BNY Mellon Benefits Guide
Plan HSA Details
With Plan HSA, you pay a lower per-pay cost. In exchange, you have a higher deductible — $1,600 for an individual or $3,200 for a family in- and out-of-network — if you need care. Also, the out-of-pocket maximum is higher.
PLAN HSA
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IN-NETWORK
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OUT-OF-NETWORK
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Deductible
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$1,600 individual; $3,200 family1 (applies to both in- and out-of-network; true family2 deductible)
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1 Family applies to the Employee + Child(ren), Employee + Spouse,/Domestic Partner or Employee + Family levels of coverage
2 Under a true family deductible, if only one family member becomes ill or injured, that person must meet the family deductible (rather than the individual deductible) before the plan reimburses for benefits. In this case, the plan requires satisfaction of a $3,200 deductible before any coinsurance will be paid.
3 Usual, customary and reasonable (UCR) limits
4 Beginning January 1, 2016, the Plan HSA out-of-pocket expenses paid for an individual family member will be limited to no more than $6,850 for in-network coverage before Plan HSA reimburses 100% of eligible expenses.
5 After deductible
6 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.
7 Medications for chronic conditions are restricted to mandatory mail order or CVS pharmacy after the prescription is filled twice at the retail level; mandatory generic; Step Therapy programs.
8 Drugs filled outside of the CVS Caremark network will initially be denied, and you will pay 100% of the cost. You will need to fill out an out-of-network paper claim to be reimbursed by the plan up to the out-of-network coinsurance, after deductible.
9 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.
10 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.