Citi Benefits Handbook
CP500 Network Features
Deductible
If you elect to use physicians or other providers in the network, you will need to meet an annual in-network deductible of $500 individual/$1,000 family before any benefit will be paid. Once you meet your deductible, the plan will pay 80% of covered in-network expenses.
The individual deductibles apply to all covered expenses, except preventive care (which is covered at 100% in-network), and must be met each calendar year before any benefits will be paid.
The family deductible represents the most a family will have to pay in individual deductibles in any calendar year. Only covered expenses that count toward your or your dependent's individual deductible can be applied toward the family deductible. The family deductible can be met as follows:
  • Two in a family: Each member must meet the $500 individual deductible; or
  • Three or more in a family: Expenses can be combined to meet the $1,000 family deductible, but no one person can apply more than the individual deductible ($500) toward the family deductible amounts.
Deductible expenses cross-apply between in-network and out-of-network limits.
Coinsurance
Coinsurance refers to the portion of a covered expense that you pay after you have met the deductible. For example, if the plan pays 80% of certain covered expenses, your coinsurance for these expenses is 20%.
Medical Out-of-Pocket Maximum
The out-of-pocket maximum for medical services rendered in the network is $3,000 (individual)/$6,000 (family). This amount represents the most you will have to pay out of your own pocket in a calendar year for in-network services. This amount does not include penalties, charges above the MAA, prescription drug expenses, or services not covered under CP500. Once this out-of-pocket maximum is met, covered medical expenses are payable at 100% of the negotiated rate contracted with the Claims Administrator for the remainder of the calendar year. In-network copayments for medical services also apply to the out-of-pocket maximums; once the out-of-pocket maximum has been satisfied, no additional in-network medical copayments will apply for the remainder of the plan year. Prescription drug copays are subject to a separate out-of-pocket maximum.
Eligible medical expenses within a family can be combined to meet the family out-of-pocket maximum, but no one person can apply more than the individual out-of-pocket maximum amount ($3,000) to the family out-of-pocket maximum ($6,000).
Not all expenses count toward your medical out-of-pocket maximum. Among those that do not count are:
  • Charges above MAA;
  • Penalties;
  • Prescription drug expenses (which count toward the separate prescription drug out-of-pocket maximum); and
  • Charges for services not covered under CP500.
To help you manage the high cost of prescription drugs, there is also a separate annual prescription drug out-of-pocket maximum. Once you reach the prescription drug out-of-pocket maximum $1,500 (individual)/$3,000 (family), the plan pays the full cost of prescription drug expenses for the remainder of the year.
Out-of-pocket maximum expenses cross-accumulate between in-network and out-of-network limits.
Primary Care Physician (PCP)
When seeking primary care services, you should choose a provider from the PCPs in the directory of network providers. You may choose a pediatrician as the PCP for your covered child. Women may also select an OB/GYN without referral from their PCP. A directory of the providers who participate in the CP500 network is available from the Claims Administrator. You may call or visit the Claims Administrator's website:
  • Aetna: www.aetna.com; select the Aetna Open Access, Choice POSII Open Access Plan or call 1 (800) 545-5862
  • Anthem BlueCross BlueShield: www.anthem.com; to access a network provider through the BlueCross BlueShield Association BlueCard® PPO Program, select "Find a Doctor." Enter your search details (provider name, provider specialty, search location,). Enter your identification prefix (which is the first three letters of your member ID located on your ID card). If you do not have your member ID card handy, select your State and your plan, PPO and click on "Search." You will have a variety of search options to help you find a provider who meets your needs. You may also call Anthem at 1 (855) 593-8123.
  • If you live in Metro-New York, Washington D.C./Maryland/Northern Virginia, Georgia, Kansas City, MO, or St. Louis, MO: You have access to an alternate network of providers. Please see your Anthem ID card to get the prefix you should use to search for providers on Anthem's website, or call Anthem's Health Guide Service Team for additional information about alternate networks and information on how to locate a participating provider.
  • Once you meet your deductible, the plan will pay 80% of covered in-network expenses.
Specialists
If you need the services of a specialist, you may seek care from a specialist directly without a referral. Once you meet your deductible, the plan will pay 80% of covered in-network expenses.
Aetna Aexcel Specialists
Aexcel is a designation within Aetna's network that includes specialists who have demonstrated effectiveness in the delivery of care based on defined measures of clinical performance and cost-efficiency. Currently, there are Aexcel-designated physicians in 12 medical specialty categories: Cardiology, cardiothoracic surgery, gastroenterology, general surgery, obstetrics and gynecology, orthopedics, otolaryngology, neurology, neurosurgery, plastic surgery, urology, and vascular surgery.
Aexcel-designated specialists are currently available to members in AZ, CA, CO, CT, DC, DE, FL, GA, IL, IN, KS, KY, MD, MA, ME, MI, MO, NJ, NV, NY, OH, OK, PA, TX, VA, and WA.
When you visit an Aexcel specialist you do not need a referral. The plan will pay 90% of covered expenses after your deductible for Aexcel specialists. To find an Aexcel specialist visit, www.aetna.com/docfind; select the Aetna Standard Plans, Aetna Select, and look for the providers listed with the blue star. This blue star identifies the Aexcel specialists.
Allergist
When you see an in-network allergist, once you meet your deductible, you will be expected to pay 20% of the first office visit. If you receive an allergy injection only (without a physician's office visit charge), benefits will be covered at 100%. If services are for other than an allergy injection, coinsurance will apply.
