Citi Benefits Handbook
HDHP at a Glance
Note: For in-network covered expenses, the plan pays a percentage of discounted rates while for out-of-network charges, the plan pays a percentage of the maximum allowed amount (MAA). See the Glossary section for a definition of MAA, which is sometimes referred to as "Recognized Charges."
Type of service
In-network
Out-of-network
Annual deductible (in-network and out-of-network combined)
  • Single
  • $1,800
  • Includes prescription drug expenses
  • $2,800
  • Includes prescription drug expenses
  • Family
  • $3,600
  • Includes prescription drug expenses
  • $5,600
  • Includes prescription drug expenses
Annual out-of-pocket maximum (includes deductible, medical/prescription drug coinsurance, and medical/prescription drug copayments)
  • Single
  • $5,000
  • Includes prescription drug expenses
  • $7,500
  • Includes prescription drug expenses
  • Family1
  • $10,000 ($6,850 per individual)
  • Includes prescription drug expenses
  • $15,000 ($15,000 per individual)
  • Includes prescription drug expenses
Lifetime maximum
  • None
  • None
Professional care (in office)
  • PCP visits
  • 80% after deductible2
  • 60% of MAA after deductible2
  • Specialist visits
  • 80% after deductible2
  • Aetna: 90% after deductible2 for Aexcel specialists
  • 60% of MAA after deductible2
  • Allergy treatment
  • 80% after deductible2
  • 60% of MAA after deductible2
Preventive care (subject to frequency limits)
  • Well-adult visits and routine immunizations
  • 100%, not subject to deductible
  • 100% of MAA, not subject to deductible
  • Well-child visits and routine immunizations
  • Routine cancer screenings (Pap smear, mammography, sigmoidoscopy, colonoscopy, PSA screening)
  • Contraceptive devices
  • 100%, not subject to deductible, for diaphragms and Mirena, an implantable device and at least one in each category of the other applicable forms of contraception in the FDA Birth Control Guide that are not covered under the Citi prescription drug program (see "Preventive Care"). All other implantable devices will be covered at 80% after deductible2
  • 60% of MAA after deductible2
  • Voluntary sterilization — including tubal ligation, sterilization implants and surgical sterilizations
  • 100%, not subject to deductible. Male sterilization services (e.g., vasectomies) are covered at 80% after deductible2
  • 60% of MAA after deductible2
Routine care (subject to frequency limits)
  • Routine vision exam
  • 100%, not subject to deductible; limit one exam per calendar year
  • 100% of MAA, not subject to deductible; limit one exam per calendar year
  • Routine hearing exam
  • 100%, not subject to deductible; limit one exam per calendar year
  • 100% of MAA, not subject to deductible; limit one exam per calendar year
Hospital inpatient and outpatient
  • Semiprivate room and board, doctor's charges, lab, X-ray, radiology, and surgical care
  • 80% after deductible2; precertification required for hospitalization and certain outpatient procedures and services
  • 60% of MAA after deductible2; precertification required for hospitalization and certain outpatient procedures and services
Non-routine outpatient
  • Lab, X-ray, and radiology
  • 80% after deductible2; precertification is required for certain outpatient procedures
  • 60% of MAA after deductible2; precertification is required for certain outpatient procedures
Maternity care
  • Physician office visit
  • 80% after deductible2
  • 60% of MAA after deductible2
  • Hospital delivery
  • 80% after deductible2
  • 60% of MAA after deductible2
Emergency care (no coverage if not a true emergency)
  • Hospital emergency room (includes emergency room facility and professional services provided in the emergency room)
  • 80% after deductible2; precertification required if admitted
  • 80% after deductible2; precertification required if admitted
  • Urgent care facility
  • 80% after deductible2
  • 80% of MAA after deductible2
Emergency Transportation Services (no coverage when used as routine transportation to receive inpatient or outpatient services)
 
80% after deductible2
Anthem: Pre-certification required for air transport
80% of MAA after deductible; pre-certification required for inter-facility transfers
Outpatient short-term rehabilitation
Physical/occupational therapy (combined):
Limited to 60 visits a year in-network and out-of-network combined; you may be eligible for additional visits with plan approval after a medical necessity review
  • 80% after deductible2
  • 70% after deductible2 for visits approved for medical necessity above plan limits
  • 60% after deductible2
  • 50% of MAA after deductible2 for visits approved for medical necessity above plan limits
Speech therapy:
Limited to 90 visits a year in-network and out-of-network combined; you may be eligible for additional visits with plan approval after a medical necessity review
  • 80% after deductible2
  • 70% after deductible2 for additional visits above plan limits
  • 60% after deductible2
  • 50% of MAA after deductible2 for additional visits above plan limits
Other services
  • Infertility treatment
  • Covered up to a $24,000 family lifetime medical maximum. The lifetime maximum will be coordinated among all non-HMO/PPO medical options.
  • 80% after deductible2; precertification required
  • Prescriptions covered through Express Scripts up to a $7,500 lifetime pharmacy maximum per family
  • Covered up to a $24,000 family lifetime medical maximum. The lifetime maximum will be coordinated among all non-HMO/PPO medical options.
  • 60% after deductible2; precertification required
  • Prescriptions covered through Express Scripts up to a $7,500 lifetime pharmacy maximum per family
Prescription drugs (see the Prescription Drugs section)
Mental health and substance abuse (see "Mental Health/Substance Abuse In- and Out-of-Network")
1 The family deductible can be satisfied as a family or by an individual within the family. Each of your covered family members has an individual out-of-pocket maximum of only $6,850 for in-network coverage. After reaching that amount, your plan will cover 100% of that individual's in-network health care expenses for the rest of the year. Once the $10,000 family in-network out-of-pocket maximum is met, your plan will cover 100% of the family's in-network health care expenses for the rest of the year.
2 The plan will pay this percentage of the cost after you first pay the full deductible of the plan. The deductible can be paid with after-tax dollars, such as cash or check, or with before-tax dollars if you have available funds in a HSA.