Vermont Standard Individual Gold Plans

MVP VT Gold 1 FRVT-HMO-G-001-S (2023)
State	Vermont
Plan Type	HMO
Exchange	On
Metal Level	Gold
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)	$5,600 / $11,200
Annual Out-of-Network Out-of-Pocket Limit	N/A
Primary Care Visit	$20 copay (First 3 PCP or MH, SA Visits Covered in Full)
Specialist Visit	$50 copay
ER	$150 copay Deductible applies.
Urgent Care	$60 copay Deductible waived.
Generic Rx Coverage (Tier 1)	$12 copay Deductible waived.
Preferred Rx Coverage (Tier 2)	$55 copay Deductible applies. Prior authorization is required for some prescriptions.
Non Preferred Rx Coverage (Tier 3)	50% 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 Gold 1 AI-AN FRVT-HMO-GA2-001-S (2023)
State	Vermont
Plan Type	HMO
Exchange	On
Metal Level	Gold
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)	$5,600 / $11,200
Annual Out-of-Network Out-of-Pocket Limit	N/A
Primary Care Visit	$20 copay (First 3 PCP or MH, SA Visits Covered in Full)
Specialist Visit	$50 copay
ER	$150 copay Deductible applies.
Urgent Care	$60 copay Deductible waived.
Generic Rx Coverage (Tier 1)	$12 copay Deductible waived.
Preferred Rx Coverage (Tier 2)	$55 copay Deductible applies. Prior authorization is required for some prescriptions.
Non Preferred Rx Coverage (Tier 3)	50% 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 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, 2023

MVP VT Gold 1 AI-AN U300% FRVT-HMO-GA1-001-S (2023)
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	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 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, 2023

Standard Individual Gold Plans