Preventive Care
Preventive care services are covered at 100%, no deductible to meet for the CP500. For additional information on what is considered to be preventive care, see "Medical Options at a Glance."
Preventive care services include:
  • Routine physical exams: Well-child care and adult care, performed by the patient's PCP at a frequency based on American Medical Association guidelines. For frequency guidelines, contact your Claims Administrator;
  • Routine diagnostic tests, for example, CBC (complete blood count), cholesterol blood test, and urinalysis;
  • Well-child services and routine pediatric care; and
  • Routine well-woman exams.
In addition, CP500 will cover both cancer-screening tests and well-adult and well-child immunizations performed by in-network providers at 100%, not subject to deductible. Routine cancer screenings are:
  • Pap smear performed by an in-network provider annually;
  • Mammogram;
  • Sigmoidoscopy;
  • Colonoscopy; and
  • Prostatic-specific antigen (PSA) screening annually with a digital rectal exam in men age50 and older.
Preventive care services covered in the network at 100% will be reviewed annually and updated prospectively to comply with recommendations of the:
  • American Medical Association;
  • United States Preventive Care Task Force;
  • Advisory Committee on Immunization Practices that have been adopted by the Director of the Centers for Disease Control and Prevention; and
  • Comprehensive Guidelines Supported by the Health Resources and Services Administration.
Routine Care
CP500 offers additional coverage for routine care services to help in the early detection of health problems.
  • Routine vision exam:
    • In-network: Covered at 100%, not subject to deductible; one exam per calendar year, performed by a network ophthalmologist or optometrist;
    • Out-of-network: Covered at 100%, not subject to deductible up to $250 per calendar year1, then covered at 60% of MAA, not subject to deductible; limited to one exam per calendar year.
1 Combined maximum with well-adult and well-child visits, routine cancer screenings and routine hearing
Aetna: covered expenses include a complete routine eye exam that includes refraction and glaucoma testing. A routine eye exam does not include a contact lens exam.
  • Routine hearing exam:
    • In-network: Covered at 100%, not subject to deductible; one exam per calendar year, performed by a network provider.
    • Out-of-network: Covered at 100%, not subject to deductible up to $250 per calendar year1, then covered at 60% of MAA, not subject to deductible; limited to one exam per calendar year.
Aetna: covered expenses include charges for an audiometric hearing exam if the exam is performed by:
  • A physician certified as an otolaryngologist or otologist; or
  • An audiologist who:
    • Is legally qualified in audiology; or
    • Holds a certificate of Clinical Competence in Audiology from the American Speech and Hearing Association (in the absence of any applicable licensing requirements); and
    • Performs the exam at the written direction of a legally qualified otolaryngologist or otologist.
Hospital
Hospital care (inpatient and outpatient) received through a preferred provider is covered at 80% for covered services after the deductible has been met. Services provided by a network physician in an out-of-network hospital are covered at the in-network benefit level.
Note: Any charges submitted by an out-of-network hospital would be treated as out-of-network claims. Precertification of an inpatient admission is required. Precertification is also required for certain outpatient procedures and services.
Emergency Care
Services provided in a hospital emergency room from a network provider are covered at 80% for covered services after the deductible has been met.
Aetna: When emergency care is necessary, please follow the guidelines below:
  • Seek the nearest emergency room, or dial 911 or your local emergency response service for medical and ambulatory assistance. If possible, call your physician provided a delay would not be detrimental to your health.
  • After assessing and stabilizing your condition, the emergency room should contact your physician to obtain your medical history to assist the emergency physician in your treatment.
  • If you are admitted to an inpatient facility, notify your physician as soon as reasonably possible.
  • If you seek care in an emergency room for a non-emergency condition, the plan will not cover the expenses you incur.
Urgent Care
Urgent care centers are listed in the provider directory available on the Claims Administrators' websites. You do not need a referral or any pre-certification to use an urgent care center. Services provided by an urgent care center are covered at 80% for covered services after the deductible has been met.
Aetna: Call your PCP if you think you need urgent care. You may contact any physician or urgent care provider, in- or out-of-network, for an urgent care condition if you cannot reach your physician. If it is not feasible to contact your physician, please do so as soon as possible after urgent care is provided. In-network providers are required to provide urgent care coverage 24 hours a day, including weekends and holidays. If you need help finding an urgent care provider you may call Member Services at the toll-free number on your I.D. card, or you may access Aetna's online provider directory at www.aetna.com. Follow-up care is not considered an emergency or urgent condition and is not covered as part of any emergency or urgent care visit. Once you have been treated and discharged, you should contact your physician for any necessary follow-up care.
Anthem BCBS: Anthem uses actual charges billed, not MAA, when determining plan payment for an out-of-network provider.
Charges Not Covered
An in-network provider contracts with the CP500 Claims Administrator to participate in the network. Under the terms of this contract, an in-network provider may not charge you or the Claims Administrator for the balance of the charges above the contracted negotiated rate for covered services.
You may agree with the in-network provider to pay any charges for services or supplies not covered under CP500 or not approved by CP500. In that case, the in-network provider may bill charges to you. However, these charges are not covered expenses under CP500 and are not payable by the Claims Administrator.
For information about how to file a claim or appeal a denied claim, see "Claims and Appeals for Aetna Medical Plans" or "Claims and Appeals for Anthem BlueCross BlueShield Medical Plans."