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 (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 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 Eligibility | American 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 Eligibility | American 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 Eligibility | American 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 Eligibility | American 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 |