Deductibles and Out-of-Pocket Maximums

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Deductibles

Here’s how much you’ll have to pay out-of-pocket up-front for the year before the Plan begins to pay coinsurance benefits.

  ALLSTATE MEDICAL SAVINGS PLAN ALLSTATE MEDICAL VALUE PLAN
  In-Network Out-of-Network In-Network Out-of-Network
Individual $2,000* $4,000* $3,000 $6,000
Family $4,000 $8,000 $6,000 $12,000
When coinsurance begins You Only coverage
After individual deductible is met:
$2,000 in-network
$4,000 out-of-network

If you cover dependents After family deductible is met:
$4,000 in-network
$8,000 out-of-network
You Only coverage
After individual deductible is met:
$3,000 in-network
$6,000 out-of-network

If you cover dependents
For an individual, after that individual’s deductible is met:
$3,000 in-network
$6,000 out-of-network

For all family members, after family deductible is met by any combination of family members:
$6,000 in-network
$12,000 out-of-network

Please Note: If you receive a preventive prescription that is subject to a copayment, the copayment does not count towards your deductible.

Out-of-Pocket Maximums (OOPM)

  ALLSTATE MEDICAL SAVINGS PLAN ALLSTATE MEDICAL VALUE PLAN
  In-Network Out-of-Network In-Network Out-of-Network
Individual $3,000 $6,000 $4,500 $9,000
Family $6,000 $12,000 $9,000 $18,000
When Plan begins paying 100% You Only coverage
After individual OOPM is met:
$3,000 in-network
$6,000 out-of-network

All other coverage tiers
After family OOPM is met:
$6,000 in-network
$12,000 out-of-network
You Only coverage
After individual OOPM is met:
$3,000 in-network
$6,000 out-of-network

All other coverage tiers
For an individual, after that individual’s OOPM is met:
$4,500 in-network
$9,000 out-of-network

For all family members, after family OOPM is met by any combination of family members:
$9,000 in-network
$18,000 out-of-network
If you require a personal response, please contact the appropriate party.