This list of covered services and supplies applies to all In-Network Only Plan, Choice Plan and High Deductible Plan with HSA medical plans sponsored by Citi, except where noted.

Covered services and supplies must be medically necessary and related to the diagnosis or treatment of an accidental injury, a sickness or a pregnancy. Reimbursement for all covered services and supplies listed in this section is subject to the maximum allowed amount (MAA) or, for in-network services, the negotiated rates of the plan.

You and your physician decide which services and supplies are required, but the plan pays only for the following covered services and supplies that are medically necessary as determined by the Claims Administrators.

Covered services and supplies also include services and supplies that are part of a case management program. A case management program is a course of treatment developed by the Claims Administrator as an alternative to the services and supplies that would otherwise have been considered covered services and supplies. Unless the case management program specifies otherwise, the provisions of the plan related to benefit amounts, maximum amounts, copays and deductibles will apply to these services.

Acupuncture must be administered by a medical doctor or a licensed acupuncturist (if state license is available).

Aetna: Acupuncture is covered for the following:

Anthem: Acupuncture is covered, with no visit limits or diagnosis requirements.

Acupuncture is covered if administered by a medical doctor, an osteopathic physician, a chiropractor or a licensed acupuncturist (if state license is available).

The following are the guidelines for covered adult immunizations:

A center's services must be given within 72 hours before or after a surgical procedure. The services must be given in connection with the procedure.

Anesthetics are drugs that produce loss of feeling or sensation either generally or locally, except when done for dental care not covered by the plan. When administered as part of a medical procedure, anesthesia must be administered by a board-certified anesthesiologist. Anesthesia is not covered when rendered in the doctor's office or when administered by the operating surgeon, unless it is administered by a dentist for dental care that is covered by the plan.

If you enroll in an Anthem or Aetna medical plan, family members who have been diagnosed with Autism Spectrum Disorder have access to autism assistance benefits, including applied behavior analysis (ABA) therapy.

Members diagnosed with Autism Spectrum Disorder (ASD) have coverage available for the diagnosis and treatment of ASD, when ordered by a physician, licensed psychologist or licensed clinical social worker as part of a treatment plan.

The following services and supplies may be given during an eligible newborn child's initial hospital confinement:

Note: If the newborn child is discharged at the same time as the mother, then the charges for the services rendered for the child are subject to coinsurance only. The mother's claims are subject to the deductible and coinsurance. If the newborn child remains in the hospital longer than the mother, the claims for the child apply to his or her own deductible and coinsurance limits if the member has not already met the family limits.

Note: If your covered dependent child gives birth, only the services for your dependent child are covered. Your newborn grandchild is not eligible for coverage.

Room and board and other services, supplies and anesthetics.

Diagnostic screenings not subject to precertification or notification include:

For cancer treatment.

Contraceptive services and devices including, but not limited to:

Nutritional counseling is covered by a licensed dietitian and/or licensed nutritionist for diabetes, bulimia, anorexia nervosa and morbid obesity.

Durable medical equipment means equipment that meets all of the following:

Some examples of durable medical equipment are:

Each Claims Administrator decides whether to cover the purchase or rental of the equipment based on coverage guidelines. Changes made to your home, automobile or personal property are not covered. Rental coverage is limited to the purchase price of the durable medical equipment. Replacement, repair and maintenance are covered only if:

Care and treatment of the feet, if afflicted by severe systemic disease. Routine care such as removal of warts, corns or calluses; the cutting and trimming of toenails; and foot care for flat feet, fallen arches and chronic foot strain is covered only if needed due to severe systemic disease.

Aetna and Anthem BlueCross BlueShield plans cover the services of a podiatrist for the treatment of a disease or injury, including the treatment of corns, calluses, keratoses, bunions and ingrown toenails.

For gender affirmation treatment benefits for members with gender dysphoria, the criteria that are used for determining the medical necessity of services for the diagnosis and treatment are based on the 8th edition of the clinical guidelines set forth by the World Professional Association for Transgender Health (WPATH) in their Standards of Care document. However, not all of the services included in WPATH are covered. Please see below for those services that are generally covered and those services that are not covered.

Many of the services noted below require pre-service authorization. Contact the Plan's Member Services for details.

It is strongly recommended that you call the applicable claims administrator before receiving any related services to ensure that the services you seek are covered under the Plan.

Generally, covered expenses include:

Note that all covered expenses are subject to plan pre-authorization limits and WPATH eligibility criteria.

