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 (2022) |
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State | Vermont |
Plan Type | HMO |
Exchange | Off |
Metal Level | Silver |
Annual In-Network Deductible (Single/Family) | $3,400 / $6,800 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit (Single/Family) | $8,550 / $17,100 |
Annual Out-of-Network Out-of-Pocket Limit | N/A |
Primary Care Visit | $35 copay |
Specialist Visit | $80 copay |
ER | $250 copay Deductible applies. |
Urgent Care | $90 copay Deductible waived. |
Generic Rx Coverage (Tier 1) | $15 copay Deductible waived. 30 day supply/90 day supply. |
Preferred Rx Coverage (Tier 2) | $60 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 |
MVP VT Reflective Silver 4 HDHP VT-HMOH-SS-004-S II (2022) |
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State | Vermont |
Plan Type | HMO |
Exchange | Off |
Metal Level | Silver |
Annual In-Network Deductible (Single/Family) | $1,850 / $3,700 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit (Single/Family) | $6,900 / $13,800 (Max $8,700 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. 30 day supply/90 day supply; preventive drugs deductible waived. |
Preferred Rx Coverage (Tier 2) | $40 copay Deductible applies. 30 day supply/90 day supply; preventive drugs deductible waived. Prior authorization is required for some prescriptions. |
Non Preferred Rx Coverage (Tier 3) | 50% coinsurance Deductible applies. 30 day supply/90 day supply; preventive drugs deductible waived. 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 |
MVP VT Silver 3 FRVT-HMO-SS-003-S (2022) |
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State | Vermont |
Plan Type | HMO |
Exchange | On |
Metal Level | Silver |
Annual In-Network Deductible (Single/Family) | $3,400 / $6,800 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit (Single/Family) | $8,550 / $17,100 |
Annual Out-of-Network Out-of-Pocket Limit | N/A |
Primary Care Visit | $35 copay |
Specialist Visit | $80 copay |
ER | $250 copay Deductible applies. |
Urgent Care | $90 copay Deductible waived. |
Generic Rx Coverage (Tier 1) | $15 copay Deductible waived. 30 day supply/90 day supply. |
Preferred Rx Coverage (Tier 2) | $60 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 |
MVP VT Silver 4 HDHP FRVT-HMOH-SS-004-S (2022) |
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State | Vermont |
Plan Type | HMO |
Exchange | On |
Metal Level | Silver |
Annual In-Network Deductible (Single/Family) | $1,850 / $3,700 |
Annual Out-of-Network Deductible | N/A |
Annual In-Network Out-of-Pocket Limit (Single/Family) | $6,900 / $13,800 (Max $8,700 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. 30 day supply/90 day supply; preventive drugs deductible waived. |
Preferred Rx Coverage (Tier 2) | $40 copay Deductible applies. 30 day supply/90 day supply. Preventive drugs deductible waived. Prior authorization is required for some prescriptions |
Non Preferred Rx Coverage (Tier 3) | 50% coinsurance Deductible applies. 30 day supply/90 day supply; preventive drugs deductible waived. 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 |