DeVal Lifecycle
Medical Benefits at a Glance — Effective 1/1/2026 (Production & Non-Production)

Healthcare costs continue to soar; however, we are pleased to announce there will be no benefit changes or reductions. After 6 years of no payroll deduction increases, this year there will be a modest change. DeVal Lifecycle continues to pay the bulk of the premium costs and increases. We are proud of our extensive array of benefits and offerings.

Employer Contribution:

  • The Company contributes approximately 85% of the cost of a single plan, and 50% toward the cost of dependent coverage (family, employee/spouse, and employee/child(ren)).
  • The Company contributes $500 in January for each employee that selects the high-deductible Bronze option that includes the HSA.
  • If you waive medical coverage for you and your family, you will receive a $100/month Medical Plan Opt-Out reimbursement.

Medical Coverage at a Glance:

  • Independence Blue Cross offers an extensive provider network in NJ and PA.
  • There are plan options with and without a referral requirement.
  • Choose from the Gold, Silver, or Bronze options. Choose what is best for you and your family—lower copays at the doctor’s office or a lower payroll deduction.

Plan Options:

  • Gold Plan (Personal Choice PPO):
    • No deductible, no referrals, out-of-network benefits included
    • PPO BlueCard National network access
    • Prescription card benefit
    • Highest payroll cost
  • Silver Plan (Keystone POS):
    • Deductible for some expenses, copays for more routine care
    • Referrals required, no out-of-network benefits (regional network access)
    • Prescription card benefit
    • Moderate payroll cost
  • Bronze Plan (Personal Choice PPO w/ HSA):
    • High Deductible Health Plan (HDHP). Deductible applies to all expenses except preventive care
    • No referrals, out-of-network benefits included
    • PPO BlueCard National network access
    • Prescription covered after the deductible
    • Health Savings Account (HSA) eligible—Company provides $500 in HSA dollars
    • Most economical payroll cost

Health Savings Account (HSA):

  • The Company will contribute $500 for each employee electing the Bronze Plan/HSA.
  • 2026 Maximum Annual HSA Pre-Tax Contribution Limits:
    • $4,400 Employee-only coverage
    • $8,750 Employee + Dependents (Includes employer contribution)
    • If over age 55, an additional $1,000 catch-up contribution is allowed
    • Combined employer and employee voluntary HSA contributions cannot exceed the annual allowed IRS maximum limit.

Select A Plan

  • Plan Name

    IBC Personal Choice PPO w/BlueCard $50/$80/$500

  • Network Access

    PPO BlueCard National Network Access. Out-of-network benefits included.

  • Primary Care Physicians (PCP)

    No (Not required)

  • Referrals for Specialists

    No (Not required)

  • Deductible (In-Network)

    $0

  • Coinsurance (In-Network)

    0%

  • Out-of-Pocket Max (In-Network)

    $7,900 Individual / $15,800 Family

  • Office Visit Copay

    $50

  • Specialist Copay

    $80

  • Telemedicine

    $40

  • Preventive Care Copay

    $0

  • Outpatient Labs (Freestanding)

    $0

  • Outpatient X-Rays

    $80

  • MRI/MRA PET/CAT Scans

    $300

  • Hospital Copay

    $500 copay/day (days 1-5), $250 copay/day (days 6-10)

  • Outpatient Surgery / Procedure Copay

    $500

  • Emergency Room Copay

    $300

  • Urgent Care

    $100

  • Out-of-Network / Self-Referred Deductible

    $2,500 Individual / $5,000 Family (Out-of-Network)

  • Out-of-Network / Self-Referred Coinsurance

    50% (Out-of-Network)

  • Out-of-Network / Self-Referred Out-of-Pocket Max

    $10,000 Individual / $20,000 Family (Out-of-Network)

  • Routine Eye Exam (Medical Plan)

    $40

  • Eyeglasses (Medical Plan)

    Not Covered

  • Generic Prescription Copay

    $3 / $20

  • Preferred Brand Name Copay

    $40

  • Non-Preferred Brand Name Copay

    $60

  • Specialty Drug

    50% ($500 copay max)

  • Health Savings Account (HSA) - Employer Contribution

    Not Available

  • Health Savings Account (HSA) - Voluntary Employee Contribution

    Not Available

  • Per Pay Deduction - Employee (52 pays)

    $33.59

  • Per Pay Deduction - Employee/Child(ren) (52 pays)

    $97.31

  • Per Pay Deduction - Employee/Spouse (52 pays)

    $139.47

  • Per Pay Deduction - Family (52 pays)

    $190.99

Carrier: Independence Blue Cross
Website / Provider Search: ibx.com
Network: PPO BlueCard National Network

To find participating providers please log onto www.ibx.com. This is a summary only. Please refer to the carrier’s plan description for detailed information.

