Standard Small Business Gold Plans
MVP VT (standard) plans for Vermont small businesses offered on Vermont Health Connect.
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 |