Non Standard Individual Bronze 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 (2022)

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 2022 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 WellBeing Rewards
Availability January 1, 2022

MVP VT Plus Bronze 5 FRVT-HMO-B-005-N (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $7,850 / $15,700
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $7,850 / $15,700
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 0% coinsurance (First 3 visits no Deductible)
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 2022 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 WellBeing Rewards
Availability January 1, 2022

MVP VT Plus Bronze 1 AI-AN FRVT-HMO-BA2-001-N (2022)

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 2022 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 WellBeing Rewards
Availability January 1, 2022

MVP VT Plus Bronze 1 AI-AN U300 FRVT-HMO-BA1-001-N (2022)

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 (Single/Family) $0 / $0
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. 30 day supply/90 day supply.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible. 30 day supply/90 day supply. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible. 30 day supply/90 day supply.; Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2022 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 WellBeing Rewards
Availability January 1, 2022

MVP VT Plus Bronze 5 AI-AN FRVT-HMO-BA2-005-N (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $7,850 / $15,700
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $7,850 / $15,700
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 0% coinsurance (First 3 visits no Deductible)
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 2022 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 WellBeing Rewards
Availability January 1, 2022

MVP VT Plus Bronze 5 AI-AN U300 FRVT-HMO-BA1-005-N (2022)

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 (Single/Family) $0 / $0
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. 30 day supply/90 day supply.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible. 30 day supply/90 day supply. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible. 30 day supply/90 day supply.; Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2022 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 WellBeing Rewards
Availability January 1, 2022