Standard Small Business Gold Plans

MVP VT (standard) plans for Vermont small businesses offered on Vermont Health Connect.

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MVP VT Gold 1 FRVT-HMO-SG-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