Citi Benefits Handbook
Your Out-of-Pocket Maximum
There is a separate prescription drug out-of-pocket maximum ($1,500 per individual and $3,000 per family) under the ChoicePlan 500 and Oxford PPO. This feature is designed to help protect you from a large annual expense for prescription drugs, since this is the most you will ever pay for prescriptions per year. Once you reach the out-of-pocket maximum, the Program will pay 100% of your covered prescription costs for the remainder of the plan year.
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 covered maintenance prescription at a retail pharmacy or after the second fill of a covered specialty medication through a retail pharmacy.
There is a combined medical and prescription drug out-of-pocket maximum under the High Deductible Health Plan (HDHP) of $5,000 individual and $10,000 ($6,850 per individual) family in-network ($7,500 individual and $15,000 family out-of-network). This amount includes your medical/prescription drug deductible, coinsurance and copays. This represents the most you will have to pay out of your own pocket in a plan year.
Note: For in-network services under the High Deductible Health Plan (HDHP), the family out-of-pocket maximum is $10,000, but 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 entire family's in-network health care expenses for the rest of the year.
For answers to your questions about the out-of-pocket maximum, call Express Scripts at 1 (800) 227-8338.