Gold Silver Bronze

Plan Name

IBC Personal Choice PPO w/BlueCard $50/$80/$500

Plan Name

Keystone POS $30/$60/100%

Plan Name

IBC Personal Choice PPO w/BlueCard $3000/$30/$60/$500 HSA

Network Access

PPO BlueCard National Network Access. Out-of-network benefits included.

Network Access

Regional Network Access. PCP & Referrals required. Self-Referred benefits available.

Network Access

High Deductible Health Plan (HDHP). PPO BlueCard National Network Access. Out-of-network benefits included. Deductible applies to all expenses except preventive care.

Primary Care Physicians (PCP)

No (Not required)

Primary Care Physicians (PCP)

Yes (Required)

Primary Care Physicians (PCP)

No (Not required)

Referrals for Specialists

No (Not required)

Referrals for Specialists

Yes (Required)

Referrals for Specialists

No (Not required)

Deductible (In-Network)

$0

Deductible (In-Network)

$3,000 Individual / $6,000 Family

Deductible (In-Network)

$3,000 Individual / $6,000 Family

Coinsurance (In-Network)

0%

Coinsurance (In-Network)

0%

Coinsurance (In-Network)

0%

Out-of-Pocket Max (In-Network)

$7,900 Individual / $15,800 Family

Out-of-Pocket Max (In-Network)

$7,900 Individual / $15,800 Family

Out-of-Pocket Max (In-Network)

$6,750 Individual / $13,500 Family

Office Visit Copay

$50

Office Visit Copay

$30

Office Visit Copay

$30 after deductible

Specialist Copay

$80

Specialist Copay

$60

Specialist Copay

$60 after deductible

Telemedicine

$40

Telemedicine

$40

Telemedicine

$40 after deductible

Preventive Care Copay

$0

Preventive Care Copay

$0

Preventive Care Copay

$0

Outpatient Labs (Freestanding)

$0

Outpatient Labs (Freestanding)

$60

Outpatient Labs (Freestanding)

$60 after deductible Freestanding / $120 Hospital

Outpatient X-Rays

$80

Outpatient X-Rays

$60

Outpatient X-Rays

$60 after deductible

MRI/MRA PET/CAT Scans

$300

MRI/MRA PET/CAT Scans

$200

MRI/MRA PET/CAT Scans

$200 after deductible

Hospital Copay

$500 copay/day (days 1-5), $250 copay/day (days 6-10)

Hospital Copay

0% after deductible

Hospital Copay

$500 copay/day (days 1-5) after deductible

Outpatient Surgery / Procedure Copay

$500

Outpatient Surgery / Procedure Copay

$300 after deductible

Outpatient Surgery / Procedure Copay

$500 after deductible

Emergency Room Copay

$300

Emergency Room Copay

$300 after deductible

Emergency Room Copay

$300 after deductible

Urgent Care

$100

Urgent Care

$100

Urgent Care

$100 after deductible

Out-of-Network / Self-Referred Deductible

$2,500 Individual / $5,000 Family (Out-of-Network)

Out-of-Network / Self-Referred Deductible

$5,000 Individual / $10,000 Family (Self-Referred)

Out-of-Network / Self-Referred Deductible

$5,000 Individual / $10,000 Family (Out-of-Network)

Out-of-Network / Self-Referred Coinsurance

50% (Out-of-Network)

Out-of-Network / Self-Referred Coinsurance

50% (Self-Referred)

Out-of-Network / Self-Referred Coinsurance

50% (Out-of-Network)

Out-of-Network / Self-Referred Out-of-Pocket Max

$10,000 Individual / $20,000 Family (Out-of-Network)

Out-of-Network / Self-Referred Out-of-Pocket Max

$30,000 Individual / $60,000 Family (Self-Referred)

Out-of-Network / Self-Referred Out-of-Pocket Max

$10,000 Individual / $20,000 Family (Out-of-Network)

Routine Eye Exam (Medical Plan)

$40

Routine Eye Exam (Medical Plan)

