Allegiance Copay Plan
A traditional copay plan with $0 in-network deductible: predictable costs for everyday care.
Plan details
HSA Eligible
No
FSA Eligible
Yes
Family Deductible
$0
Deductible & Out-of-Pocket
| Feature | In Network | Out Of Network |
|---|---|---|
| Individual Deductible | $0 | $9,000 |
| Family Deductible | $0 | $18,000 |
| Coinsurance (Member Pays) | 100% | 50% |
| Individual Out-of-Pocket Max | $9,000 | $18,000 |
| Family Out-of-Pocket Max | $18,000 | $36,000 |
- Feature
- Individual Deductible
- In Network
- $0
- Out Of Network
- $9,000
- Feature
- Family Deductible
- In Network
- $0
- Out Of Network
- $18,000
- Feature
- Coinsurance (Member Pays)
- In Network
- 100%
- Out Of Network
- 50%
- Feature
- Individual Out-of-Pocket Max
- In Network
- $9,000
- Out Of Network
- $18,000
- Feature
- Family Out-of-Pocket Max
- In Network
- $18,000
- Out Of Network
- $36,000
Medical Services
| Feature | In Network | Out Of Network |
|---|---|---|
| Preventive Care | Covered 100% | 50% after deductible |
| Primary Care Visit | $10 copay | 50% |
| Specialist Visit | $20 copay | 50% |
| Virtual Visit | 100%, deductible waived | 100%, deductible waived |
| Telemedicine Other Than MDLive | $10 copay PCP / $20 copay Specialist | N/A |
| Urgent Care | $35 copay | 50% after deductible |
| Emergency Room | $250 copay (waived if admitted) | $250 copay (waived if admitted) |
| Inpatient Hospital | All major services must apply to OOP max | 50% after deductible |
| Outpatient Services | All major services must apply to OOP max | 50% after deductible |
| Advanced Imaging | All major services must apply to OOP max | 50% after deductible |
- Feature
- Preventive Care
- In Network
- Covered 100%
- Out Of Network
- 50% after deductible
- Feature
- Primary Care Visit
- In Network
- $10 copay
- Out Of Network
- 50%
- Feature
- Specialist Visit
- In Network
- $20 copay
- Out Of Network
- 50%
- Feature
- Virtual Visit
- In Network
- 100%, deductible waived
- Out Of Network
- 100%, deductible waived
- Feature
- Telemedicine Other Than MDLive
- In Network
- $10 copay PCP / $20 copay Specialist
- Out Of Network
- N/A
- Feature
- Urgent Care
- In Network
- $35 copay
- Out Of Network
- 50% after deductible
- Feature
- Emergency Room
- In Network
- $250 copay (waived if admitted)
- Out Of Network
- $250 copay (waived if admitted)
- Feature
- Inpatient Hospital
- In Network
- All major services must apply to OOP max
- Out Of Network
- 50% after deductible
- Feature
- Outpatient Services
- In Network
- All major services must apply to OOP max
- Out Of Network
- 50% after deductible
- Feature
- Advanced Imaging
- In Network
- All major services must apply to OOP max
- Out Of Network
- 50% after deductible
Pharmacy Benefits
| Tier | Cost |
|---|---|
| Preferred Generic | $5 copay |
| Preferred Brand | $30 copay |
| Non Preferred | $100 copay |
| Specialty | 30% |
- Tier
- Preferred Generic
- Cost
- $5 copay
- Tier
- Preferred Brand
- Cost
- $30 copay
- Tier
- Non Preferred
- Cost
- $100 copay
- Tier
- Specialty
- Cost
- 30%
Plan Notes
- Virtual Visit (MDLive): 100%, deductible waived. Visit https://www.mdlive.com/allegiance or call (877) 753-7992.
- Calendar Year Prescription Drug Deductible: N/A
Plan Contact
Allegiance Member Services (Cigna Network)