Standard Individual Plans

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

View all MVP VT Individual & Family Plans

MVP VT Bronze 2 FRVT-HMO-B-002-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $6,450 / $12,900
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $8,700 / $17,400
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $35 copay
Specialist Visit $90 copay
ER 50% coinsurance Deductible applies.
Urgent Care $100 copay Deductible applies.
Generic Rx Coverage (Tier 1) $15 copay Deductible waived. 30 day supply/90 day supply.
Preferred Rx Coverage (Tier 2) $85 copay Deductible applies. 30 day supply/90 day supply; Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 60% coinsurance Deductible applies. 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
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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Bronze 3 HDHP FRVT-HMOH-B-003-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $5,700 / $11,400
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $7,050 / $14,100 (Max $8,700 per family member)
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 50% coinsurance
Specialist Visit 50% coinsurance
ER 50% coinsurance Deductible applies.
Urgent Care 50% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) $12 copay Deductible applies. 30 day supply/90 day supply; preventive drugs deductible waived.
Preferred Rx Coverage (Tier 2) 40% coinsurance Deductible applies. 30 day supply/90 supply; preventive drugs deductible waived. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 60% coinsurance Deductible applies. 30 day supply/90 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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Bronze 4 FRVT-HMO-B-004-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $8,700 / $17,400
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $8,700 / $17,400
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $40 copay
Specialist Visit $100 copay
ER 0% coinsurance Deductible applies.
Urgent Care 0% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) $30 copay Deductible waived. 30 day supply/90 day supply.
Preferred Rx Coverage (Tier 2) 0% coinsurance Deductible applies. 30 day supply/90 day supply; Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 0% coinsurance Deductible applies. 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
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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Silver 3 FRVT-HMO-S-003-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $3,400 / $6,800
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $8,550 / $17,100
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $35 copay
Specialist Visit $80 copay
ER $250 copay Deductible applies.
Urgent Care $90 copay Deductible waived.
Generic Rx Coverage (Tier 1) $15 copay Deductible waived. 30 day supply/90 day supply.
Preferred Rx Coverage (Tier 2) $60 copay Deductible applies. 30 day supply/90 day supply; Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 50% coinsurance Deductible applies. 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
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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Silver 4 HDHP FRVT-HMOH-S-004-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $1,850 / $3,700
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $6,900 / $13,800 (Max $8,700 per family member)
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 10% coinsurance
Specialist Visit 30% coinsurance
ER 30% coinsurance Deductible applies.
Urgent Care 30% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) $10 copay Deductible applies. 30 day supply/90 day supply; preventive drugs deductible waived.
Preferred Rx Coverage (Tier 2) $40 copay 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) 50% 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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Gold 1 FRVT-HMO-G-001-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $1,200 / $2,400
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $5,400 / $10,800
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $20 copay
Specialist Visit $50 copay
ER $150 copay Deductible applies.
Urgent Care $60 copay Deductible waived.
Generic Rx Coverage (Tier 1) $12 copay Deductible waived. 30 day supply/90 day supply.
Preferred Rx Coverage (Tier 2) $55 copay Deductible applies. 30 day supply/90 day supply; Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 50% coinsurance Deductible applies. 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
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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Platinum 1 FRVT-HMO-P-001-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Platinum
Annual In-Network Deductible (Single/Family) $400 / $800
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $1,400 / $2,800
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $15 copay
Specialist Visit $40 copay
ER $100 copay Deductible applies.
Urgent Care $50 copay Deductible waived.
Generic Rx Coverage (Tier 1) $10 copay Deductible waived. 30 day supply/90 day supply.
Preferred Rx Coverage (Tier 2) $50 copay Deductible waived. 30 day supply/90 day supply. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 50% coinsurance Deductible waived. 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
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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Secure FRVT-HMOC-001-N (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level NA
