Citi Benefits Handbook
HDHP 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 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
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 deductible;2 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
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 facility
80% after deductible2
80% of MAA after deductible2
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)
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
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
Other services
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 In and Out of Network")
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.