Citi Benefits Handbook
Prescription Drug Benefits at a Glance
PRESCRIPTION DRUG BENEFITS
 
ChoicePlan 500
High Deductible Health Plan1
Oxford PPO
Annual deductible (in-network and out-of-network combined in ChoicePlan 500 and Oxford PPO)
Individual
$100 per person (prescription drug deductible)
$1,800 in-network/$2,800 out of network; includes medical expenses
$100 maximum (prescription drug deductible)
Maximum per family
$200 family maximum (prescription drug deductible)
$3,600 in-network/$5,600 out of network; includes medical expenses
(no benefits will be paid to an individual until the family deductible has been met)
$200 family maximum (prescription drug deductible)
Annual out of pocket maximum
ChoicePlan 500 and Oxford PPO: Annual prescription drug out-of-pocket maximum includes prescription deductible, prescription coinsurance and prescription copayments. In-network and out-of-network are combined. Note: This is separate from the annual medical out-of-pocket maximum.
Eligible prescription 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 ($1,500) to the family out-of-pocket maximum ($3,000).
High Deductible Health Plan: Prescription drug expenses count toward the medical annual out-of-pocket maximum.
Keep in mind, you will still pay 100% of the prescription cost after the out-of-pocket maximum is met after the third fill of a maintenance prescription at a retail pharmacy or after the second fill of a specialty medication through a retail pharmacy.
Individual
$1,500 per person (prescription drug out-of-pocket maximum)
$5,000 in-network/$7,500 out of network, includes medical expenses
$1,500 per person (prescription drug out-of-pocket maximum)
Maximum per family
$3,000 family maximum (prescription drug out-of-pocket maximum)
$10,000 ($6,850 per individual) in-network/$15,000 ($15,000 per individual) out of network, includes medical expenses
$3,000 family maximum (prescription drug out-of-pocket maximum)
Copayment/Coinsurance — In-network retail pharmacy
Copayment/coinsurance for up to a 34-day supply at an in-network retail pharmacy, after you meet your deductible. You may have the same maintenance prescription filled up to three times at a retail pharmacy; on the fourth fill, you will pay 100% of the cost of the medication. However, this medication will be available from home delivery for your 90-day copay.2
  • Generic drug3
$10
  • Preferred brand-name drug4
$30
  • Non-preferred brand-name drug
50% of the cost of the drug with a minimum payment of $50 up to a maximum of $150. If the cost of the drug is less than $50, you will pay the cost of the prescription drug.
  • Contraceptives (hormonal and emergency)
Generics: not subject to annual deductible, and no cost to you
Brand name drugs: subject to the annual deductible and applicable preferred or non-preferred cost share requirement
Note: If you cannot take generics, brand-name drugs will be available at no cost to you if the prescriber writes "Dispense as written" on the prescription.
Copayment/Coinsurance — Home Delivery program
Copayment/coinsurance for a 90-day supply through the Express Scripts Home Delivery program after you meet your deductible
  • Generic drug3
$20
  • Preferred brand-name drug4
$75
  • Non-preferred brand-name drug
50% of the cost of the drug with a minimum payment of $125 to a maximum of $375
  • Oral contraceptives (hormonal and emergency)
Generics: not subject to annual deductible, and no cost to you
Brand name drugs: subject to the annual deductible and applicable preferred or non-preferred cost share requirement
Note: If you cannot take generics, brand-name drugs will be available at no cost to you if the prescriber writes "Dispense as written" on the prescription.
Copayment/Coinsurance — Specialty medication
Copayment/coinsurance for a 30-day supply of specialty medication through the Accredo Specialty Pharmacy after you meet your deductible5
  • Generic drug3
$20
  • Preferred brand-name drug4
25% of the cost of the drug with a minimum payment of $50 to a maximum of $150
  • Non-preferred brand-name drug
50% of the cost of the drug with a minimum payment of $100 to a maximum of $250
Out-of-network benefits
Benefits at an out-of-network pharmacy
Reimbursed at the contracted rate after you have met the annual deductible and paid the applicable copay
Lifetime maximum benefit for fertility drugs
Fertility drugs are limited to $7,500 per lifetime per covered family
1 In the High Deductible Health Plan (HDHP), you must meet your combined medical/prescription drug deductible before the Program will pay benefits, except for certain preventive drugs. To determine if your medication is considered preventive, visit www.express-scripts.com. Your cost for these preventive drugs is the applicable copayment or coinsurance, which will count toward your out-of-pocket maximum.
2 Retail pharmacy purchases are not reimbursable under the Program after three refills of the same maintenance drug.
3 The use of generic equivalents whenever possible (through both the retail and Express Scripts Home Delivery programs) is more cost-effective. Ask your medical professional about this distinction. If you request a brand-name drug and a generic alternative is available, you will pay the difference between the cost of the brand-name drug and the generic drug in addition to the copayment for the generic drug.
4 Citi does not determine preferred brand-name drugs. Rather, Express Scripts brings together an independent group of practicing physicians and pharmacists who meet quarterly to review the preferred brand-name formulary list and make determinations based on current clinical information. Call Express Scripts at 1 (800) 227-8338 or visit www.express-scripts.com for a copy of its Preferred Formulary (updated at least quarterly).
5 Except in case of an emergency, each prescription for specialty medications can be filled only twice through a retail pharmacy. For third and future refills, you are required to fill the prescription through Accredo.
Note: For the ChoicePlan 500 and Oxford PPO, pharmacy and/or Express Scripts Home Delivery copayments do not count toward your medical plan's annual deductible or out-of-pocket maximum as there is a separate pharmacy deductible and a separate pharmacy out-of-pocket maximum.