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