Citi Benefits Handbook
Medical Options at a Glance
Although each of the Citi medical plans offers comprehensive coverage, there are differences between the plans. Some high-level information is available in the table below. For HMO information, visit "2017 Insured HMOs" or see the Health Plan Comparison Charts on Your Benefits Resources™ (YBR™). To access YBR™, visit TotalComp@Citi at www.totalcomponline.com, available from the Citi intranet and the Internet.
Note: Precertification is required for certain procedures and services both in-network and out-of-network. Penalties may apply. Call your plan at the number listed on the back of your ID card for details.
For in-network covered expenses, the plans pay a percentage of discounted rates while for out-of-network charges, the plans pay 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." For out-of-network services, providers may balance bill you for the charges above MAA, and you are responsible for those charges.
Remember: You can save on out-of-pocket costs by using providers who participate in the plan's network. If you use an out-of-network doctor, you'll pay more when you need care.
ChoicePlan 500
Administered by Aetna and
Anthem BlueCross BlueShield
Oxford Health Plans PPO
(Available in CT, NJ, and NY only)
In-network
Out-of-network
In-network
Out-of-network
Annual deductible
Individual
$5001
$1,5001
$500
$1,500
Maximum per family
$1,0001
$3,0001
$1,000
$3,000
Annual medical out-of-pocket maximum (includes medical deductible, medical coinsurance, and medical copayments)
Note: There is a separate out-of-pocket maximum for prescription drug expenses.
Individual
$3,0001
$6,0001
$3,000
$6,000
Maximum per family
$6,0001
$12,0001
$6,000
$12,000
Lifetime maximum
None
None
None
None
Professional care (in office)
Doctor/primary care physician (PCP) visits
80% after deductible2
60% of MAA after deductible2
80% after deductible2
60% of MAA after deductible2
Specialist visits
80% after deductible; Aetna: 90% after deductible2for Aexcel specialists
60% of MAA after deductible2
80% after deductible2
60% of MAA after deductible2
Preventive care (subject to frequency limits)
Well-adult visits
100%, not subject to deductible
100% of MAA, not subject to deductible up to $250 combined maximum3, then covered at 60% of MAA, not subject to deductible
100%, not subject to deductible
100% of MAA, not subject to deductible up to $250 combined maximum3, then covered at 60% of MAA, not subject to deductible
Well-child visits
100%, not subject to deductible
100% of MAA, not subject to deductible up to $250 combined maximum3, then covered at 60% of MAA, not subject to deductible
100%, not subject to deductible
100% of MAA, not subject to deductible up to $250 combined maximum3, then covered at 60% of MAA, not subject to deductible
Adult and child routine immunizations
100%, not subject to deductible
60% of MAA, not subject to deductible
100%, not subject to deductible
60% of MAA, not subject to deductible
Routine cancer screenings
(PAP test, mammogram, sigmoidoscopy, colonoscopy, PSA screening)
100%, not subject to deductible
100% of MAA, not subject to deductible up to $250 combined maximum3, then covered at 60% of MAA, not subject to deductible
100%, not subject to deductible
100% of MAA, not subject to deductible up to $250 combined maximum3, then covered at 60% of MAA, not subject to deductible
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
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
(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
100%, not subject to deductible. Male sterilization services (e.g., vasectomies) are covered at 80% after deductible2
60% of MAA after deductible2
Hospital emergency room (no coverage in any medical option if not a true emergency)
 
80% after deductible2 precertification is required for hospitalization and certain outpatient procedures
80% of MAA after deductible2 precertification is required for hospitalization and certain outpatient procedures
80% after deductible2 precertification is required for hospitalization and certain outpatient procedures
80% after deductible2precertification is required for hospitalization and certain outpatient procedures
Emergency Transportation Services (no coverage when used as routine transportation to receive inpatient or outpatient services)
 
100%, not subject to the deductible; for transport to and from the nearest medical facility qualified to give the required treatment; precertification required for air transport
100%, not subject to the deductible; for transport to and from the nearest medical facility qualified to give the required treatment; pre-certification required for inter-facility transfers
Urgent care center
 
