Allegiance PPO $1500
An in-network-only PPO plan with lower copays and a $1,500 deductible. No out-of-network coverage.
Plan details
HSA Eligible
No
FSA Eligible
Yes
Family Deductible
$4,500
Deductible & Out-of-Pocket
| Feature | In Network |
|---|---|
| Individual Deductible | $1,500 |
| Family Deductible | $4,500 |
| Coinsurance (Member Pays) | 20% |
| Individual Out-of-Pocket Max | $9,000 |
| Family Out-of-Pocket Max | $18,000 |
- Feature
- Individual Deductible
- In Network
- $1,500
- Feature
- Family Deductible
- In Network
- $4,500
- Feature
- Coinsurance (Member Pays)
- In Network
- 20%
- Feature
- Individual Out-of-Pocket Max
- In Network
- $9,000
- Feature
- Family Out-of-Pocket Max
- In Network
- $18,000
Medical Services
| Feature | In Network |
|---|---|
| Preventive Care | Covered 100% |
| Primary Care Visit | $30 copay |
| Specialist Visit | $60 copay |
| Virtual Visit MDLive | 100%, deductible waived |
| Telemedicine Other Primary Care Or Specialty | 100% after PCP $10 or $20 SPC, deductible waived |
| Telemedicine Other Mental Health Or Substance Use | 100% after $10 copay, deductible waived |
| Urgent Care | $75 copay |
| Emergency Room | 20% coinsurance after deductible (waived if admitted) |
| Inpatient Hospital | 20% after deductible |
| Outpatient Services Hospital Based | 20% after deductible |
| Outpatient Services Free Standing Facility | $150 + 20% after deductible |
| Advanced Imaging | 20% after deductible |
- Feature
- Preventive Care
- In Network
- Covered 100%
- Feature
- Primary Care Visit
- In Network
- $30 copay
- Feature
- Specialist Visit
- In Network
- $60 copay
- Feature
- Virtual Visit MDLive
- In Network
- 100%, deductible waived
- Feature
- Telemedicine Other Primary Care Or Specialty
- In Network
- 100% after PCP $10 or $20 SPC, deductible waived
- Feature
- Telemedicine Other Mental Health Or Substance Use
- In Network
- 100% after $10 copay, deductible waived
- Feature
- Urgent Care
- In Network
- $75 copay
- Feature
- Emergency Room
- In Network
- 20% coinsurance after deductible (waived if admitted)
- Feature
- Inpatient Hospital
- In Network
- 20% after deductible
- Feature
- Outpatient Services Hospital Based
- In Network
- 20% after deductible
- Feature
- Outpatient Services Free Standing Facility
- In Network
- $150 + 20% after deductible
- Feature
- Advanced Imaging
- In Network
- 20% after deductible
Pharmacy Benefits
| Tier | Cost |
|---|---|
| Preferred Generic | $5 copay |
| Preferred Brand | $45 copay |
| Non Preferred | $90 copay |
| Specialty | 25% coinsurance, up to $450 per Rx |
- Tier
- Preferred Generic
- Cost
- $5 copay
- Tier
- Preferred Brand
- Cost
- $45 copay
- Tier
- Non Preferred
- Cost
- $90 copay
- Tier
- Specialty
- Cost
- 25% coinsurance, up to $450 per Rx
Plan Notes
- IMPORTANT: This plan DOES NOT include Out-of-Network (OON) benefits. If you receive care from out-of-network providers, you are responsible for the full cost.
- MDLive virtual visit details: www.mdlive.com/allegiance or (877) 753-7992
Plan Contact
Allegiance Member Services (Cigna Network)