In-Network Only Plan at a Glance

Citi Benefits Handbook

Note: For in-network covered expenses, the plan pays a percentage of discounted rates. Under the In-Network Only Plan, there are no payments/reimbursements for out-of-network services.


Type of Service
Annual deductible
Individual	$250
Maximum per family	$500
Annual medical out-of-pocket maximum (includes medical deductible and medical copays) Note: There is a separate annual out-of-pocket maximum for prescription drugs.
Individual	$4,000
Maximum per family	$8,000
Lifetime maximum	None
Professional care (in office)
PCP visits	$25 copay
Specialist visits	$45 copay
Allergy treatment	100%; not subject to deductible after applicable PCP or Specialist copay
Preventive care (subject to frequency limits)
Well-adult visits	100%, not subject to deductible
Well-child visits	100%, not subject to deductible
Routine cancer screenings (Pap smear, mammography, sigmoidoscopy, colonoscopy, PSA screening)	100%, not subject to deductible
Adult and child routine immunizations	100%, 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 100% after deductible.
Voluntary sterilization (including tubal ligation, sterilization implants and surgical sterilizations)	100%, not subject to deductible after PCP/specialist copay at an inpatient facility or $200 at an outpatient facility (e.g., vasectomies) and abortions.
Routine care (subject to frequency limits)
Routine vision exams	100%, not subject to deductible, limited to one exam per calendar year
Routine hearing exams	100%, not subject to deductible, limited to one exam per calendar year
Hospital (inpatient and outpatient services)
Semiprivate room and board, doctor's charges, lab, X-ray, radiology and surgical care	100% after deductible and $400 copay per confinement for inpatient; 100% after deductible and $200 copay for outpatient
Anesthesia	100%, not subject to deductible
Non-routine outpatient
Lab, X-ray and radiology	100%, not subject to deductible after $25 copay for independent lab or freestanding facility. If during office visit, PCP or specialist copay will apply (no separate copay). 100% after deductible after $200 copay for outpatient hospital
Maternity care
Physician office visit	100%, not subject to deductible after $25 copay Prenatal and postpartum care services considered preventive are covered at 100%, see "How the In-Network Only Plan Works" for details
Hospital delivery	100% after deductible and $400 copay per confinement (confinement copay waived for newborn initial confinement) Precertification required if admission exceeds 48 hours for a vaginal delivery or 96 hours for a cesarean section delivery
Emergency care (no coverage if not a true emergency)
Hospital emergency room (includes emergency room facility and professional services provided in the emergency room)	100% after deductible and after $200 copay Precertification is required for hospitalization and certain outpatient procedures
Emergency Transportation Services (no coverage when used as routine transportation to receive inpatient or outpatient services)
Ambulance	100% after deductible and after $150 copay Precertification required for air transport
Urgent care center/Walk-In clinic
Urgent care facility	100%, not subject to deductible, after $45 copay
CVS MinuteClinic and HealthHub	100%, not subject to deductible (lab tests covered at standard cost)
Outpatient short-term rehabilitation
Physical or occupational therapy* (All therapy visits are reviewed for medical necessity. PT/OT therapy visits are combined with a 60-visit per-year maximum. Additional visits may be approved.)	100%, not subject to deductible, after $25 copay with Anthem (no copay with Aetna)
Speech therapy* (90-visit per-year maximum. Additional visits may be approved.)	100%, not subject to deductible, after $25 copay
Chiropractic therapy* (medically necessary), up to 20 visits per year	100%, not subject to deductible, after $45 copay
Other services
Durable medical equipment (includes orthotics/ prosthetics and appliances)	100%, not subject to deductible, after $25 copay
Private-duty nursing and home health care	100%, not subject to deductible, after $45 copay. Limited to 200 visits annually; precertification required
Hospice	Inpatient: 100% after deductible, after $400 copay per confinement; precertification required Outpatient: 100% not subject to deductible, after $45 copay
Skilled nursing facility	100% after deductible, after $400 copay per confinement (limited to 120 days annually); precertification required
Infertility treatment	Covered up to a $24,000 per person lifetime medical maximum. The lifetime maximum will be coordinated among all non-HMO/PPO medical options. 100%, not subject to deductible, after $45 copay per visit up to the lifetime maximum; precertification required Prescriptions covered through CVS Caremark up to a $7,500 lifetime pharmacy maximum per person
Prescription drugs (see the Prescription Drugs section) Mental health and substance abuse (see "Mental Health/Substance Abuse" )

* Visit limit is not applicable when there is a diagnosis of mental health, behavioral health or substance abuse, including Autism Spectrum Disorder.)

This table is intended as a brief summary of benefits. Not all covered services, exclusions and limitations are shown. For additional information and/or clarification of benefits, see "Covered Services and Supplies" and "Exclusions and Limitations."

Like all the other options under the Plan, the In-Network Only Plan option is self-insured; therefore, Citi pays the claims incurred. The In-Network Only Plan is not subject to state laws.

The Plan only cover services that are deemed medically necessary.

Precertification is required before any inpatient hospital stay and certain outpatient procedures.