80% after deductible2
80% of MAA after deductible2
80% after deductible2
80% of MAA after deductible2
Hospital (inpatient and outpatient services)
Semiprivate room and board, doctor's charges, lab, radiology, and X-ray
80% after deductible2; precertification required for hospitalization and certain outpatient procedures
60% of MAA after deductible2; precertification required for certain outpatient procedures
80% after deductible2; precertification required for hospitalization and certain outpatient procedures
60% of MAA after deductible2; precertification required for hospitalization and certain outpatient procedures
Anesthesia
80% after deductible2
60% of MAA after deductible2
80% after deductible2
60% of MAA after deductible2
Non-routine outpatient
Lab, radiology, and X-ray
80% after deductible2; precertification required for certain outpatient procedures
60% of MAA after deductible2; precertification required for certain outpatient procedures
100%, not subject to deductible if performed in an office setting (or in-network facility for lab services); 80% after deductible2if performed in another place of service; precertification required for certain outpatient procedures
60% of MAA after deductible2precertification required for certain outpatient procedures
Mental health and substance abuse
Inpatient
80% after deductible2; precertification required
60% of MAA after deductible2; precertification required
80% after deductible2; precertification required
60% of MAA after deductible2; precertification required
Outpatient
80% after deductible2, precertification required for certain outpatient procedures
60% of MAA after deductible2, precertification required for certain outpatient procedures
80% after deductible2; precertification required for certain outpatient procedures
60% of MAA after deductible2 precertification required for certain outpatient procedures
Therapies
Physical/occupational therapy (combined):
Limited to 60 visits per plan year for in-network and out-of-network combined
Aetna and Anthem: You may be eligible for additional visits at a lower benefit level with plan approval after a medical necessity review
Oxford: Limited to 90 visits per plan year for physical/speech/occupational therapy in-network and out-of-network combined.
80% after deductible2; 70% after deductible2for approved visits over plan limits
60% of MAA after deductible2; 50% of MAA after deductible2for approved visits over plan limits
80% after deductible2; 60% after deductible2 for approved visits over plan limits
60% of MAA after deductible2, 50% of MAA after deductible2 for approved visits over plan limits
Speech therapy:
Limited to 90 visits per plan year for in-network and out-of-network combined
Aetna and Anthem: You may be eligible for additional visits at a lower benefit level with plan approval after a medical necessity review
Oxford: You may be eligible for additional visits at a lower benefit level with plan approval after a medical necessity review
80% after deductible2; 70% after deductible2 for additional visits over plan limits
60% of MAA after deductible2; 50% of MAA after deductible2 for additional visits over plan limits
80% after deductible2; 60% after deductible2 for approved visits over plan limits
60% of MAA after deductible2; 50% of MAA after deductible2 for approved visits over plan limits
Chiropractic therapy:
Limited to 20 visits per plan year for in-network and out-of-network combined
80% after deductible2
60% of MAA after deductible2
80% after deductible2; precertification required
60% of MAA after deductible2; precertification required
Acupuncture
Must be administered by a medical doctor or a licensed acupuncturist
80% after deductible2
60% of MAA after deductible2
80% after deductible2
60% of MAA after deductible2
Applied behavioral analysis therapy
80% after deductible
60% of MAA after deductible.
80% after deductible
60% of MAA after deductible.
1 The annual deductible and out-of-pocket maximum combine in-network and out-of-network expenses.
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 Health Care Spending Account (HCSA).
3 Combined maximum benefit applies to well-adult visits, well-child visits, routine cancer screenings, routine hearing, and routine vision. The maximum is measured on a calendar year basis.
High Deductible Health Plan (HDHP)
Administered by Aetna and Anthem BlueCross BlueShield
 
In-network
Out-of-network
Annual deductible (in-network and out-of-network combined)
Individual
$1,8001
Includes prescription drug expenses
$2,8001
Includes prescription drug expenses
Maximum per family (no benefits will be paid to an individual until the family deductible has been met)
$3,6001
Includes prescription drug expenses
$5,6001
Includes prescription drug expenses
Annual out-of-pocket maximum (includes deductible, medical and prescription drug coinsurance and medical and prescription drug copayments; in-network and out-of-network combined)
Individual
$5,000
Includes prescription drug expenses
$7,500
Includes prescription drug expenses
Maximum per family2
$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)
Doctor/primary care physician (PCP) visits
80% after deductible3
60% of MAA after deductible3
Specialist visits
80% after deductible3
Aetna: 90% after deductible for Aexcel specialists
60% of MAA after deductible3
Preventive care (subject to frequency limits)
Well-adult visits
100%, not subject to deductible
100% of MAA, not subject to deductible
Well-child visits
100%, not subject to deductible
100% of MAA, not subject to deductible
Adult and child immunizations
100%, not subject to deductible
100% of MAA, not subject to deductible
Routine cancer screenings
(PAP test, mammogram, sigmoidoscopy, colonoscopy, PSA screening)
100%, not subject to deductible
100% of MAA, not subject to deductible
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 deductible3
60% of MAA after deductible3
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 deductible3
60% of MAA after deductible3
Hospital emergency room (no coverage in any medical option if not a true emergency)
 
80% after deductible3; precertification required if admitted
80% after deductible3; precertification required if admitted
Emergency Transportation Services (no coverage when used as routine transportation to receive inpatient or outpatient services)
 
80% after deductible3
Anthem: Pre-certification required for air transport
80% of MAA after deductible; pre-certification required for inter-facility transfers
Urgent care center
 
80% after deductible3
80% of MAA after deductible
Hospital (inpatient and outpatient services)
Semiprivate room and board, doctor's charges, lab, radiology, and X-ray
80% after deductible3; precertification required for hospitalization and certain outpatient procedures
60% of MAA after deductible3;
precertification required for hospitalization and certain outpatient procedures
Anesthesia
80% after deductible3
60% of MAA after deductible3
Non-routine outpatient
Lab, radiology, and X-ray
80% after deductible3;
precertification required for certain outpatient procedures
60% of MAA after deductible3;
precertification required for certain outpatient procedures
Mental health and substance abuse
Inpatient
80% after deductible3, precertification required
60% of MAA after deductible3; precertification required
Outpatient
80% after deductible3
60% of MAA after deductible3
Therapies
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 deductible3;
70% after deductible3 for approved visits over plan limits
60% of MAA after deductible3;
50% of MAA after deductible3 for approved visits over 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 deductible3;
70% after deductible3 for additional visits over plan limits
60% of MAA after deductible3;
50% of MAA after deductible3 for additional visits over plan limits
Chiropractic therapy:
Limited to 20 visits a year in-network and out-of-network combined
80% after deductible3
60% of MAA after deductible3
Acupuncture
Must be administered by a medical doctor or a licensed acupuncturist
80% after deductible3
60% of MAA after deductible3
Applied behavioral analysis therapy
80% after deductible3
60% of MAA after deductible3
1 The annual deductible combines in-network and out-of-network expenses.
2 In the HDHP, the out-of-network family out-of-pocket maximum can be satisfied as a family or by an individual within the family. For In-network services, each of your covered family members has an individual out-of-pocket maximum of only $6,850. 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.
3 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 Health Savings Account (HSA).