BNY Mellon Benefits Guide
Plan HRA Details
Plan HRA offers a lower deductible — $1,000 for an individual or $2,000 for a family in-network — and a lower out-of-pocket maximum than Plan HSA, in exchange for a higher per-pay cost.
PLAN HRA
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IN-NETWORK
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OUT-OF-NETWORK
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Deductible
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$1,000 individual; $2,000 family
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$2,000 individual; $4,000 family
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1 Usual, customary and reasonable (UCR) limits
2 After deductible
3 Any amounts applied toward this lifetime maximum under coverage with another carrier will be applied toward the $25,000 lifetime medical maximum and/or the $10,000 lifetime drug maximum under this plan.
4 Prescription drugs filled outside of the CVS Caremark network will initially be denied, and you will pay 100 percent of the cost. You will need to file an out-of-network paper claim to be reimbursed by the plan up to the out-of-network coinsurance, after deductible.
5 Mandatory mail order or CVS pharmacy applies after the prescription is filled twice at the retail level; mandatory generic and step therapy programs.
6 Both of the following conditions must be met before the plan will pay benefits: (i) prior authorization for infertility services must be obtained from your medical carrier, and (ii) services must be obtained from a recognized Center of Excellence, if one is available in your area.
7 Both of the following conditions must be met before the plan will pay benefits: (i) prior authorization for bariatric services must be obtained from your medical carrier, and (ii) services, including surgery, must be obtained from a recognized Center of Excellence.