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 premium cost.
PLAN HRA
 
IN-NETWORK
OUT-OF-NETWORK
Deductible
$1,000 individual
$2,000 family
$2,000 individual
$4,000 family
Annual Out-of-Pocket Maximum (Includes deductible and coinsurance for medical and prescription drugs. Excludes any amount over UCR1, non-covered expenses and pre-certification penalties.)
BASE PAY RANGE
INDIVIDUAL
FAMILY
INDIVIDUAL
FAMILY
$0 – $29,999
$2,250
$4,500
$4,500
$9,000
$30,000 – $49,999
$2,750
$5,500
$6,300
$12,600
$50,000 – $79,999
$3,750
$7,500
$8,300
$16,600
$80,000 – $124,999
$4,750
$9,500
$10,100
$20,200
$125,000 and above
$5,750
$11,500
$11,100
$22,200
Services
Office Visits (Family/General Practice, Internal Medicine, Pediatrician, Ob/Gyn)
80%2
60%2
Preventive Care, Routine Physicals (Adult and Child), Mammograms, Well Childcare (immunizations)
100% (no deductible)
60%2
Mental Health, Behavioral Health and Substance Abuse (inpatient and outpatient services)
80%2
60%2
Outpatient Surgery
80%2
60%2
Hospital Care
80%2
60%2
Emergency Room
80%2
Physical, Speech and Occupational Therapy
80%2 (Combined in- and out-of-network limit of 60 visits per calendar year for combined therapies)
60%2 (Combined in- and out-of-network limit of 60 visits per calendar year for combined therapies)
Infertility
Plan pays up to $25,000 lifetime medical maximum benefit (in addition to $10,000 lifetime drug maximum benefit)3,6
Hearing Aid (per member)
Plan pays up to $5,000 every two years
Bariatric Surgery
80%2,7
Applied Behavior Analysis (ABA) Therapy
80%2
60%2
Joint and Spine Surgery
100%2, if performed at an Aetna Institute of Quality or UHC Center of Excellence
80%2, if performed at any other in-network facility
60%2
Organ Transplant
80%2, must be obtained from an Aetna Institute of Quality or a UHC Center of Excellence
Lifetime Maximum Benefit (per member)
Unlimited
Prescription Drugs (In-Network Only)4,5
Preventive Retail (30-day supply maximum)
  • Generic: Lesser of $10 or the retailer's regular cost
  • Formulary (Preferred) Brand: 25% coinsurance ($50 minimum/$75 maximum)
  • Non-Formulary (or Non-Preferred) Brand: 40% coinsurance ($75 minimum/$100 maximum)
Preventive Mail Order (90-day supply maximum)
  • Generic: Lesser of $25 or regular discount cost
  • Formulary (or Preferred) Brand: 25% coinsurance ($125 minimum/$187.50 maximum)
  • Non-Formulary (or Non-Preferred) Brand: 40% coinsurance ($187.50 minimum/$250 maximum)
Specialty
  • Generic: $10
  • Formulary (Preferred) Brand: $75
  • Non-Formulary (or Non-Preferred) Brand: $100
30 days' supply maximum at Retail and Mail Order; required to use CVS Caremark Specialty pharmacies after initial fill.
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. Note, there may be a transition of care benefit available for care currently in process. Contact your medical plan provider for more information.
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. Note, there may be a transition of care benefit available for care currently in process. Contact your medical plan provider for more information.