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MVP VT Plus Silver 2019

Which medical plans are best for you? Use Vermont Plan Comparison Tool 2019 to find out.

Plan id 77566VT0040007-05
CSR Variation Type 87% AV Level Silver Plan
Insurance Company What is this? MVP Health Care
Plan Type What is this? HMO
Plan Metal Level What is this? Silver
Link to Plan's Doctor Directory What is this? View Plan's Doctor Directory
Summary of Benefits and Coverage What is this? View Summary of Benefits and Coverage
Estimated Monthly Premium Savings (APTC) What is this?
Monthly Premium Cost after Subtracting the Estimated Subsidy
(Subsidies are not available for Catastrophic Plans)
Cost in a Good Year: Estimated Yearly Cost to You if Your Health Care Usage is Low
(for Very Healthy Consumers "Low" is Defined as Only Preventive Care) What is this?
Your Chances of Having a Good Year--a Year with No More Than Low-Usage What is this?
Cost in an Average Year: Average for People Like You What is this?
Cost in a Bad Year: Estimate for People Like You in a High-Health Care Usage Year What is this?
Your Chances of Having a Bad Year--a Year with Very High Usage What is this?
Actual Maximum Out-of-Pocket (includes premiums) What is this?
Benefits and Coverage (assuming you use preferred providers) expand

(Note: For a more detailed and accurate explanation of the benefits offered by this plan please refer to the Summary of Benefits and Coverage [SBC]. The benefits are described in more detail in the SBC and it will include additional information about those benefits. Some nuances about the benefits like visit limits and other details are not listed below. You should refer to the SBC for those details about the plan. Click on the "View Summary of Benefits and Coverage" link above to view the SBC.)

In-Network Deductible What is this?
(Note: Unless excepted in the plan's benefit description, you must pay all the costs up to the deductible amount before the plan begins to pay for covered services you use. There may be additional details about the deductible that are not shown below. Please refer to the SBC for additional details.)
Extra Deductible for Drugs What is this? $0
Doctor Visits
Doctor Visit - Preventive Care Copay: No Charge
Doctor Visit - Primary Care Copay: $5.00
Doctor Visit - Specialist Copay: $30.00
Doctor Visit - Well Baby Visits and Care Copay: No Charge
Other Practitioner Office Visit (Nurse, Physician Assistant) Copay: $30.00
Inpatient Hospital Facility Coinsurance: 10.00%
Inpatient Hospital Physician/Surgeon Coinsurance: 10.00%
Outpatient Hospital Facility Copay: $200.00
Outpatient Hospital Physician/Surgeon Copay: $100.00
Inpatient Maternity Services Coinsurance: 10.00%
Emergency Room Services Copay: $50.00
Emergency Medical Transportation Copay: $50.00
Urgent Care Centers or Facilities Copay: $30.00
Plan's Drug Formulary What is this? View Plan's Drug Formulary
Generic Drug on Formulary in a Local Pharmacy Copay: $4.00
Preferred Brand Drug on Formulary in a Local Pharmacy Coinsurance: 20.00%
Non-Preferred Brand Drug on Formulary in a Local Pharmacy Coinsurance: 40.00%
Specialty Drug on Formulary in a Local Pharmacy Coinsurance: 40.00%
Tests & Imaging
Diagnostic Tests (Blood work) Copay: $30.00
X-Rays Copay: $30.00
Imaging (CT/PET Scans, MRI, etc) Copay: $100.00
Mental/Behavioral Health
Mental/Behavioral Health Inpatient Services Coinsurance: 10.00%
Mental/Behavioral Health Outpatient Services Copay: $5.00
Substance Use Disorder Inpatient Coinsurance: 10.00%
Substance Use Disorder Outpatient Copay: $5.00
Vision/Hearing Aids
Routine Eye Exam for Child Copay: $30.00
Eye Glasses for Child Coinsurance: 50.00%
Routine Eye Exam - Adult Not Covered
Hearing Aids Not Covered
Child Dental Coverage
Dental Check-Up for Children Copay: No Charge
Basic Dental Care – Child Coinsurance: 30.00%
Major Dental Care – Child Coinsurance: 50.00%
Orthodontia – Child Coinsurance: 50.00%
Adult Dental Coverage
Basic Dental Care – Adult Not Covered
Major Dental Care – Adult Not Covered
Orthodontia – Adult Not Covered
Accidental Dental Coinsurance: 10.00%
Home and Nursing Care
Home Health Care Services Copay: $30.00
Skilled Nursing Care - Facility Coinsurance: 10.00%
Rehabilitative and habilitative services
Habilitation Services Copay: $30.00
Outpatient Rehabilitation Services Copay: $30.00
Rehabilitative Occupational and Rehabilitative Physical Therapy Copay: $30.00
Rehabilitative Speech Therapy Copay: $30.00
Other Services What is this?
Is HSA Eligible? No
Allergy Testing Copay: $30.00
Chemotherapy Copay: $30.00
Chiropractic Copay: $5.00
Diabetes Education Copay: $5.00
Dialysis Copay: $30.00
Durable Medical Equipment Coinsurance: 10.00%
Hospice Service Coinsurance: 10.00%
Infusion Therapy Copay: $30.00
Nutritional Counseling Copay: $30.00
Prosthetic Devices Coinsurance: 10.00%
Radiation Copay: $30.00
Reconstructive Surgery Coinsurance: 10.00%
Routine Foot Care Not Covered
Treatment for Temporomandibular Joint Disorders Copay: $30.00
Transplant Coinsurance: 10.00%
Weight Loss Programs Not Covered
Wellness Programs What is this?
Asthma Program Not Available
Heart Disease Program Not Available
Depression Program Not Available
Diabetes Program Not Available
High Blood Pressure & Cholesterol Program Not Available
Low Back Pain Program Not Available
Pain Management Program Not Available
Pregnancy Program Not Available
Weight Loss Programs Not Available
Out-of-Network - See Summary of Benefits and Coverage What is this? View Summary of Benefits and Coverage
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