Citi Benefits Handbook
CP500 at a Glance
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 deductible2
Specialist visits
80% after deductible2
60% of MAA after deductible2
Allergy treatment
80% after deductible2 for the first office visit; 100% for each additional injection if office visit fee is not charged
60% of MAA after deductible2
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 deductible2
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 deductible2
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 deductible2
60% of MAA after deductible2
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 deductible2
60% of MAA after deductible2
Hospital delivery
  • 80% after deductible2
  • Precertification required if admission exceeds 48 hours for a vaginal delivery or 96 hours for a cesarean section delivery
  • 60% of MAA after deductible2
  • 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 deductible2
  • Precertification is required for hospitalization and certain outpatient procedures
  • 80% of MAA after deductible2
  • 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 deductible2 for transport to and from the nearest medical facility qualified to give the required treatment
  • Precertification is required for air transport
  • 80% of MAA after deductible2 for transport to and from the nearest medical facility qualified to give the required treatment
  • Precertification is required for air transport
Urgent care center/Walk-In clinic
Urgent care facility
80% after deductible2
80% of MAA after deductible2
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.) This limit applies to in-network and out-of-network services combined.
  • 80% after deductible2
  • 70% after deductible2 for visits approved for medical necessity over plan limits
  • 60% of MAA after deductible2
  • 50% of MAA after deductible2 for visits approved for medical necessity over plan limits
Speech therapy
(90-visit per-year maximum. Additional visits may be approved.) This limit applies to in-network and out-of-network services combined.
  • 80% after deductible2
  • 70% after deductible2 for visits approved for medical necessity over plan limits
  • 60% of MAA after deductible2
  • 50% after deductible2 for visits approved for medical necessity over plan limits
Chiropractic therapy
(medically necessary), up to 20 visits per year for in-network and out-of-network services combined
80% after deductible2
60% of MAA after deductible2
Other services
Durable medical equipment
(includes orthotics/ prosthetics and appliances)
80% after deductible2
60% of MAA after deductible2
Private-duty nursing and home health care
(ventilator management services are considered a skilled need)
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 deductible2 (limited to 120 days annually for in-network and out-of-network services combined); precertification required
60% of MAA after deductible2 (limited to 120 days annually for in-network and out-of-network services combined); precertification required
Infertility treatment
  • Covered up to a $24,000 family lifetime medical maximum. The lifetime maximum will be coordinated among all non-HMO/PPO medical options.
  • 80% after deductible2 up to the family lifetime maximum; precertification required
  • Prescriptions covered through CVS Caremark up to a $7,500 lifetime pharmacy maximum per family
  • Covered up to a $24,000 family lifetime medical maximum. The lifetime maximum will be coordinated among all non-HMO/PPO medical options.
  • 60% after deductible2 up to the family lifetime maximum; precertification required
  • Prescriptions covered through CVS Caremark up to a $7,500 lifetime pharmacy maximum per family
Prescription drugs (see the Prescription Drugs section)
Mental health and substance abuse (see "Mental Health/Substance Abuse In and Out of Network" )
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).
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 CP500 is self-insured; therefore, Citi pays the claims incurred. The CP500 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.