Non Standard Small Business Gold Plans
MVP VT Plus (non-standard) plans for Vermont small businesses offered on Vermont Health Connect.
MVP VT Plus Gold 2 FRVT-HMO-SG-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-SG-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 |