Each medical plan option (except the “no coverage” option) offers the same basic plan components, including prescription drug and behavioral health care benefits. For more detailed medical plan comparison charts, review the Summaries of Benefits and Coverage. U.S. expatriates, click here.
|
Plan option |
What it offers |
|---|---|
|
|
|
Health Plan Plus Hawaii HMO |
|
|
No coverage option |
This option may make sense if you have medical coverage elsewhere (for example, through a spouse’s/domestic partner’s plan). For residents of Hawaii: Due to state law requirements, employees who opt out or waive their employer’s medical coverage must sign a coverage waiver form. If you live or work in Hawaii, and you choose the “no coverage” option under the Merck medical plan, a coverage waiver form will be mailed to you to complete and return. Contact the Benefits Service Center for more information. |
Monthly contributions for 2024 (full-time and part-time)
|
Monthly contributions |
Employee only |
Employee + spouse/domestic partner |
Employee + child(ren) |
Employee + spouse/domestic partner + child(ren) |
|---|---|---|---|---|
|
$100 |
$250 |
$200 |
$350 |
|
|
Health Plan Plus Hawaii HMO |
$75 |
$190 |
$151 |
$265 |
The following is a high-level summary of the benefits offered under the Merck PPO medical plan. For details about the medical plan, including other options and any exclusions and limitations that may apply, click here to access the plan documents.
|
In-network |
Out-of-network |
|
|
Plan features, highlights and limitations |
||
|
Annual deductible |
$500/$1,000 |
$1,000/$2,000 |
|
Annual out-of-pocket maximum
|
|
|
|
80%, after deductible |
70% of reasonable and customary limit, after deductible |
|
|
N/A |
You pay amounts above reasonable and customary |
|
|
None |
None |
|
|
Wellness benefits |
||
|
Routine annual physical exams |
100%, no deductible |
70% of reasonable and customary limit, no deductible |
|
Wellness/preventive services |
100%, no deductible |
70% of reasonable and customary limit, no deductible |
|
Routine cancer screening |
100%, no deductible |
70% of reasonable and customary limit, no deductible |
|
Outpatient medical care (other than preventive care) |
||
|
Physician office visits |
80%, after deductible |
70% of reasonable and customary limit, after deductible |
|
Telehealth consultations |
80%, after deductible |
Not covered |
|
Urgent care |
80%, after deductible |
70% of reasonable and customary limit, after deductible |
|
Emergency services |
||
|
Ambulance |
80%, after deductible |
80%, after deductible |
|
Emergency room |
80%, after deductible |
80%, after deductible |
|
Special services |
||
|
Chiropractic care Up to 25 visits per calendar year per person; maintenance therapy not covered |
80%, after deductible |
70% of reasonable and customary limit, after deductible |
|
Fertility benefits Artificial insemination, ovulation induction, advanced reproductive treatment (ART) |
80%, after deductible |
70% of reasonable and customary limit, after deductible |
|
Note: A combined lifetime maximum of $25,000 applies for medical benefits across all medical plan options |
||
|
Maternity delivery Charges in a hospital or approved, licensed birthing center |
80%, after deductible |
70% of reasonable and customary limit, after deductible |
|
Short-term rehabilitation Physical therapy, occupational therapy, speech therapy |
80%, after deductible |
70% of reasonable and customary limit, after deductible |
|
Transgender benefits |
80%, after in-network deductible |
80%, after deductible |
|
In-home drug therapy |
80%, after deductible |
Not covered |
|
Mental health and substance abuse |
||
|
80%, after deductible |
70% of reasonable and customary limit, after deductible |
Click here to access the Horizon claim form.
The managed prescription drug program (including Merck-brand drugs) is included with all medical options except the “no coverage” option. Our managed drug program is administered by CVS Caremark.
Visit caremark.com, where you can:
You can also download the free CVS Caremark app to refill and renew prescriptions, check your order status and more! When downloading the CVS app, choose “CVS Caremark” (blue) and not the in-store retail app called “CVS Pharmacy” (red). Apps can be downloaded from the App Store or Google Play.
The following is a high-level summary of the prescription drug coverage offered under the Merck PPO medical plan option. For details about any exclusions and limitations that may apply and other medical plan options, click here to access the plan documents.
|
Participating retail pharmacy up to a 30-day supply |
CVS Caremark (home delivery service) or Retail90 (retail) up to a 90-day supply |
|
|---|---|---|
|
Annual out-of-pocket maximum |
$1,500/$3,000 (combined retail and home delivery service) |
|
|
Non-diabetic medications |
Amount you pay |
Amount you pay |
|
Generic drugs |
$10 |
$20 |
|
Brand drugs when a generic equivalent is NOT available
|
$0 |
$0 |
|
Brand drugs when generic equivalent is available
|
40% of discounted price, up to $100 maximum (per prescription) |
40% of discounted price, up to $200 maximum (per prescription) |
|
Diabetic medications and supplies |
||
|
Generic and Merck-brand diabetes medication and supplies |
$0 |
$0 |
|
Non-Merck brand diabetes medications and supplies |
$10 |
$20 |
Note: Fertility benefits have a $10,000 prescription lifetime maximum per patient.
