High Deductible Plan with HSA 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 services combined)
Single	$1,800 Includes prescription drug expenses	$2,800 Includes prescription drug expenses
Family	$3,600 Includes prescription drug expenses	$5,600 Includes prescription drug expenses
Annual out-of-pocket maximum (includes deductible, medical/prescription drug coinsurance and medical/prescription drug copays)
Single	$5,000 Includes prescription drug expenses	$7,500 Includes prescription drug expenses
Family¹	$10,000 ($6,850 per individual) Includes prescription drug expenses	$15,000 ($15,000 per individual) Includes prescription drug expenses
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	60% of MAA after deductible²
Preventive care (subject to frequency limits)
Well-adult visits and routine immunizations	100%, not subject to deductible	100% of MAA, not subject to deductible
Well-child visits and routine immunizations
Routine cancer screenings (Pap smear, mammography, sigmoidoscopy, colonoscopy, PSA screening)
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 exam	100%, not subject to deductible; limited to one exam per calendar year	100% of MAA, not subject to deductible; limited to one exam per calendar year
Routine hearing exam	100%, not subject to deductible; limited to one exam per calendar year	100% of MAA, not subject to deductible; limited to one exam per calendar year
Hospital inpatient and outpatient
Semiprivate room and board, doctor's charges, lab, X-ray, radiology and surgical care	80% after deductible;² precertification required for hospitalization and certain outpatient procedures and services	60% of MAA after deductible;² precertification required for hospitalization and certain outpatient procedures and services
Non-routine outpatient
Lab, X-ray and radiology	80% after deductible²; precertification required for certain outpatient procedures	60% of MAA after deductible;² precertification required for certain outpatient procedures
Maternity care
Physician office visit	80% after deductible² Prenatal and postpartum care services considered preventive are covered at 100%, not subject to deductible	60% of MAA after deductible²
Hospital delivery	80% after deductible²	60% of MAA after deductible²
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 required if admitted	80% after deductible;² precertification required if admitted
Urgent Care/Walk-In Clinics
Urgent care facility	80% after deductible²	80% of MAA after deductible²
CVS MinuteClinic and HealthHub	100%, after deductible, 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
Emergency Transportation Services (no coverage when used as routine transportation to receive inpatient or outpatient services)
Ambulance	80% after deductible² Precertification required for air transport	80% of MAA after deductible; precertification required for inter-facility transfers Precertification required for air transport
Outpatient short-term rehabilitation
Physical/occupational therapy (combined)³ Limited to 60 visits a year in-network and out-of-network combined; you may be eligible for additional visits with plan approval after a medical necessity review.	80% after deductible² 70% after deductible² for visits approved for medical necessity above plan limits	60% after deductible² 50% of MAA after deductible² for visits approved for medical necessity above plan limits
Speech therapy ³ Limited to 90 visits a year in-network and out-of-network combined; you may be eligible for additional visits with plan approval after a medical necessity review.	80% after deductible² 70% after deductible² for additional visits above plan limits	60% after deductible² 50% of MAA after deductible² for additional visits above plan limits
Chiropractic therapy³ (medically necessary), up to 20 visits per year for in-network and out-of-network services combined	80% after deductible²	60% after deductible²
Other services
Durable medical equipment (includes orthotics/ prosthetics and appliances)	80% after deductible²	60% after deductible²
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 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 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 The family deductible can be satisfied as a family or by an individual within the family. Each of your covered family members has an individual out-of-pocket maximum of only $6,850 for in-network coverage. After reaching that amount, your plan will cover 100% of that individual's in-network health care expenses for the rest of the year. Once the $10,000 family in-network out-of-pocket maximum is met, your plan will cover 100% of the family's in-network health care expenses for the rest of the year.

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 an HSA.

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