BNY Mellon Benefits Guide
Medical and Prescription Drug
Your health plan options offer quality care, broad coverage and money-saving opportunities. BNY Mellon offers most employees a choice between two national health plan options, each offered by Aetna and UnitedHealthcare, with prescription drug coverage offered through CVS Caremark. Your cost for coverage depends on the plan you elect and the family members you choose to enroll.
Your health plan options:
  • Lower Deductible HSA Plan (through Aetna or UnitedHealthcare)
  • Higher Deductible HSA Plan (through Aetna or UnitedHealthcare)
  • Kaiser Permanente Plan (Los Angeles and San Francisco only)
  • HMSA Hawaii Plan (Hawaii only)
  • Aetna International Plan (International Expats only)
  • No coverage
Your health plan coverage levels:
  • Employee
  • Employee + Child(ren)
  • Employee + Spouse/Qualified Domestic Partner
  • Employee + Family (you + your spouse/qualified domestic partner and child or children)
Please note: Summaries of benefits and coverage under Kaiser Permanente, HMSA Hawaii and Aetna International Plans are available on the MyBenefit Solutions enrollment website.
2019 HSA PLAN OPTIONS COMPARISON
 
LOWER DEDUCTIBLE HSA PLAN (IN-NETWORK)
LOWER DEDUCTIBLE HSA PLAN (OUT-OF-NETWORK)
HIGHER DEDUCTIBLE HSA PLAN (IN-NETWORK)
HIGHER DEDUCTIBLE HSA PLAN (OUT-OF-NETWORK)
Annual
Deductible1,2
$1,350 Individual;
$2,700 Family
(True Family Deductible)
$2,700 Individual;
$5,400 Family
(True Family Deductible)
$2,200 Individual;
$4,400 Family
(True Family Deductible)
$4,400 Individual;
$8,800 Family
(True Family Deductible)
Annual Out-of-Pocket Maximum
Includes deductible and coinsurance for medical and prescription drugs. Excludes any amount over UCR,3 non-covered expenses and pre-certification penalties.
Base Pay Range
Individual
Family
Individual
Family
Individual
Family
Individual
Family
$0-$29,999
$2,250
$3,500
$4,500
$7,000
$2,800
$5,600
$5,600
$11,200
$30,000-
$49,999
$2,750
$4,500
$5,500
$9,000
$4,000
$8,0004
$8,000
$16,000
$50,000-
$79,999
$3,750
$6,000
$7,500
$12,000
$5,000
$10,0004
$10,000
$20,000
$80,000-
$124,999
$5,650
$9,5004
$11,300
$19,000
$6,000
$12,0004
$12,000
$24,000
$125,000+
$6,300
$11,5004
$12,600
$23,000
$6,650
$13,3004
$13,300
$26,600
PREVENTIVE CARE
Adult Physical Exam (including Diagnostic Tests and Immunizations)
100% covered (deductible does not apply); according to preventive schedule
60% covered after deductible
100% covered (deductible does not apply); according to preventive schedule
60% covered after deductible
Routine Pediatric Care (including Diagnostic Tests and Immunizations)
100% covered (deductible does not apply)
60% covered after deductible
100% covered (deductible does not apply)
60% covered after deductible
Routine OB/GYN Care (including Pap Tests)
100% covered (deductible does not apply)
60% covered after deductible
100% covered (deductible does not apply)
60% covered after deductible
Mammograms/ PSA Tests
100% covered (deductible does not apply)
60% covered after deductible
100% covered (deductible does not apply)
60% covered after deductible
OFFICE VISITS
Primary Care Physician
80% covered after deductible
60% covered after deductible
80% covered after deductible
60% covered after deductible
Specialists
80% covered after deductible
60% covered after deductible
80% covered after deductible
60% covered after deductible
PROFESSIONAL SERVICES
Lab Tests and X-Rays
80% covered after deductible
60% covered after deductible
80% covered after deductible
60% covered after deductible
Advanced Imaging (including MRIs and CAT Scans)
80% covered after deductible
60% covered after deductible
80% covered after deductible
60% covered after deductible
OUTPATIENT CARE
Outpatient Surgery
80% covered after deductible
60% covered after deductible
80% covered after deductible
60% covered after deductible
Outpatient Physical, Occupational and Speech Therapy
80% covered after deductible; combined
in-/out-of-network limit of 60 visits per calendar year for all therapies combined
60% covered after deductible; combined
in-/out-of-network limit of 60 visits per calendar year for all therapies combined
80% covered after deductible; combined
in-/out-of-network limit of 60 visits per calendar year for all therapies combined
60% covered after deductible; combined