$40

Routine Eye Exam (Medical Plan)

Not Covered (See Guardian Vision Plan)

Eyeglasses (Medical Plan)

Not Covered

Eyeglasses (Medical Plan)

Not Covered

Eyeglasses (Medical Plan)

Not Covered

Generic Prescription Copay

$3 / $20

Generic Prescription Copay

$3 / $20

Generic Prescription Copay

$3 / $20 after deductible

Preferred Brand Name Copay

$40

Preferred Brand Name Copay

$40

Preferred Brand Name Copay

$40 after deductible

Non-Preferred Brand Name Copay

$60

Non-Preferred Brand Name Copay

$60

Non-Preferred Brand Name Copay

$70 after deductible

Specialty Drug

50% ($500 copay max)

Specialty Drug

50% ($500 copay max)

Specialty Drug

50% ($500 copay max) after deductible

Health Savings Account (HSA) - Employer Contribution

Not Available

Health Savings Account (HSA) - Employer Contribution

Not Available

Health Savings Account (HSA) - Employer Contribution

$500 annual upfront employer HSA contribution

Health Savings Account (HSA) - Voluntary Employee Contribution

Not Available

Health Savings Account (HSA) - Voluntary Employee Contribution

Not Available

Health Savings Account (HSA) - Voluntary Employee Contribution

2026 gross maximum annual HSA pre-tax contribution: $4,400 Employee / $8,750 Employee + Dependents (Includes employer contribution). If over age 55, additional $1,000 catch-up contribution allowed. Employer + Employee voluntary HSA contributions cannot exceed the annual allowed IRS maximum limit.

Per Pay Deduction - Employee (52 pays)

$33.59

Per Pay Deduction - Employee (52 pays)

$20.48

Per Pay Deduction - Employee (52 pays)

$7.64

Per Pay Deduction - Employee/Child(ren) (52 pays)

$97.31

Per Pay Deduction - Employee/Child(ren) (52 pays)

$73.94

Per Pay Deduction - Employee/Child(ren) (52 pays)

$55.96

Per Pay Deduction - Employee/Spouse (52 pays)

$139.47

Per Pay Deduction - Employee/Spouse (52 pays)

$109.31

Per Pay Deduction - Employee/Spouse (52 pays)

$86.27

Per Pay Deduction - Family (52 pays)

$190.99

Per Pay Deduction - Family (52 pays)

$152.53

Per Pay Deduction - Family (52 pays)

$124.52

  • Plan Name

    Keystone POS $30/$60/100%

  • Network Access

    Regional Network Access. PCP & Referrals required. Self-Referred benefits available.

  • Primary Care Physicians (PCP)

    Yes (Required)

  • Referrals for Specialists

    Yes (Required)

  • Deductible (In-Network)

    $3,000 Individual / $6,000 Family

  • Coinsurance (In-Network)

    0%

  • Out-of-Pocket Max (In-Network)

    $7,900 Individual / $15,800 Family

  • Office Visit Copay

    $30

  • Specialist Copay

    $60

  • Telemedicine

    $40

  • Preventive Care Copay

    $0

  • Outpatient Labs (Freestanding)

    $60

  • Outpatient X-Rays

    $60

  • MRI/MRA PET/CAT Scans

    $200

  • Hospital Copay

    0% after deductible

  • Outpatient Surgery / Procedure Copay

    $300 after deductible

  • Emergency Room Copay

    $300 after deductible

  • Urgent Care

    $100

  • Out-of-Network / Self-Referred Deductible

    $5,000 Individual / $10,000 Family (Self-Referred)

  • Out-of-Network / Self-Referred Coinsurance

    50% (Self-Referred)

  • Out-of-Network / Self-Referred Out-of-Pocket Max

    $30,000 Individual / $60,000 Family (Self-Referred)

  • Routine Eye Exam (Medical Plan)

    $40

  • Eyeglasses (Medical Plan)

    Not Covered

  • Generic Prescription Copay

    $3 / $20

  • Preferred Brand Name Copay

    $40

  • Non-Preferred Brand Name Copay

    $60

  • Specialty Drug

    50% ($500 copay max)

  • Health Savings Account (HSA) - Employer Contribution

    Not Available

  • Health Savings Account (HSA) - Voluntary Employee Contribution

    Not Available

  • Per Pay Deduction - Employee (52 pays)

    $20.48

  • Per Pay Deduction - Employee/Child(ren) (52 pays)

    $73.94

  • Per Pay Deduction - Employee/Spouse (52 pays)

    $109.31

  • Per Pay Deduction - Family (52 pays)

    $152.53

Carrier: Independence Blue Cross
Website / Provider Search: ibx.com
Network: Keystone POS (Regional Network)

To find participating providers please log onto www.ibx.com. This is a summary only. Please refer to the carrier’s plan description for detailed information.

