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
 
IN-NETWORK
OUT-OF-NETWORK
Deductible
$1,600 individual
$3,200 family1
true family deductible2
$1,600 individual
$3,200 family1
true family deductible2
Annual Out-of-Pocket Maximum (Includes deductible and coinsurance for medical and prescription drugs. Excludes any amount over UCR3, non-covered expenses and pre-certification penalties.)
 
BASE PAY RANGE
INDIVIDUAL
FAMILY
INDIVIDUAL
FAMILY
 
$0 – $29,999
$2,400
$4,800
$4,800
$9,600
 
$30,000 – $49,999
$3,900
$7,8004
$7,800
$15,600
 
$50,000 – $79,999
$5,500
$11,0004
$11,000
$22,000
 
$80,000 – $124,999
$6,350
$12,7004
$14,200
$28,400
 
$125,000 and above
$6,350
$12,7004
$15,600
$31,200
 
Services
 
Office Visits (Family/General Practice, Internal Medicine, Pediatrician, Ob/Gyn)
80%5
60%5
 
Preventive Care, Routine Physicals (Adult and Child), Mammograms, Well Childcare (immunizations)
100% (no deductible)
60%5
 
Mental Health, Behavioral Health and Substance Abuse (inpatient and outpatient t services)
80%5
60%5
 
Outpatient Surgery
80%5
60%5
 
Hospital Care
80%5
60%5
 
Emergency Room
80%5
 
Physical, Speech and Occupational Therapy
80%5 (Combined in- and out-of-network limit of 60 visits per calendar year for combined therapies)
60%5 (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)6,9
 
Hearing Aid (per member)
Plan pays up to $5,000 every two years
 
Bariatric Services
80%5,10
 
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
 
Applied Behavior Analysis (ABA) Therapy
80%5
60%5
 
Lifetime Maximum Benefit (per member)
Unlimited
 
Prescription Drugs (In-Network Only)
 
Retail
Preventive Drugs
  • Generic: Lesser of $10 or 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)
Non-Preventive Drugs
  • Generic: 20% coinsurance after deductible
  • Formulary (Preferred) Brand: 20% coinsurance after deductible
  • Non-Formulary (or Non-Preferred) Brand: 40% coinsurance after deductible
 
Mail Order7
Preventive Drugs
  • Generic: Lesser of $25 or regular discount cost
  • Formulary (Preferred) Brand: 25% coinsurance ($125 minimum; $187.50 maximum)
  • Non-Formulary (or Non-Preferred) Brand: 40% coinsurance ($187.50 minimum; $250 maximum)
Non-Preventive Drugs
  • Generic: 20% coinsurance after deductible
  • Formulary (Preferred) Brand: 20% coinsurance after deductible
  • Non-Formulary (or Non-Preferred) Brand: 40% coinsurance after deductible
 
Specialty
  • Generic: 20% coinsurance after deductible8
  • Formulary (Preferred) Brand: 20% coinsurance after deductible8
  • Non-Formulary (or Non-Preferred) Brand: 40% coinsurance after deductible
 
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 Plan HSA out-of-pocket expenses paid for an individual family member are limited to no more than $6,850 for in-network coverage before Plan HSA reimburses 100 percent 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 percent 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. Note, there may be a transition of care benefit available for care currently in process. Contact your medical plan provider for more information.
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. Note, there may be a transition of care benefit available for care currently in process. Contact your medical plan provider for more information.