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