Non Standard Small Business Plans
MVP VT Plus (non-standard) plans for Vermont small businesses offered on Vermont Health Connect.
MVP VT Plus Bronze 1 FRVT-HMO-SB-001-N (2022) |
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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-SB-005-N (2022) |
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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 Reflective Silver 1 VT-HMO-SS-001-N II (2022) |
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State | Vermont |
Plan Type | HMO |
Exchange | Off |
Metal Level | Silver |
Annual In-Network Deductible (Single/Family) | $1,750 / $3,500 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit (Single/Family) | $6,950 / $13,900 |
Annual Out-of-Network Out-of-Pocket Limit | N/A |
Primary Care Visit | $30 copay (First 3 visits no Deductible) |
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 | 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 Reflective Silver 2 HDHP VT-HMOH-SS-002-N II (2022) |
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State | Vermont |
Plan Type | HMO |
Exchange | Off |
Metal Level | Silver |
Annual In-Network Deductible (Single/Family) | $5,100 / $10,200 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit (Single/Family) | $5,100 / $10,200 |
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. 30 day supply/90 day supply; preventive drugs deductible waived. |
Preferred Rx Coverage (Tier 2) | 0% coinsurance Deductible applies. 30 day supply/90 day supply; preventive drugs deductible waived. Prior authorization is required for some prescriptions |
Non Preferred Rx Coverage (Tier 3) | 0% coinsurance Deductible applies. 30 day supply/90 day supply; preventive drugs deductible waived. 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 Silver 1 FRVT-HMO-SS-001-N (2022) |
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State | Vermont |
Plan Type | HMO |
Exchange | On |
Metal Level | Silver |
Annual In-Network Deductible (Single/Family) | $1,750 / $3,500 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit (Single/Family) | $6,950 / $13,900 |
Annual Out-of-Network Out-of-Pocket Limit | N/A |
Primary Care Visit | $30 copay (First 3 visits no Deductible) |
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 | 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 Silver 2 HDHP FRVT-HMOH-SS-002-N (2022) |
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State | Vermont |
Plan Type | HMO |
Exchange | On |
Metal Level | Silver |
Annual In-Network Deductible (Single/Family) | $5,075 / $10,150 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit (Single/Family) | $5,075 / $10,150 |
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. 30 day supply/90 day supply; preventive drugs deductible waived. |
Preferred Rx Coverage (Tier 2) | 0% coinsurance Deductible applies. 30 day supply/90 day supply. Preventive drugs deductible waived. Prior authorization is required for some prescriptions |
Non Preferred Rx Coverage (Tier 3) | 0% coinsurance Deductible applies. 30 day supply/90 day supply; preventive drugs deductible waived. 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 Gold 2 FRVT-HMO-SG-002-N (2022) |
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State | Vermont |
Plan Type | HMO |
Exchange | On |
Metal Level | Gold |
Annual In-Network Deductible (Single/Family) | $700 / $1,400 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit (Single/Family) | $6,500 / $13,000 |
Annual Out-of-Network Out-of-Pocket Limit | N/A |
Primary Care Visit | $20 copay |
Specialist Visit | $40 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 | 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 Gold 3 HDHP FRVT-HMOH-SG-003-N (2022) |
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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 |
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, Deductible 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 | 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 |