Standard Individual Bronze 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 (2023)

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) $9,100 / $18,200
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.
Preferred Rx Coverage (Tier 2) $85 copay Deductible applies. Prior authorization is required for some prescriptions.
Non Preferred Rx Coverage (Tier 3) 60% coinsurance Deductible applies. 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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2023

MVP VT Bronze 3 HDHP FRVT-HMOH-B-003-S (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $5,800 / $11,600
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $7,100 / $14,200 (Max $9,100 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. Preventive drugs deductible waived
Preferred Rx Coverage (Tier 2) 40% coinsurance Deductible applies. Preventive drugs deductible waived. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 60% coinsurance Deductible applies. Preventive drugs 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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2023

MVP VT Bronze 4 FRVT-HMO-B-004-S (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $9,000 / $18,000
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $9,000 / $18,000
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $40 copay (First 3 PCP or MH, SA Visits Covered in Full)
Specialist Visit $100 copay
ER 0% coinsurance Deductible applies.
Urgent Care 0% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) $30 copay Deductible waived.
Preferred Rx Coverage (Tier 2) 0% coinsurance Deductible applies. Prior authorization is required for some prescriptions.
Non Preferred Rx Coverage (Tier 3) 0% coinsurance Deductible applies. 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 Cigna national network, pediatric dental, 20% discount on CVS brand health-related items
Well-Being Features Not covered
Availability January 1, 2023

MVP VT Bronze 2 AI-AN FRVT-HMO-BA2-002-S (2023)

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) $9,100 / $18,200
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.
Preferred Rx Coverage (Tier 2) $85 copay Deductible applies. Prior authorization is required for some prescriptions.
Non Preferred Rx Coverage (Tier 3) 60% coinsurance Deductible applies. Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special 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, 2023

MVP VT Bronze 2 AI-AN U300% FRVT-HMO-BA1-002-S (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible.Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible.Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special 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, 2023

MVP VT Bronze 3 AI-AN U300% FRVT-HMOH-BA1-003-S (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible.Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible.Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special 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, 2023

MVP VT Bronze 3 HDHP AI-AN FRVT-HMOH-BA2-003-S (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $5,800 / $11,600
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $7,100 / $14,200 (Max $9,100 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. Preventive drugs deductible waived
Preferred Rx Coverage (Tier 2) 40% coinsurance Deductible applies. Preventive drugs deductible waived. Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) 60% coinsurance Deductible applies. Preventive drugs 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
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, 2023

MVP VT Bronze 4 AI-AN FRVT-HMO-BA2-004-S (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $9,000 / $18,000
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit (Single/Family) $9,000 / $18,000
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $40 copay (First 3 PCP or MH, SA Visits Covered in Full)
Specialist Visit $100 copay
ER 0% coinsurance Deductible applies.
Urgent Care 0% coinsurance Deductible applies.
Generic Rx Coverage (Tier 1) $30 copay Deductible waived.
Preferred Rx Coverage (Tier 2) 0% coinsurance Deductible applies. Prior authorization is required for some prescriptions.
Non Preferred Rx Coverage (Tier 3) 0% coinsurance Deductible applies. Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special 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, 2023

MVP VT Bronze 4 AI-AN U300% FRVT-HMO-BA1-004-S (2023)

State Vermont
Plan Type HMO
Exchange On
Metal Level Bronze
Annual In-Network Deductible (Single/Family) $0 / $0
Annual Out-of-Network Deductible N/A
Annual In-Network Out-of-Pocket Limit N/A
Annual Out-of-Network Out-of-Pocket Limit N/A
Primary Care Visit $0 copay
Specialist Visit $0 copay
ER $0 copay No Deductible.
Urgent Care $0 copay No Deductible.
Generic Rx Coverage (Tier 1) $0 copay No Deductible.
Preferred Rx Coverage (Tier 2) $0 copay No Deductible.Prior authorization is required for some prescriptions
Non Preferred Rx Coverage (Tier 3) $0 copay No Deductible.Prior authorization is required for some prescriptions. Includes Diabetic Supplies and Equipment
Rx Formulary 2023 MVP Marketplace Formulary (PDF)
Rx Drug Search Pharmacy Information for Vermont’s Prescription Drug Program
Special 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, 2023