Annual In-Network Deductible (Single/Family) $8,700 / $17,400
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $8,700 / $17,400
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. 30 day supply/90 day supply
Preferred Rx Coverage (Tier 2) 0% coinsurance Deductible applies. 30 day supply/90 day supply; Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 0% coinsurance Deductible applies. 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
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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Bronze 2 AI-AN FRVT-HMO-BA2-002-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $6,450 / $12,900
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $8,700 / $17,400
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $35 copay
Specialist Visit $90 copay
ER 50% coinsurance Deductible applies.
Urgent Care $100 copay Deductible applies.
Generic Rx Coverage (Tier 1) $15 copay Deductible waived. 30 day supply/90 day supply.
Preferred Rx Coverage (Tier 2) $85 copay Deductible applies. 30 day supply/90 day supply; Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 60% coinsurance Deductible applies. 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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Bronze 2 AI-AN U300 FRVT-HMO-BA1-002-S (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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Bronze 3 AI-AN U300 FRVT-HMOH-BA1-003-S (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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Bronze 3 HDHP AI-AN FRVT-HMOH-BA2-003-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $5,700 / $11,400
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $7,050 / $14,100 (Max $8,700 per family member)
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 50% coinsurance
Specialist Visit 50% coinsurance
ER 50% coinsurance Deductible applies.
Urgent Care 50% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) $12 copay Deductible applies. 30 day supply/90 day supply; preventive drugs deductible waived.
Preferred Rx Coverage (Tier 2) 40% coinsurance Deductible applies. 30 day supply/90 supply; preventive drugs deductible waived. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 60% coinsurance Deductible applies. 30 day supply/90 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
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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Bronze 4 AI-AN FRVT-HMO-BA2-004-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $8,700 / $17,400
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $8,700 / $17,400
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $40 copay
Specialist Visit $100 copay
ER 0% coinsurance Deductible applies.
Urgent Care 0% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) $30 copay Deductible waived. 30 day supply/90 day supply.
Preferred Rx Coverage (Tier 2) 0% coinsurance Deductible applies. 30 day supply/90 day supply; Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 0% coinsurance Deductible applies. 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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Bronze 4 AI-AN U300 FRVT-HMO-BA1-004-S (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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Silver 3 73 FRVT-HMO-S3-001-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $3,100 / $6,200
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $6,750 / $13,500
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $35 copay
Specialist Visit $70 copay
ER $250 copay Deductible applies.
Urgent Care $80 copay Deductible waived.
Generic Rx Coverage (Tier 1) $12 copay Deductible waived. 30 day supply/90 day supply.
Preferred Rx Coverage (Tier 2) $60 copay Deductible applies. 30 day supply/90 day supply; Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 50% coinsurance Deductible applies. 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 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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Silver 3 77 FRVT-HMO-S3-004-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $2,600 / $5,200
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $6,000 / $12,000
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $25 copay
Specialist Visit $50 copay
ER $250 copay Deductible applies.
Urgent Care $60 copay Deductible waived.
Generic Rx Coverage (Tier 1) $12 copay Deductible waived. 30 day supply/90 day supply.
Preferred Rx Coverage (Tier 2) $60 copay Deductible applies. 30 day supply/90 day supply; Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 50% coinsurance Deductible applies. 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 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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Silver 3 87 FRVT-HMO-S3-002-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $1,100 / $2,200
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $2,200 / $4,400
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $10 copay
Specialist Visit $30 copay
ER $250 copay Deductible applies.
Urgent Care $40 copay Deductible waived.
Generic Rx Coverage (Tier 1) $10 copay Deductible waived. 30 day supply/90 day supply.
Preferred Rx Coverage (Tier 2) $50 copay Deductible applies. 30 day supply/90 day supply; Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 50% coinsurance Deductible applies. 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 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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Silver 3 94 FRVT-HMO-S3-003-S (2022)