Silver Gold Bronze

Plan Name

Keystone POS $30/$60/100%

Plan Name

IBC Personal Choice PPO w/BlueCard $50/$80/$500

Plan Name

IBC Personal Choice PPO w/BlueCard $3000/$30/$60/$500 HSA

Network Access

Regional Network Access. PCP & Referrals required. Self-Referred benefits available.

Network Access

PPO BlueCard National Network Access. Out-of-network benefits included.

Network Access

High Deductible Health Plan (HDHP). PPO BlueCard National Network Access. Out-of-network benefits included. Deductible applies to all expenses except preventive care.

Primary Care Physicians (PCP)

Yes (Required)

Primary Care Physicians (PCP)

No (Not required)

Primary Care Physicians (PCP)

No (Not required)

Referrals for Specialists

Yes (Required)

Referrals for Specialists

No (Not required)

Referrals for Specialists

No (Not required)

Deductible (In-Network)

$3,000 Individual / $6,000 Family

Deductible (In-Network)

$0

Deductible (In-Network)

$3,000 Individual / $6,000 Family

Coinsurance (In-Network)

0%

Coinsurance (In-Network)

0%

Coinsurance (In-Network)

0%

Out-of-Pocket Max (In-Network)

$7,900 Individual / $15,800 Family

Out-of-Pocket Max (In-Network)

$7,900 Individual / $15,800 Family

Out-of-Pocket Max (In-Network)

$6,750 Individual / $13,500 Family

Office Visit Copay

$30

Office Visit Copay

$50

Office Visit Copay

$30 after deductible

Specialist Copay

$60

Specialist Copay

$80

Specialist Copay

$60 after deductible

Telemedicine

$40

Telemedicine

$40

Telemedicine

$40 after deductible

Preventive Care Copay

$0

Preventive Care Copay

$0

Preventive Care Copay

$0

Outpatient Labs (Freestanding)

$60

Outpatient Labs (Freestanding)

$0

Outpatient Labs (Freestanding)

$60 after deductible Freestanding / $120 Hospital

Outpatient X-Rays

$60

Outpatient X-Rays

$80

Outpatient X-Rays

$60 after deductible

MRI/MRA PET/CAT Scans

$200

MRI/MRA PET/CAT Scans

$300

MRI/MRA PET/CAT Scans

$200 after deductible

Hospital Copay

0% after deductible

Hospital Copay

$500 copay/day (days 1-5), $250 copay/day (days 6-10)

Hospital Copay

$500 copay/day (days 1-5) after deductible

Outpatient Surgery / Procedure Copay

$300 after deductible

Outpatient Surgery / Procedure Copay

$500

Outpatient Surgery / Procedure Copay

$500 after deductible

Emergency Room Copay

$300 after deductible

Emergency Room Copay

$300

Emergency Room Copay

$300 after deductible

Urgent Care

$100

Urgent Care

$100

Urgent Care

$100 after deductible

Out-of-Network / Self-Referred Deductible

$5,000 Individual / $10,000 Family (Self-Referred)

Out-of-Network / Self-Referred Deductible

$2,500 Individual / $5,000 Family (Out-of-Network)

Out-of-Network / Self-Referred Deductible

$5,000 Individual / $10,000 Family (Out-of-Network)

Out-of-Network / Self-Referred Coinsurance

50% (Self-Referred)

Out-of-Network / Self-Referred Coinsurance

50% (Out-of-Network)

Out-of-Network / Self-Referred Coinsurance

50% (Out-of-Network)

Out-of-Network / Self-Referred Out-of-Pocket Max

$30,000 Individual / $60,000 Family (Self-Referred)

Out-of-Network / Self-Referred Out-of-Pocket Max

$10,000 Individual / $20,000 Family (Out-of-Network)

Out-of-Network / Self-Referred Out-of-Pocket Max

$10,000 Individual / $20,000 Family (Out-of-Network)

Routine Eye Exam (Medical Plan)

$40

Routine Eye Exam (Medical Plan)

