR)
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Silver 2 HDHP AI-AN FRVT-HMOH-SA2-002-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $5,500 / $11,000
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $5,500 / $11,000
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 0% coinsurance
Specialist Visit 0% coinsurance
ER 0% coinsurance Deductible applies.
Urgent Care 0% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) 0% coinsurance Deductible applies. Preventive drugs deductible waived
Preferred Rx Coverage (Tier 2) 0% coinsurance Deductible applies. Preventive drugs deductible waived. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 0% coinsurance Deductible applies. Preventive drugs deductible waived. Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Gold 2 AI-AN FRVT-HMO-GA2-002-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $850 / $1,700
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $6,600 / $13,200
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $20 copay
Specialist Visit $45 copay
ER $250 copay Deductible applies.
Urgent Care $30 copay Deductible waived.
Generic Rx Coverage (Tier 1) $15 copay Deductible waived. VBID 30 day supply $1/90 day supply $2.50
Preferred Rx Coverage (Tier 2) $40 copay Deductible applies. VBID 30 day supply $1/90 day supply $2.50. Prior authorization required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 50% coinsurance Deductible applies. VBID 30 day supply $1/90 day supply $2.50. Prior authorization required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Gold 2 AI-AN U300% FRVT-HMO-GA1-002-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible.Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible.Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Gold 3 AI-AN U300% FRVT-HMOH-GA1-003-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible.Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible.Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023

MVP VT Plus Gold 3 HDHP AI-AN FRVT-HMOH-GA2-003-N (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $3,200 / $6,400
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $3,200 / $6,400 (aggregate)
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 0% coinsurance
Specialist Visit 0% coinsurance
ER 0% coinsurance Deductible applies.
Urgent Care 0% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) 0% coinsurance Deductible applies. Preventive drugs 30 day supply $10; 90 day supply $25, deductible waived
Preferred Rx Coverage (Tier 2) 0% coinsurance Deductible applies. Preventive drugs 30 day supply $15; 90 day supply $37.50, DD Waived. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 0% coinsurance Deductible applies. Preventive drugs 30 day/90 supply 5% deductible waived. Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special EligibilityAmerican Indian/Alaska Native
Find a Doctor Doctor Search
Summary of Benefits and Coverage (SBC) Click here to open detailed plan benefit information
Plan Overview Click here to open the plan overview document
Plan Highlights $500 acupuncture allowance, Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features $600 Well-Being Reimbursement
Availability January 1, 2023