Allegiance HDHP $3500
A lower-premium high-deductible plan paired with a Health Savings Account: Catalis contributes to your HSA.
Plan details
HSA Eligible
Yes
FSA Eligible
No
Family Deductible
$7,000
Deductible & Out-of-Pocket
| Feature | In Network | Out Of Network |
|---|---|---|
| Individual Deductible | $3,500 | $10,500 |
| Family Deductible | $7,000 | $21,000 |
| Coinsurance (Member Pays) | 20% | 50% |
| Individual Out-of-Pocket Max | $8,500 | $23,700 |
| Family Out-of-Pocket Max | $17,000 | $47,400 |
- Feature
- Individual Deductible
- In Network
- $3,500
- Out Of Network
- $10,500
- Feature
- Family Deductible
- In Network
- $7,000
- Out Of Network
- $21,000
- Feature
- Coinsurance (Member Pays)
- In Network
- 20%
- Out Of Network
- 50%
- Feature
- Individual Out-of-Pocket Max
- In Network
- $8,500
- Out Of Network
- $23,700
- Feature
- Family Out-of-Pocket Max
- In Network
- $17,000
- Out Of Network
- $47,400
Medical Services
| Feature | In Network | Out Of Network |
|---|---|---|
| Preventive Care | Covered 100% | 50% after deductible |
| Primary Care Visit | 20% after deductible | 50% after deductible |
| Specialist Visit | 20% after deductible | 50% after deductible |
| Virtual Visit | 20% after deductible | 20% after deductible |
| Telemedicine Other | 20% after deductible | N/A |
| Urgent Care | 20% after deductible | 50% coinsurance after deductible |
| Emergency Room | 20% after deductible (waived if admitted) | 20% after deductible (waived if admitted) |
| Inpatient Hospital | 20% after deductible | 50% after deductible |
| Outpatient Services | 20% after deductible | 50% after deductible |
| Advanced Imaging | 20% after deductible | 50% after deductible |
- Feature
- Preventive Care
- In Network
- Covered 100%
- Out Of Network
- 50% after deductible
- Feature
- Primary Care Visit
- In Network
- 20% after deductible
- Out Of Network
- 50% after deductible
- Feature
- Specialist Visit
- In Network
- 20% after deductible
- Out Of Network
- 50% after deductible
- Feature
- Virtual Visit
- In Network
- 20% after deductible
- Out Of Network
- 20% after deductible
- Feature
- Telemedicine Other
- In Network
- 20% after deductible
- Out Of Network
- N/A
- Feature
- Urgent Care
- In Network
- 20% after deductible
- Out Of Network
- 50% coinsurance after deductible
- Feature
- Emergency Room
- In Network
- 20% after deductible (waived if admitted)
- Out Of Network
- 20% after deductible (waived if admitted)
- Feature
- Inpatient Hospital
- In Network
- 20% after deductible
- Out Of Network
- 50% after deductible
- Feature
- Outpatient Services
- In Network
- 20% after deductible
- Out Of Network
- 50% after deductible
- Feature
- Advanced Imaging
- In Network
- 20% after deductible
- Out Of Network
- 50% after deductible
Pharmacy Benefits
| Tier | Cost |
|---|---|
| Preferred Generic | 20% coinsurance after deductible |
| Preferred Brand | 20% coinsurance after deductible |
| Non Preferred | 20% coinsurance after deductible |
| Specialty | 20% coinsurance after deductible |
- Tier
- Preferred Generic
- Cost
- 20% coinsurance after deductible
- Tier
- Preferred Brand
- Cost
- 20% coinsurance after deductible
- Tier
- Non Preferred
- Cost
- 20% coinsurance after deductible
- Tier
- Specialty
- Cost
- 20% coinsurance after deductible
Plan Notes
- MDLive virtual visit details: www.mdlive.com/allegiance or (877) 753-7992
- Pairs with HSA: Catalis contributes $28.50/semi-monthly (employee only) or $56.50/semi-monthly (employee + dependent)
Plan Contact
Allegiance Member Services (Cigna Network)