$40

Routine Eye Exam (Medical Plan)

Not Covered (See Guardian Vision Plan)

Eyeglasses (Medical Plan)

Not Covered

Eyeglasses (Medical Plan)

Not Covered

Eyeglasses (Medical Plan)

Not Covered

Generic Prescription Copay

$3 / $20

Generic Prescription Copay

$3 / $20

Generic Prescription Copay

$3 / $20 after deductible

Preferred Brand Name Copay

$40

Preferred Brand Name Copay

$40

Preferred Brand Name Copay

$40 after deductible

Non-Preferred Brand Name Copay

$60

Non-Preferred Brand Name Copay

$60

Non-Preferred Brand Name Copay

$70 after deductible

Specialty Drug

50% ($500 copay max)

Specialty Drug

50% ($500 copay max)

Specialty Drug

50% ($500 copay max) after deductible

Health Savings Account (HSA) - Employer Contribution

Not Available

Health Savings Account (HSA) - Employer Contribution

Not Available

Health Savings Account (HSA) - Employer Contribution

$500 annual upfront employer HSA contribution

Health Savings Account (HSA) - Voluntary Employee Contribution

Not Available

Health Savings Account (HSA) - Voluntary Employee Contribution

Not Available

Health Savings Account (HSA) - Voluntary Employee Contribution

2026 gross maximum annual HSA pre-tax contribution: $4,400 Employee / $8,750 Employee + Dependents (Includes employer contribution). If over age 55, additional $1,000 catch-up contribution allowed. Employer + Employee voluntary HSA contributions cannot exceed the annual allowed IRS maximum limit.

Per Pay Deduction - Employee (52 pays)

$20.48

Per Pay Deduction - Employee (52 pays)

$33.59

Per Pay Deduction - Employee (52 pays)

$7.64

Per Pay Deduction - Employee/Child(ren) (52 pays)

$73.94

Per Pay Deduction - Employee/Child(ren) (52 pays)

$97.31

Per Pay Deduction - Employee/Child(ren) (52 pays)

$55.96

Per Pay Deduction - Employee/Spouse (52 pays)

$109.31

Per Pay Deduction - Employee/Spouse (52 pays)

$139.47

Per Pay Deduction - Employee/Spouse (52 pays)

$86.27

Per Pay Deduction - Family (52 pays)

$152.53

Per Pay Deduction - Family (52 pays)

$190.99

Per Pay Deduction - Family (52 pays)

$124.52

  • Plan Name

    IBC Personal Choice PPO w/BlueCard $3000/$30/$60/$500 HSA

  • Network Access

    High Deductible Health Plan (HDHP). PPO BlueCard National Network Access. Out-of-network benefits included. Deductible applies to all expenses except preventive care.

  • Primary Care Physicians (PCP)

    No (Not required)

  • Referrals for Specialists

    No (Not required)

  • Deductible (In-Network)

    $3,000 Individual / $6,000 Family

  • Coinsurance (In-Network)

    0%

  • Out-of-Pocket Max (In-Network)

    $6,750 Individual / $13,500 Family

  • Office Visit Copay

    $30 after deductible

  • Specialist Copay

    $60 after deductible

  • Telemedicine

    $40 after deductible

  • Preventive Care Copay

    $0

  • Outpatient Labs (Freestanding)

    $60 after deductible Freestanding / $120 Hospital

  • Outpatient X-Rays

    $60 after deductible

  • MRI/MRA PET/CAT Scans

    $200 after deductible

  • Hospital Copay

    $500 copay/day (days 1-5) after deductible

  • Outpatient Surgery / Procedure Copay

    $500 after deductible

  • Emergency Room Copay

    $300 after deductible

  • Urgent Care

    $100 after deductible

  • Out-of-Network / Self-Referred Deductible

    $5,000 Individual / $10,000 Family (Out-of-Network)

  • Out-of-Network / Self-Referred Coinsurance

    50% (Out-of-Network)

  • Out-of-Network / Self-Referred Out-of-Pocket Max

    $10,000 Individual / $20,000 Family (Out-of-Network)

  • Routine Eye Exam (Medical Plan)

    Not Covered (See Guardian Vision Plan)

  • Eyeglasses (Medical Plan)

    Not Covered

  • Generic Prescription Copay

    $3 / $20 after deductible

  • Preferred Brand Name Copay

    $40 after deductible

  • Non-Preferred Brand Name Copay

    $70 after deductible

  • Specialty Drug

    50% ($500 copay max) after deductible

  • Health Savings Account (HSA) - Employer Contribution

    $500 annual upfront employer HSA contribution

  • Health Savings Account (HSA) - Voluntary Employee Contribution

    2026 gross maximum annual HSA pre-tax contribution: $4,400 Employee / $8,750 Employee + Dependents (Includes employer contribution). If over age 55, additional $1,000 catch-up contribution allowed. Employer + Employee voluntary HSA contributions cannot exceed the annual allowed IRS maximum limit.