Not covered

If a member has followed all of the criteria and clinical guidelines outlined in the WPATH Standards of Care, the plan will not cover costs related to reversal procedures or services. However, complications of procedures derived from reversal surgeries or treatments that are medically necessary will be covered.

Anthem BlueCross BlueShield: The Plan includes benefits for gene therapy services, when Anthem approves the benefits in advance through precertification. To be eligible for coverage, services must be medically necessary and performed by an approved provider at an approved treatment center. Even if a provider is an in-network provider for other services it may not be an approved provider for certain gene therapy services. Please call Anthem Member Services to find out which providers are approved providers. (When calling Member Services, ask for the transplant case manager for further details.)

Your Plan does not include benefits for services determined to be experimental/investigational or services provided by a non-approved provider or at a non-approved facility.

Hearing aids are covered, regardless of the reason for hearing loss.

The following covered services must be given by a home health care agency:

Covered services are limited to 200 visits each calendar year (combined visits with private-duty nursing), and you must notify the plan in advance. Each period of home health aide care of up to eight hours given in the same day counts as one visit. Each visit by any other member of the home health team will count as one visit. Multiple services provided on the same day count as one visit and are billed by the same provider on the same bill. Visits may be increased with prior approval from your health plan.

Hospice services for a participant who is terminally ill include:

Bereavement counseling must be provided by a licensed counselor. Services for the patient must be given in an inpatient hospice facility or in the patient's home. The physician must certify that the patient is terminally ill with six months or less to live.

Anthem BlueCross BlueShield: You are eligible for hospice care if your doctor and hospice medical director certify that you are terminally ill and likely have less than twelve (12) months to live. You may access hospice care while participating in a clinical trial or continuing disease modifying therapy, as ordered by your treating provider. Disease modifying therapy treats the underlying terminal illness.

The services and supplies listed below are covered services when given by a hospice for the palliative care of pain and other symptoms that are part of a terminal disease. Palliative care means care that controls pain and relieves symptoms, but is not meant to cure a terminal illness. Covered Services include:

Aetna and Anthem BlueCross BlueShield: Hospital services include:

Emergency room services are covered only if determined to be medically appropriate and there is not a less intensive or more appropriate place of service, diagnostic or treatment alternative that could be used. If your health plan, at its discretion, determines that a less intensive or more appropriate treatment could have been given, then no benefits are payable.

Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours as applicable). Authorizations are required for longer stays.

Precertification is recommended for treatment of infertility. However, no penalties apply if the treatment is received without precertification.

In order to be eligible for fertility benefits you must be a covered employee, spouse/partner or eligible dependent ("covered person") under a Citi medical plan

Medical expenses for infertility treatment are covered up to a covered person's lifetime maximum of $24,000. Only expenses for elective cryopreservation, advanced services (e.g., IVF, GIFT, ZIFT) and comprehensive services (e.g., artificial insemination) accumulate toward the lifetime maximum.

Expenses for diagnosis and treatment of the underlying medical condition do not count toward the lifetime maximum.

Prescription drug expenses associated with infertility treatment and elective cryopreservation are covered up to a lifetime maximum of $7,500 per covered person under the Plan, as outlined in the Prescription Drugs section.

HMOs

Each HMO offers different infertility coverage and limits, if they offer any such coverage at all. Check with your HMO for details of infertility coverage.

Structured, multidisciplinary behavioral health treatment that provides a combination of individual, group and family therapy in a program that operates no less than 3 hours per day, 3 days per week. Out-of-Network Facility-based Programs must occur at Facilities that are both licensed and accredited.

X-rays or tests for diagnosis or treatment.

Services of a licensed counselor for mental health and substance abuse treatment.

Aetna and Anthem BlueCross BlueShield

Covered expenses for ground ambulance include charges for transportation:

Air Transportation

In extremely rare occasions, exceptions may be made based on the Medical Director discretion.

Covered medical expenses include charges made on an inpatient or outpatient basis by a hospital or a physician for the surgical treatment of morbid obesity of a covered person. Limitations apply. For more information, contact your plan directly.

Dietician/nutritionist coverage is also available for morbid obesity. See "Dietitian/Nutritionist."

Services of a licensed or certified nurse-midwife. Maternity-related benefits are payable on the same basis as services given by a physician.

Services of a licensed or certified nurse practitioner acting within the scope of that license or certification. Benefits are payable on the same basis as covered services given by a physician.

The plan pays first (the primary plan) for oral surgery if needed as a necessary, but incidental, part of a larger service in treatment of an underlying medical condition.