in-/out-of-network limit of 60 visits per calendar year for all therapies combined
INPATIENT CARE
Surgical Services
80% covered after deductible
60% covered after deductible
80% covered after deductible
60% covered after deductible
Semi-Private Room/Board
80% covered after deductible
60% covered after deductible
80% covered after deductible
60% covered after deductible
EMERGENCY ROOM/URGENT CARE
Emergency Room
80% covered after deductible
80% covered after deductible for medical emergency only
80% covered after deductible
80% covered after deductible for medical emergency only
Urgent Care Facility
80% covered after deductible
60% covered after deductible
80% covered after deductible
60% covered after deductible
MATERNITY CARE
Prenatal, Delivery and Postnatal Care by OB/GYN
80% covered after deductible (preventive prenatal care is 100% covered)
60% covered after deductible
80% covered after deductible (preventive prenatal care is 100% covered)
60% covered after deductible
Lab Tests and Radiology Services
80% covered after deductible
60% covered after deductible
80% covered after deductible
60% covered after deductible
Inpatient Hospital
80% covered after deductible
60% covered after deductible
80% covered after deductible
60% covered after deductible
Fertility Services5,6
80% covered after deductible; pre- authorization required; must use Institute of Excellence, if available; lifetime $25K medical and $10K Rx maximum; check with Plan for details
Not covered
80% covered after deductible; pre- authorization required; must use Institute of Excellence, if available; lifetime $25K medical and $10K Rx maximum; check with Plan for details
Not covered
MENTAL HEALTH/ SUBSTANCE ABUSE
Office Visits
80% covered after deductible
60% covered after deductible
80% covered after deductible
60% covered after deductible
Inpatient
80% covered after deductible
60% covered after deductible
80% covered after deductible
60% covered after deductible
OTHER BENEFITS
Hearing Aids
80% covered after deductible (max coverage of $5,000 every 2 years in- and out-of- network combined)
60% covered after deductible (max coverage of $5,000 every 2 years in- and out-of- network combined)
80% covered after deductible (max coverage of $5,000 every 2 years in- and out-of- network combined)
60% covered after deductible (max coverage of $5,000 every 2 years in- and out-of- network combined)
Bariatric Surgery7
80% covered after deductible; pre- authorization required; must be obtained from an Aetna Institute of Quality or a UHC Center of Excellence
Not covered
80% covered after deductible; pre- authorization required; must be obtained from an Aetna Institute of Quality or a UHC Center of Excellence
Not covered
Applied Behavior Analysis (ABA) Therapy
80% covered after deductible; pre- authorization required
60% covered after deductible; pre- authorization required
80% covered after deductible; pre- authorization required
60% covered after deductible; pre-authorization required
Joint and Spine Surgery
Certain complex joint and spinal surgeries covered 100% after deductible if services are obtained from an eligible Aetna Institute of Quality or a UHC Center of Excellence
All other: 80% covered after deductible
60% covered after deductible
Certain complex joint and spinal surgeries covered 100% after deductible if services are obtained from an eligible Aetna Institute of Quality or a UHC Center of Excellence
All other: 80% covered after deductible
60% covered after deductible
Transplant Surgery
80% after deductible; must be obtained from an eligible Aetna Institute of Quality or a UHC Center of Excellence
Not covered
80% after deductible; must be obtained from an eligible Aetna Institute of Quality or a UHC Center of Excellence
Not covered
Lifetime Coverage Limit
Unlimited
1 Family applies to the Employee + Child(ren), Employee + Spouse/Qualified Domestic Partner and 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 the family deductible before any coinsurance will be paid.
3 Usual, customary and reasonable (UCR) limits.
4 Out-of-pocket expenses paid for an individual with family coverage are limited to no more than $7,900 for in-network coverage before the Plan reimburses 100 percent of eligible expenses.
5 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.
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.