Prescription Drug Benefits at a Glance

Citi Benefits Handbook


	Prescription Drug Benefits
	In-Network Only Plan	Choice Plan	High Deductible Plan with HSA¹
Annual Deductible Choice Plan: In-network and out-of-network expenses combined count toward meeting your annual deductible.
Individual	$100 per person (prescription drug deductible)		$1,800 in-network/$2,800 out-of-network; includes medical expenses
Maximum per family	$200 family maximum (prescription drug deductible)		$3,600 in-network/$5,600 out-of-network; includes medical expenses (no benefits will be paid to an individual until the family deductible has been met)
Annual Out-of-Pocket Maximum In-Network Only Plan: Annual prescription drug out-of-pocket maximum includes prescription deductible, copays and prescription coinsurance. This is separate from the annual medical out-of-pocket maximum. Choice Plan: Annual prescription drug out-of-pocket maximum includes prescription deductible, prescription coinsurance and prescription copays. In-network and out-of-network expenses are combined. This is separate from the annual medical out-of-pocket maximum. Eligible prescription expenses within a family can be combined to meet the family out-of-pocket maximum, but no one person can apply more than the individual out-of-pocket maximum amount ($1,500) to the family out-of-pocket maximum ($3,000). High Deductible Plan with HSA: Prescription drug expenses count toward the medical annual out-of-pocket maximum Keep in mind, you will still pay 100% of the prescription cost after the out-of-pocket maximum is met after the third fill of a maintenance prescription at a non-CVS pharmacy.
Individual	$1,500 per person (prescription drug out-of-pocket maximum)			$5,000 in-network/$7,500 out-of-network Includes both medical and prescription drug expenses
Maximum per family	$3,000 family maximum (prescription drug out-of-pocket maximum)			$10,000 ($6,850 per individual) in-network/ $$15,000 ($15,000 per individual) out-of-network Includes both medical and prescription drug expenses
Copay/Coinsurance — In-Network Retail Pharmacy Copay/coinsurance for up to a 31-day supply at an in-network retail pharmacy (including Target pharmacies), after you meet your deductible. You may have the same maintenance prescription filled up to three times at a non-CVS pharmacy; on the fourth fill, you will pay 100% of the cost of the medication. However, maintenance medication will be available through a CVS pharmacy or through Mail Service for your 90-day copay.²
Generic drug²	$10
Preferred brand-name drug³	$30
Non-preferred brand-name drug	50% of the cost of the drug, with a minimum payment of $50, to a maximum of $150. If the cost of the drug is less than $50, you will pay the cost of the prescription drug.
Certain preventive care drugs as required under ACA	Generics and Single Source Brands: not subject to annual deductible, and no cost to you Brand-name drugs: subject to the annual deductible and applicable preferred or non-preferred cost share requirement
Copay/Coinsurance — Mail Service Program or Maintenance Choice Program Copay/coinsurance for a 90-day supply through the CVS Caremark Mail Service program or Maintenance Choice program (through a CVS pharmacy) after you meet your deductible.
Generic drug²	$20
Preferred brand-name drug³	$75
Non-preferred brand-name drug	50% of the cost of the drug, with a minimum payment of $125, to a maximum of $375
Certain preventive care drugs as required by ACA	Generics and Single Source Brands: not subject to annual deductible, and no cost to you Brand-name drugs: subject to the annual deductible and applicable preferred or non-preferred cost share requirement
Copay/Coinsurance — Specialty Medication Copay/coinsurance for a 31-day supply of specialty medication dispensed through the CVS Specialty Pharmacy after you meet your deductible.⁴
Generic drug², ⁴	$20
Preferred brand-name drug³, ⁴	25% of the cost of the drug, with a minimum payment of $50, to a maximum of $150
Non-preferred brand-name drug4	50% of the cost of the drug, with a minimum payment of $100, to a maximum of $250
Out-of-Network Benefits
Benefits at an out-of-network pharmacy	Reimbursed at the contracted rate after you have met the annual deductible and paid the applicable copay
Lifetime maximum benefit for fertility drugs	Fertility drugs are limited to $7,500 per lifetime per covered person

¹ In the High Deductible Plan with HSA, you must meet your combined medical/prescription drug deductible before the Program will pay benefits, except for certain preventive drugs. To determine whether your medication is considered preventive, visit www.caremark.com. Your cost for these preventive drugs is the applicable copay or coinsurance, which will count toward your out-of-pocket maximum.

² The use of generic equivalents whenever possible (through both the retail and CVS Caremark Mail Service programs) is more cost-effective. Ask your medical professional about this distinction. If you or your doctor requests a brand-name drug and a generic alternative is available, you will pay the difference between the cost of the brand-name drug and the generic drug in addition to the copay for the generic drug Pharmacy and/or CVS Caremark Mail Service Dispense as Written (DAW) penalty amounts do not count toward your pharmacy or medical plan's annual deductible or out-of-pocket maximum.

³ Citi does not determine preferred brand-name drugs. Rather, CVS Caremark brings together an independent group of practicing physicians and pharmacists who meet quarterly to review the preferred brand-name formulary list and make determinations based on current clinical information. Call CVS Caremark Customer Care at 1 (844) 214-6601 or visit www.caremark.com for a copy of its Preferred Formulary (updated at least quarterly).

⁴ You are required to fill a specialty prescription through CVS Specialty Pharmacy. However, specialty prescriptions can be dropped off or picked up at a CVS retail pharmacy (yet, they typically take more time to fill than non-specialty prescriptions). In the event of an emergency, please contact CVS Specialty Pharmacy Services to fill the prescription. You will be charged only the applicable retail/specialty copay.

Note: For the In-Network Only Plan and Choice Plan, pharmacy and/or CVS Caremark Mail Service copays do not count toward your medical plan's annual deductible or out-of-pocket maximum, as there is a separate pharmacy deductible and a separate pharmacy out-of-pocket maximum. See "PrudentRx Copay Program" for In-Network Only Plan and Choice Plan details.