Lyra Health provides fast access to high-quality evidence-based mental health care. The first 12 sessions are free and available to you, your spouse/domestic partner, any of your household members and your dependent children outside the household (up to age 26). Following your online assessment, Lyra creates a care plan for you, designed specifically for your unique needs and lifestyle, including a curated selection of mental health coaches and therapists who are currently taking appointments. With Lyra, you can book an appointment with the provider who works best for you. For more information about Lyra, go to the Mentally well section of this site.
Visit merck.lyrahealth.com or call 844-737-9423 to get started.
*Merck medical plan members enrolled in the Merck PPO with Horizon BCBS can continue therapy with their Lyra provider beyond the 12 free sessions, and access medication management, all subject to in-network deductibles and coinsurance. Please note: Guided self-care and coaching are not available beyond the 12 free sessions. Medication management sessions are not included in the 12 free sessions. Lyra’s pricing varies based on the provider and type of service. For details on the in-network deductible and/or coinsurance you will be expected to pay, go to the Medical and prescription drugs section of this site. For questions about Lyra provider session rates, contact the Lyra Care Navigator Team at 844-737-9423 or email them at care@lyrahealth.com.
Get medical care 24/7 from U.S. board-certified, licensed doctors for conditions such as: abdominal pain, colds and flu, fever, skin irritations, sinusitis and more.
Visit horizonblue.com/merck.
2nd.MD will provide expert second opinions — such as confirming a complex or rare diagnosis, weighing in on a prescribed treatment plan or providing an alternative approach — with medical specialists at leading institutions.
Call a Horizon Health Guide at 877-663-7258, Monday through Friday, 8 a.m. to 11 p.m. ET to get started.
MSK Direct can facilitate access to expert cancer care, guarantee an expedited appointment as fast as clinically appropriate, help you gather all necessary medical records and introduce you to your clinical team at your first appointment. You do not need to be enrolled in the Merck medical plan to take advantage of MSK Direct, and it’s available to your immediate and extended family members. For more information, go to mskcc.org/merck or call 833-986-1751.
In addition, you have fast access to high-quality cancer care through Dana-Farber, the #1 cancer hospital in New England. Dana-Farber’s dedicated team of experts is there to provide support during your cancer diagnosis, treatment or a second opinion. You do not need to be enrolled in Merck medical plan to take advantage of Dana-Farber Direct Connect. For more information, go to dana-farber.org/merck, call 866-977-3262 Monday through Friday from 8 a.m. to 5 p.m. ET or email DirectConnect@dfci.harvard.edu.
Livongo is a diabetes management program offered at no cost to you and your covered dependents who are Merck medical plan participants diagnosed with type 1 or type 2 diabetes. It provides personalized, relevant, timely support to help you to lead a better life. The program includes:
Click here (company code: Merck) to register or call 800-945-4355 to learn more.
The first step to using Merck’s fertility benefits is to contact a Horizon Health Guide. They will connect you with WINFertility, a family-building advocacy support program. Fertility nurse care managers and behavioral health specialists will guide you through every step of your journey with medical expertise and emotional support.
Call a Horizon Health Guide at 877-663-7258, Monday through Friday, 8 a.m. to 11 p.m. ET to get started.
We provide a full range of transgender-related benefits and procedures for those with a diagnosis of gender dysphoria.
Since only a handful of doctors specialize in trans-care, you can use any accredited physician or provider, regardless of location or whether they accept insurance, and receive coverage as if it were in-network. This includes behavioral health therapists who specialize in transgender patients.
We follow evidence-based guidelines provided by the World Professional Association for Transgender Health (WPATH).
To speak to a dedicated Horizon Health Guide transgender specialist, call 877-663-7258, Monday through Friday, 8 a.m. to 11 p.m. ET.
If you’re planning to retire soon, and you are eligible for subsidized retiree medical coverage and you or your dependent are or soon will be at least age 65 and Medicare-eligible, you must take action by carefully reviewing the following information:
The “no coverage” option under the medical plan
If you are enrolled in the “no coverage” option under the medical plan on the date your employment ends, or you do not cover all of your eligible dependents, and you are eligible for subsidized retiree medical coverage, and you or your dependent is at least age 65 and Medicare-eligible, the choices of the Medicare-eligible individual for coverage through Alight Retiree Health Solutions may be limited. For example, you or your dependent may be subject to underwriting and may not be able to enroll in the Alight Retiree Health Solutions until the next Medicare Open Enrollment period, which may result in a gap in coverage or Medicare late enrollment penalties, if not enrolled elsewhere.
