Citi Benefits Handbook
How the In-Network Only Plan Works
In-Network Doctors and Hospitals
When you need health care, you'll choose a doctor or hospital from the network you selected when you enrolled in the plan — either the Aetna Premier Care Plus Network (APCN+) or Anthem's National Blue High Performance Network (BlueHPN). These networks are made up of a select group of doctors and hospitals that consistently deliver high-quality care at lower costs.
A copay is a flat fee you pay for medical care. When you go to the doctor to address a health concern, you'll pay either $25 for a primary care visit or $45 for a specialist visit. When you go to the hospital for treatment, you must first meet the medical deductible, then you pay either $200 for emergency room and outpatient care or $400 for inpatient care.
For prescriptions, you'll pay a copay for generic and preferred brand-name drugs after meeting the separate annual deductible for prescription drugs. This deductible is the same as the prescription drug deductible for the Choice Plan. (Non-preferred brand name drugs and some specialty drugs charge a coinsurance percentage, instead of a flat copay.)
The deductible does not apply to office visits — all you pay is the copay. The deductible does apply if you need a surgical procedure or care at a hospital. You'll pay your hospital fees up to the plan's annual medical deductible ($250 individual/$500 family), plus a copay ($200 for emergency room and outpatient care or $400 for inpatient care). Note: Your prescription drug copays and coinsurance are subject to a separate annual deductible ($100 individual/$200 family).
Medical Out-of-Pocket Maximum
The medical out-of-pocket maximum is $4,000 individual/$8,000 family. This amount represents the most you will have to pay out of your own pocket in a calendar year for medical services. Once the out-of-pocket maximum has been satisfied, no additional medical copays will apply for the rest of the plan year. Note: Your prescription drug copays and coinsurance are subject to a separate out-of-pocket maximum ($1,500 individual/$3,000 family).
Not all expenses count toward your medical out-of-pocket maximum. Among those that do not count are:
- Charges above MAA;
- Prescription drug expenses (which count toward the separate prescription drug out-of-pocket maximum); and
- Charges for services not covered under the In-Network Only Plan.
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 In-Network Only Plan network is available from the Claims Administrator. You may call or visit the Claims Administrator's website:
- Aetna: www.aetna.com. use the customized doc finder tool at www.aetnadocfind.com/in-networkonlyplan. Enter your home ZIP code in the 2023 Provider Search box, then click "Start Your Search." This automatically brings you to the APCN+ network directory. Enter your ZIP code again and continue as a guest to search for in-network doctors. For personal assistance, call 1 (800) 545-5862.
- Anthem BlueCross BlueShield: use the Find Care tool at www.anthem.com/find-care; to access a network provider. Select the "Guests" tile then choose "Medical" for the type of care. Choose the state you want to search in. Select Medical (Employer-Sponsored) for type of plan. Select National Blue High Performance Network Non-Tiered (prefix E7F) for the plan/network. Click the "Continue" button and search for a doctor nearby or a special doctor by name. For personal assistance, you can also download the Engage Wellbeing app to search for doctors or call your Citi Health Concierge at 1 (855) 593-8123.
If you need the services of a specialist, you may seek care from an in-network specialist directly without a referral. You will pay a flat copay of $45 per visit.
Preventive care services are covered at 100% with no deductible to meet for the In-Network Only Plan. For additional information on what is considered to be preventive care, see "Your Medical Options".
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, the In-Network Only Plan 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;
- Colonoscopy; and
- Prostate-specific antigen (PSA) screening annually with a digital rectal exam in men age 50 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 of the Centers for Disease Control and Prevention; and
- Comprehensive Guidelines Supported by the Health Resources and Services Administration.
In-Network Only Plan offers additional coverage for routine care services to help in the early detection of health problems.
- Routine vision exam:
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:
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 care (inpatient and outpatient) received through a preferred provider is covered at 100% for covered services after the deductible has been met, after a copay of $400 inpatient/$200 outpatient. Precertification of an inpatient admission is required. Precertification is also required for certain outpatient procedures and services.
Services provided in a hospital emergency room are covered at 100% for covered services after the deductible has been met and after a $200 copay (even out of network).
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 centers are listed in the provider directory available on the Claims Administrators' websites. You do not need a referral or any precertification to use an urgent care center. Services provided by an urgent care center are covered at 100% for covered services after the deductible and the $45 copay has been met.
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 you need help finding an urgent care provider, you may call Member Services at the toll-free number on your ID card, or you may access Aetna's online provider directory at www.aetna.com, or Anthem BlueCross BlueShield's Find Care tool at www.anthem.com/find-care. 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.
Charges Not Covered
An in-network provider contracts with the In-Network Only Plan 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 the in-Network Only Plan or not approved by the In-Network Only Plan. In that case, the in-network provider may bill charges to you. However, these charges are not covered expenses under the In-Network Only Plan 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 Plan".