Choice Plan at a Glance

Citi Benefits Handbook

Note: For in-network covered expenses, the plan pays a percentage of discounted rates, while for out-of-network charges, the plan pays a percentage of the maximum allowed amount (MAA). See the Glossary section for a definition of MAA, which is sometimes referred to as "Recognized Charges."


Type of Service	In Network	Out of Network
Annual deductible (in-network and out-of-network combined)
Individual	$500	$1,500
Maximum per family	$1,000	$3,000
Annual medical out-of-pocket maximum (includes medical deductible, medical coinsurance and medical copays; in-network and out-of-network combined) Note: There is a separate annual out-of-pocket maximum for prescription drugs.
Individual	$3,000	$6,000
Maximum per family	$6,000	$12,000
Lifetime maximum	None	None
Professional care (in office)
PCP visits	80% after deductible²	60% of MAA after deductible ²
Specialist visits	80% after deductible ²	60% of MAA after deductible²
Allergy treatment	80% after deductible ² for the first office visit; 100% for each additional injection if office visit fee is not charged	60% of MAA after deductible ²
Preventive care (subject to frequency limits)
Well-adult visits	100%, not subject to deductible	100% of MAA, not subject to deductible, up to $250 combined maximum; ¹ then covered at 60% of MAA, not subject to deductible
Well-child visits	100%, not subject to deductible	100% of MAA, not subject to deductible, up to $250 combined maximum; ¹ then covered at 60% of MAA, not subject to deductible
Routine cancer screenings (Pap smear, mammography, sigmoidoscopy, colonoscopy, PSA screening)	100%, not subject to deductible	100% of MAA, not subject to deductible, up to $250 combined maximum; ¹ then covered at 60% of MAA, not subject to deductible
Adult and child routine immunizations	100%, not subject to deductible	60% of MAA, 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 80% after deductible. ²	60% of MAA after deductible ²
Voluntary sterilization (including tubal ligation, sterilization implants and surgical sterilizations)	100%, not subject to deductible. Male sterilization services (e.g., vasectomies) and abortions are covered at 80% after deductible. ²	60% of MAA after deductible ²
Routine care (subject to frequency limits)
Routine vision exams	100%, not subject to deductible, limited to one exam per calendar year	100% of MAA, not subject to deductible, up to $250 combined maximum; ¹ then covered at 60% of MAA, 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	100% of MAA, not subject to deductible, up to $250 combined maximum; ¹ then covered at 60% of MAA, 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	80% after deductible;² precertification is required for hospitalization and certain outpatient procedures	60% of MAA after deductible; ² precertification is required for hospitalization and certain outpatient procedures
Anesthesia	80% after deductible ²	60% of MAA after deductible ²
Non-routine outpatient
Lab, X-ray and radiology	80% after deductible; ² precertification is required for certain outpatient procedures	60% of MAA after deductible; ² precertification is required for certain outpatient procedures
Maternity care
Physician office visit	80% after deductible ² Prenatal and postpartum care services considered preventive are covered at 100%, not subject to deductible, see page 35 for details	60% of MAA after deductible ²
Hospital delivery	80% after deductible ² Precertification required if admission exceeds 48 hours for a vaginal delivery or 96 hours for a cesarean section delivery	60% of MAA after deductible ² Prenotification 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)	80% after deductible ² Precertification is required for hospitalization and certain outpatient procedures	80% of MAA after deductible ² 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	80% after deductible ² for transport to and from the nearest medical facility qualified to give the required treatment Precertification required for air transport	80% of MAA after deductible ² for transport to and from the nearest medical facility qualified to give the required treatment Precertification required for air transport
Urgent care center/Walk-In clinic
Urgent care facility	80% after deductible ²	80% of MAA after deductible ²
CVS MinuteClinic and HealthHub	100% for immediate treatment of minor health conditions, such as ear infections or rashes (associated lab tests and prescriptions will be covered at standard cost). See the Prescription Drug section for details about the cost of filling prescription medications.	n/a
Outpatient short-term rehabilitation
Physical or occupational therapy ³ (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.) This limit applies to in-network and out-of-network services combined.	80% after deductible ² 70% after deductible ² for visits approved for medical necessity over plan limits	60% of MAA after deductible ² 50% of MAA after deductible ² for visits approved for medical necessity over plan limits
Speech therapy ³ (90-visit per-year maximum. Additional visits may be approved.) This limit applies to in-network and out-of-network services combined.	80% after deductible ² 70% after deductible ² for visits approved for medical necessity over plan limits	60% of MAA after deductible ² 50% after deductible ² for visits approved for medical necessity over plan limits
Chiropractic therapy ³ (medically necessary), up to 20 visits per year for in-network and out-of-network services combined	80% after deductible ²	60% of MAA after deductible ²
Other services
Durable medical equipment (includes orthotics/ prosthetics and appliances)	80% after deductible ²	60% of MAA after deductible ²
Private-duty nursing and home health care	80% after deductible, ² limited to 200 visits annually for in-network and out-of-network services combined; precertification required	60% of MAA after deductible, ² limited to 200 visits annually for in-network and out-of-network services combined; precertification required
Hospice	80% after deductible; ² precertification required	60% of MAA after deductible; ² precertification required
Skilled nursing facility	80% after deductible ² (limited to 120 days annually for in-network and out-of-network services combined); precertification required	60% of MAA after deductible ² (limited to 120 days annually for in-network and out-of-network services combined); 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. 80% after deductible ² up to the lifetime maximum; precertification required Prescriptions covered through CVS Caremark up to a $7,500 lifetime pharmacy maximum per person	Covered up to a $24,000 per person lifetime medical maximum. The lifetime maximum will be coordinated among all non-HMO/PPO medical options. 60% after deductible ² 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" )

¹ Combined maximum benefit applies to well-adult visits, well-child visits, routine cancer screenings, routine hearing and routine vision. The maximum is measured on a calendar-year basis.

² The plan will pay this percentage of the cost after you first pay the full deductible of the plan. The deductible can be paid with after-tax dollars, such as by cash or check, or with before-tax dollars if you have available funds in a Health Care Spending Account (HCSA).

³ Visit limit is not applicable when there is a diagnosis of mental health, behavioral health or substance abuse, including Autism Spectrum Disorder.

These tables are 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."

The Choice Plan is self-insured; therefore, Citi pays the claims incurred. The Choice Plan is not subject to state laws.

You have the freedom to choose your doctor or health care facility when you need health care. How that care is covered and how much you pay for your care out of your own pocket depend on whether the expense is covered by the plan and whether you choose a preferred provider or a non-preferred provider. Using preferred providers (in-network providers) saves you money in two ways. First, preferred providers charge special, negotiated rates, which are generally lower than the maximum allowed amounts (MAA). Second, the level of reimbursement for many services is higher when using preferred providers. Citi plans only cover services that are deemed medically necessary.

You must meet a deductible before the plan will pay benefits. Both in-network and out-of-network services will apply to meeting the deductible. Precertification is required before any inpatient hospital stay and certain outpatient procedures.