See the Merck Group Retiree Medical Plan SPD and the Merck Retiree HRA SPD for more information on retiree medical coverage or contact the Alight Retiree Health Solutions at 844-868-6229 or visit retiree.alight.com/merck.
Reminder: Enroll in Medicare as soon as first eligible
The Merck medical plan and the Merck Group Retiree Medical Plan coordinate with Medicare as primary whenever it is legally permitted to do so. Generally, you become eligible for Medicare coverage on the 1st of the month that precedes your 65th birthday. In addition, if you are or become disabled and receive Social Security Disability Income (SSDI) benefits (generally 24 months after you become disabled), you are generally eligible for Medicare.
As long as you remain an active employee receiving a salary from Merck, the medical plan pays benefits first — before Medicare, unless you are not active due to disability. If you are not an active employee due to disability (or otherwise) for at least six months, or terminate employment (including benefits continuation, COBRA and retirement), and if you are eligible for medical coverage under the Merck medical plan or the Merck Group Retiree Medical Plan, then Medicare becomes the primary plan and all bills should be submitted to Medicare first.
All of the medical plan options available to you require you and your covered dependents who are eligible for Medicare to enroll in Medicare — Parts A and B — when you are first eligible. The medical plan options will coordinate coverage with Medicare Parts A and B, even if you fail to enroll. Accordingly, to avoid a gap in coverage and also ensure you are not subject to Medicare late enrollment penalties, you should make sure you enroll in Medicare. Note that you are responsible for paying to Medicare all premiums required by Medicare in addition to any contribution required by Merck to continue coverage under the Merck medical plan or the Merck Group Retiree Medical Plan. While participation in Medicare Parts A and B is required, participation in Medicare Part D prescription drug coverage is voluntary and the company does not require that you or your covered dependents sign up for Medicare Part D while covered under the Merck medical plan or the Merck Group Retiree Medical Plan.
If you or an eligible dependent becomes eligible for Medicare coverage under circumstances where Medicare is primary, the medical plan will assume full Medicare Parts A and B coverage has been elected as soon as you or your covered dependents are eligible for Medicare coverage. Should you or your dependent elect anything other than full Medicare Parts A and B coverage, the medical plan will reduce benefits to reflect whatever Medicare would have paid had you elected the full Medicare Parts A and B coverage.
See the Merck Medical Plan SPD and the Merck Group Retiree Medical Plan SPD for detailed information on coordination with Medicare. See the Merck Retiree HRA SPD for additional information about the retiree HRA.
877-663-7258
(group number: 76016)
horizonblue.com/merck
808-948-6372
(group number: 93683)
hmsa.com
If you live in Hawaii refer to the medical plan comparison chart on netbenefits.com/merck.
The amount you pay each year before the Medical Plan begins to pay benefits for covered medical expenses for you and your covered dependents. Amounts higher than Reasonable & Customary (R&C) limits and non-covered expenses do not count toward your annual deductible. Expenses incurred to satisfy your deductible will be credited to both your in-network and out-of-network deductibles. Expenses in excess of the R&C limit do not count toward your deductible.
The most you and your covered dependents are required to pay for covered prescription drug expenses in a year (combined retail and home delivery service). Generally, once the out-of-pocket maximum is reached, the plan will pay 100% of the cost for covered prescriptions for the remainder of the plan year for the person who met the limit.
The percentage of the cost of an eligible expense you pay — 80% of pre-negotiated, discounted fees (in-network) or 70% of Reasonable & Customary (R&C) charges (out-of-network).
The amount you pay each year before the Medical Plan begins to pay benefits for covered medical expenses for you and your covered dependents. Expenses incurred to satisfy your deductible will be credited to both your in-network and out-of-network deductibles. Expenses in excess of Reasonable & Customary limits and non-covered expenses do not count toward your annual deductible.
The maximum amount of benefits you and your eligible covered dependents can receive under the Medical Plan. Only Infertility Diagnosis and Treatment have a lifetime maximum.
The health care provider will determine whether or not the condition being diagnosed and/or treated is appropriate for a telehealth encounter. Additionally, the scope of care is at the sole discretion of the provider with no guarantee of diagnosis, treatment or prescription.
Merck-brand drugs are offered at a $0 copay unless they have a generic equivalent. Merck-brand drugs with a generic equivalent will follow the same cost-sharing provisions as other brand drugs with a generic equivalent.
Together, Medicare Parts A and B are often referred to as Original Medicare, a fee-for-service health plan. Part A is hospital insurance; Part B is medical insurance. After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles).
Medicare prescription drug coverage.
