BNY Mellon Benefits Guide
Understand Your Out-of-Pocket Maximum
Your out-of-pocket maximum is the most you pay in deductible and coinsurance each year for certain medical and prescription drug services. Remember, you must meet your deductible for certain medical expenses before your coinsurance applies. If you reach your out-of-pocket maximum, BNY Mellon will pay 100 percent of eligible expenses.
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HSA PLAN
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LOWER DEDUCTIBLE HSA PLAN (IN-NETWORK)
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LOWER DEDUCTIBLE HSA PLAN (OUT-OF-NETWORK)
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HIGHER DEDUCTIBLE HSA PLAN (IN-NETWORK)
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HIGHER DEDUCTIBLE HSA PLAN (OUT-OF-NETWORK)
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Annual Out-of-Pocket Maximum
Includes deductible and coinsurance for medical and prescription drugs. Excludes any amount over UCR,* non-covered expenses and pre-certification penalties.
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Base Pay Range
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Individual
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Family
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Individual
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Family
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Individual
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Family
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Individual
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Family
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$0-$29,999
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$2,250
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$3,500
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$4,500
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$7,000
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$2,800
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$5,600
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$5,600
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$11,200
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$30,000-
$49,999
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$2,750
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$4,500
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$5,500
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$9,000
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$4,000
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$8,000**
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$8,000
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$16,000
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$50,000-
$79,999
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$3,750
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$6,000
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$7,500
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$12,000
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$5,000
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$10,000**
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$10,000
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$20,000
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$80,000-
$124,999
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$5,650
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$9,500**
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$11,300
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$19,000
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$6,000
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$12,000**
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$12,000
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$24,000
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$125,000+
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$6,300
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$11,500**
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$12,600
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$23,000
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$6,650
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$13,300**
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$13,300
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$26,600
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* Usual, customary and reasonable (CR) limits
** Out-of-pocket expenses paid for an individual with family coverage will be limited to no more than $7,900 for in-network coverage before the HSA plan reimburses 100 percent of eligible expenses.