The following oral surgeries are considered medical in nature and covered under the medical plan as necessary:

Corrective surgery is covered if medically necessary for purposes of chewing and speaking.

The following services and supplies are covered only if needed because of accidental injury to sound and natural teeth that happened to you or your dependent while covered under this plan.:

Keep in mind that qualified transplant procedures will be covered at the out-of-network level when performed at a facility that is not deemed a Center of Excellence (COE) or Blue Distinction Center (BDC) through BlueCross BlueShield. Contact your plan for more information about locating a COE (or BDC).

Your Claims Administrator must be notified before the scheduled date (or as soon as reasonably possible) of any of the following:

Donor Charges for Organ/Tissue Transplants

Qualified Procedures

If a qualified procedure, listed in this section, is medically necessary and performed at a designated transplant facility, the "medical care and treatment" and "transportation and lodging" provisions described in this section apply.

For Aetna, transplant services are covered as long as the transplant is not experimental or investigational and has been approved in advance. Transplants must be performed in hospitals specifically approved and designated by Aetna to perform the procedure. The Institutes of Excellence (IOE) network is Aetna's network of providers for transplants and transplant-related services, including evaluations and follow-up care. Each facility has been selected to perform only certain types of transplants, based on its quality of care and successful clinical outcomes.

For Aetna plans (Choice Plan and High Deductible Plan with HSA), a transplant will be covered as an in-network service only if performed in a facility that has been designated as an IOE facility for the type of transplant in question. Any facility that is not specified as an Institute of Excellence network facility is considered a non-participating facility for transplant-related services, even if the facility is considered a participating facility for other types of services. With the In-Network Only Plan, any approved IOE or a participating Aetna facility.

The National Medical Excellence (NME) Program® will coordinate all solid organ, bone marrow and CAR-T and T-cell therapy services, and other specialized care you need.

Many pre and post-transplant medical services, even routine ones, are related to and may affect the success of your transplant. While your transplant care is being coordinated by the NME Program, all medical services must be managed through NME so that you receive the highest level of benefits at the appropriate facility. This is true even if the covered service is not directly related to your transplant.

Members must receive precertification for transplant procedures. When a member or physician calls Aetna to precertify a transplant evaluation, a case nurse will direct him or her to an IOE facility.

For Anthem BlueCross BlueShield (Choice Plan and High Deductible Health Plan with HSA), coverage is based on the facility used for the transplant. If a Blue Distinction Center (BDC or BDC+) is used, the service will be covered at 80% with access to the travel and lodging benefit. Blue Distinction Centers meet stringent clinical criteria, established in collaboration with expert physician panels and national medical societies, including the Center for International Blood and Marrow Transplant Research (CIBMTR), the Scientific Registry of Transplant Recipients (SRTR), and the Foundation for the Accreditation of Cellular Therapy (FACT), and are subject to periodic re-evaluation as criteria continue to evolve. Call Anthem at 1 (855) 593-8123 for additional coverage information as well as assistance in locating a BDC or BDC+ facility. With the In-Network Only Plan, any network provider will be covered.

Precertification is required for these services. Services performed at BDC or BDC+ facilities are covered at 80% with access to the travel and lodging benefit; all other facilities are covered at 60% with no access to the travel and lodging benefit under the Choice Plan and High Deductible Health Plan with HSA. With the In-Network Only Plan, transplants are covered at 100% after deductible with a $400 copay per confinement for services in an approved network facility.

Medical Care and Treatment

Covered expenses for services provided in connection with the transplant procedure include:

When available, the plan will assist the patient and family with travel and lodging arrangements when a qualified procedure, listed in this section, is medically necessary and performed at a designated Center of Excellence facility. See "Travel and Lodging."

If the covered person chooses not to receive his or her care in connection with a qualified procedure pursuant to this organ/tissue transplant section, the services and supplies received by the covered person in connection with that qualified procedure will be paid under the plan if and to the extent covered by the plan without regard to this organ/tissue transplant section.

Keep in mind that qualified orthopedic procedures will be covered at the out-of-network level when performed at a facility that is not deemed a Center of Excellence (COE) or a Blue Distinction Center (BDC or BDC+) through BlueCross BlueShield. Contact Member Services at your health carrier for more information about locating a COE (or BDC).

Qualified Procedures

If a qualified procedure, listed in this section, is medically necessary and performed at a designated Center of Excellence facility, the "medical care and treatment" and "transportation and lodging" provisions described in this section apply.

