Standard Small Business Plans
MVP VT (standard) plans for Vermont small businesses offered on Vermont Health Connect.
MVP VT Bronze 2 FRVT-HMO-SB-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-SB-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-SB-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 Reflective Silver 3 VT-HMO-SS-003-S II (2023) |
|
|---|---|
| State | Vermont |
| Plan Type | HMO |
| Exchange | Off |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $4,000 / $8,000 |
| 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 | $40 copay (First 3 PCP or MH, SA Visits Covered in Full) |
| Specialist Visit | $90 copay |
| ER | $500 copay Deductible applies. |
| Urgent Care | $100 copay Deductible waived. |
| Generic Rx Coverage (Tier 1) | $20 copay Deductible waived. |
| Preferred Rx Coverage (Tier 2) | $70 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 Reflective Silver 4 HDHP VT-HMOH-SS-004-S II (2023) |
|
|---|---|
| State | Vermont |
| Plan Type | HMO |
| Exchange | Off |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $2,100 / $4,200 |
| Annual Out-of-Network Deductible | N/A |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $7,050 / $14,100 (Max $9,100 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. Preventive drugs deductible waived |
| Preferred Rx Coverage (Tier 2) | $40 copay Deductible applies. Preventive drugs deductible waived. Prior authorization is required for some prescriptions |
| Non Preferred Rx Coverage (Tier 3) | 50% 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 Silver 3 FRVT-HMO-SS-003-S (2023) |
|
|---|---|
| State | Vermont |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $4,000 / $8,000 |
| 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 | $40 copay (First 3 PCP or MH, SA Visits Covered in Full) |
| Specialist Visit | $90 copay |
| ER | $500 copay Deductible applies. |
| Urgent Care | $100 copay Deductible waived. |
| Generic Rx Coverage (Tier 1) | $20 copay Deductible waived. |
| Preferred Rx Coverage (Tier 2) | $70 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 Silver 4 HDHP FRVT-HMOH-SS-004-S (2023) |
|
|---|---|
| State | Vermont |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Silver |
| Annual In-Network Deductible (Single/Family) | $2,100 / $4,200 |
| Annual Out-of-Network Deductible | N/A |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $7,050 / $14,100 (Max $9,100 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. Preventive drugs deductible waived |
| Preferred Rx Coverage (Tier 2) | $40 copay Deductible applies. Preventive drugs deductible waived. Prior authorization is required for some prescriptions |
| Non Preferred Rx Coverage (Tier 3) | 50% 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 Gold 1 FRVT-HMO-SG-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 Platinum 1 FRVT-HMO-SP-001-S (2023) |
|
|---|---|
| State | Vermont |
| Plan Type | HMO |
| Exchange | On |
| Metal Level | Platinum |
| Annual In-Network Deductible (Single/Family) | $425 / $850 |
| Annual Out-of-Network Deductible | N/A |
| Annual In-Network Out-of-Pocket Limit (Single/Family) | $1,500 / $3,000 |
| Annual Out-of-Network Out-of-Pocket Limit | N/A |
| Primary Care Visit | $15 copay (First 3 PCP or MH, SA Visits Covered in Full) |
| Specialist Visit | $40 copay |
| ER | $100 copay Deductible applies. |
| Urgent Care | $50 copay Deductible waived. |
| Generic Rx Coverage (Tier 1) | $10 copay Deductible waived. |
| Preferred Rx Coverage (Tier 2) | $50 copay Deductible waived. Prior authorization is required for some prescriptions |
| Non Preferred Rx Coverage (Tier 3) | 50% coinsurance 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 |