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) $900 / $1,800
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $5 copay
Specialist Visit $15 copay
ER $75 copay Deductible applies.
Urgent Care $25 copay Deductible waived.
Generic Rx Coverage (Tier 1) $5 copay Deductible waived. 30 day supply/90 day supply.
Preferred Rx Coverage (Tier 2) $20 copay Deductible waived. 30 day supply/90 day supply. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 30% coinsurance Deductible waived. 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 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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Silver 3 AI-AN FRVT-HMO-SA2-003-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $3,400 / $6,800
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $8,550 / $17,100
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $35 copay
Specialist Visit $80 copay
ER $250 copay Deductible applies.
Urgent Care $90 copay Deductible waived.
Generic Rx Coverage (Tier 1) $15 copay Deductible waived. 30 day supply/90 day supply.
Preferred Rx Coverage (Tier 2) $60 copay Deductible applies. 30 day supply/90 day supply; Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 50% coinsurance Deductible applies. 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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Silver 3 AI-AN U300 FRVT-HMO-SA1-003-S (2022)

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) $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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Silver 4 94 FRVT-HMOH-S4-003-S (2022)

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. 30 day supply/90 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
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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Silver 4 AI-AN U300 FRVT-HMOH-SA1-004-S (2022)

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) $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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Silver 4 HDHP 73 FRVT-HMOH-S4-001-S (2022)

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) $5,200 / $10,400 (Max $8,700 per family member)
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 10% coinsurance
Specialist Visit 25% coinsurance
ER 25% coinsurance Deductible applies.
Urgent Care 25% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) $10 copay Deductible applies. 30 day supply/90 day supply; preventive drugs deductible waived.
Preferred Rx Coverage (Tier 2) $40 copay 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) 50% 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
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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Silver 4 HDHP 77 FRVT-HMOH-S4-004-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $1,600 / $3,200
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $4,400 / $8,800 (Max $8,700 per family member)
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 10% coinsurance
Specialist Visit 25% coinsurance
ER 25% coinsurance Deductible applies.
Urgent Care 25% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) $10 copay Deductible applies. 30 day supply/90 day supply; preventive drugs deductible waived.
Preferred Rx Coverage (Tier 2) $40 copay 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) 50% 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
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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Silver 4 HDHP 87 FRVT-HMOH-S4-002-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $1,400 / $2,800
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $1,400 / $2,800
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
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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Silver 4 HDHP AI-AN FRVT-HMOH-SA2-004-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Silver
Annual In-Network Deductible (Single/Family) $1,850 / $3,700
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $6,900 / $13,800 (Max $8,700 per family member)
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit 10% coinsurance
Specialist Visit 30% coinsurance
ER 30% coinsurance Deductible applies.
Urgent Care 30% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) $10 copay Deductible applies. 30 day supply/90 day supply; preventive drugs deductible waived.
Preferred Rx Coverage (Tier 2) $40 copay 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) 50% 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
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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Gold 1 AI-AN FRVT-HMO-GA2-001-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Gold
Annual In-Network Deductible (Single/Family) $1,200 / $2,400
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $5,400 / $10,800
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $20 copay
Specialist Visit $50 copay
ER $150 copay Deductible applies.
Urgent Care $60 copay Deductible waived.
Generic Rx Coverage (Tier 1) $12 copay Deductible waived. 30 day supply/90 day supply.
Preferred Rx Coverage (Tier 2) $55 copay Deductible applies. 30 day supply/90 day supply; Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 50% coinsurance Deductible applies. 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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Gold 1 AI-AN U300 FRVT-HMO-GA1-001-S (2022)

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 (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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Platinum 1 AI-AN FRVT-HMO-PA2-001-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Platinum
Annual In-Network Deductible (Single/Family) $400 / $800
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $1,400 / $2,800
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $15 copay
Specialist Visit $40 copay
ER $100 copay Deductible applies.
Urgent Care $50 copay Deductible waived.
Generic Rx Coverage (Tier 1) $10 copay Deductible waived. 30 day supply/90 day supply.
Preferred Rx Coverage (Tier 2) $50 copay Deductible waived. 30 day supply/90 day supply. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 50% coinsurance Deductible waived. 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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022

MVP VT Platinum 1 AI-AN U300 FRVT-HMO-PA1-001-S (2022)

State Vermont
Plan Type HMO
Exchange On
Metal Level Platinum
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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2022