When available, the plan will assist the patient and family with travel and lodging arrangements when a qualified procedure, listed in this section, is medically necessary and performed at a designated Center of Excellence facility. See "Travel and Lodging."

For Anthem BlueCross BlueShield, coverage is based on the facility used for the transplant. If a Blue Distinction Center (BDC or BDC+) is used, the procedure will be covered at 80%. Blue Distinction Centers meet stringent clinical criteria, established in collaboration with expert physician panels and national medical societies and are subject to periodic re-evaluation as criteria continue to evolve. Call Anthem at 1 (855) 593-8123 for additional coverage information as well as assistance in locating a BDC or BDC+ facility.

Precertification is required for these services. Services performed at BDC or BDC+ facilities are covered at 80% benefit; all other facilities are covered at 60%. If care at a BDC or BDC+ facility requires you to travel 75 miles or more from your home, you'll have access to a travel and lodging benefit, with a maximum of $10,000 per surgery or treatment. There is no travel and lodging benefit for services rendered outside of a Blue Distinction Center.

Training by a licensed optometrist or an orthoptic technician. The plan covers a hidden ocular muscle condition where the eyes have a tendency to under-converge or over-converge. Manifest conditions of exotropia (turning out) or esotropia (turning in) are covered. Coverage is limited to 32 visits per calendar year.

See "Rehabilitation Therapy."

See "Rehabilitation Therapy."

Structured, multidisciplinary behavioral health treatment that offers nursing care and active individual, group and family treatment in a program that operates no less than six hours per day, five days per week. Out-of-Network Facility-based Programs must occur at Facilities that are both licensed and accredited.

Prescribed drugs and medicines for inpatient services.

Covered expenses include:

A $250 calendar-year maximum applies to out-of-network services per covered family member. (Choice Plan only). Each participant has a $250 annual credit toward all out-of-network wellness services. Thereafter, covered expenses are not subject to the deductible, and expenses that exceed the $250 credit are covered at 60% of MAA.

For more specific information regarding what is considered to be Preventive Care, see "Preventive Care."

Private-duty nursing care is given on an outpatient basis by an RN, LPN or licensed vocational nurse (LVN). This service must be approved by your Claims Administrator.

Services of a psychologist for psychological testing and psychotherapy.

Defined as short-term occupational therapy, physical therapy, speech therapy and spinal manipulation:

Inpatient

Outpatient

Covered expenses include:

A $250 calendar year maximum applies to out-of-network services per covered family member (Choice Plan only).Each participant has a $250 annual credit toward all out-of-network wellness services. Thereafter, covered expenses are not subject to the deductible, and expenses that exceed the $250 credit are covered at 60% of MAA

A provider licensed and operated as required by law, which includes:

The term Residential Treatment Center/Facility does not include a provider, or that part of a provider, used mainly for:

Covered services are limited to the first 120 days of confinement each calendar year.

See "Rehabilitation Therapy."

Services of a physician given for the detection or correction (manipulation) by manual or mechanical means of structural imbalance or distortion of the spine. Routine maintenance and adjustments are not a covered service under this plan.

Services for surgical procedures.

Reconstructive Surgery

Assistant-Surgeon Services

Covered expenses for assistant-surgeon services are limited to 20% of the amount of covered expenses for the primary surgeon's charge for the surgery for non-HMO/PPO plans. An assistant-surgeon generally must be a licensed physician. Physician's-assistant services are not covered if billed on his or her own behalf. (Aetna and Anthem BlueCross BlueShield cover assistant surgeon services for certain surgeries. Aetna covers registered nurses acting as assistant surgeons for certain surgeries. Contact Anthem BlueCross BlueShield for information about which providers qualify as assistant surgeons.)

Multiple Surgical Procedure Guidelines

If you are using an out-of-network provider for a surgical procedure, the following multiple surgical procedure guidelines will apply.

If more than one procedure will be performed during one operation — through the same incision or operative field — the plan will pay according to the following guidelines:

If billed separately, incidental surgeries will not be covered. An incidental surgery is a procedure performed at the same time as a primary procedure and requires few additional physician resources and/or is clinically an integral part of the performance of the primary procedure.

Surgical treatment of TMJ does not include treatment performed by prosthesis placed directly on the teeth or physical therapy for TMJ.

Transsexual Surgery, Sex Change or Transformation

The plan does cover procedures, treatments and related services designed to alter a participant's physical characteristics from his or her biologically determined sex to those of another sex.

Reversals are not covered.

Office visit charges for routine well-child care exams and immunizations based on guidelines from the American Medical Association.