  • Per Pay Deduction - Employee (52 pays)

    $7.64

  • Per Pay Deduction - Employee/Child(ren) (52 pays)

    $55.96

  • Per Pay Deduction - Employee/Spouse (52 pays)

    $86.27

  • Per Pay Deduction - Family (52 pays)

    $124.52

Carrier: Independence Blue Cross
Website / Provider Search: ibx.com
Network: PPO BlueCard National Network

To find participating providers please log onto www.ibx.com. This is a summary only. Please refer to the carrier’s plan description for detailed information.

Bronze Gold Silver

Plan Name

IBC Personal Choice PPO w/BlueCard $3000/$30/$60/$500 HSA

Plan Name

IBC Personal Choice PPO w/BlueCard $50/$80/$500

Plan Name

Keystone POS $30/$60/100%

Network Access

High Deductible Health Plan (HDHP). PPO BlueCard National Network Access. Out-of-network benefits included. Deductible applies to all expenses except preventive care.

Network Access

PPO BlueCard National Network Access. Out-of-network benefits included.

Network Access

Regional Network Access. PCP & Referrals required. Self-Referred benefits available.

Primary Care Physicians (PCP)

No (Not required)

Primary Care Physicians (PCP)

No (Not required)

Primary Care Physicians (PCP)

Yes (Required)

Referrals for Specialists

No (Not required)

Referrals for Specialists

No (Not required)

Referrals for Specialists

Yes (Required)

Deductible (In-Network)

$3,000 Individual / $6,000 Family

Deductible (In-Network)

$0

Deductible (In-Network)

$3,000 Individual / $6,000 Family

Coinsurance (In-Network)

0%

Coinsurance (In-Network)

0%

Coinsurance (In-Network)

0%

Out-of-Pocket Max (In-Network)

$6,750 Individual / $13,500 Family

Out-of-Pocket Max (In-Network)

$7,900 Individual / $15,800 Family

Out-of-Pocket Max (In-Network)

$7,900 Individual / $15,800 Family

Office Visit Copay

$30 after deductible

Office Visit Copay

$50

Office Visit Copay

$30

Specialist Copay

$60 after deductible

Specialist Copay

$80

Specialist Copay

$60

Telemedicine

$40 after deductible

Telemedicine

$40

Telemedicine

$40

Preventive Care Copay

$0

Preventive Care Copay

$0

Preventive Care Copay

$0

Outpatient Labs (Freestanding)

$60 after deductible Freestanding / $120 Hospital

Outpatient Labs (Freestanding)

$0

Outpatient Labs (Freestanding)

$60

Outpatient X-Rays

$60 after deductible

Outpatient X-Rays

$80

Outpatient X-Rays

$60

MRI/MRA PET/CAT Scans

$200 after deductible

MRI/MRA PET/CAT Scans

$300

MRI/MRA PET/CAT Scans

$200

Hospital Copay

$500 copay/day (days 1-5) after deductible

Hospital Copay

$500 copay/day (days 1-5), $250 copay/day (days 6-10)

Hospital Copay

0% after deductible

Outpatient Surgery / Procedure Copay

$500 after deductible

Outpatient Surgery / Procedure Copay

$500

Outpatient Surgery / Procedure Copay

$300 after deductible

Emergency Room Copay

$300 after deductible

Emergency Room Copay

$300

Emergency Room Copay

$300 after deductible

Urgent Care

$100 after deductible

Urgent Care

$100

Urgent Care

$100

Out-of-Network / Self-Referred Deductible

$5,000 Individual / $10,000 Family (Out-of-Network)

Out-of-Network / Self-Referred Deductible

$2,500 Individual / $5,000 Family (Out-of-Network)

Out-of-Network / Self-Referred Deductible

$5,000 Individual / $10,000 Family (Self-Referred)

Out-of-Network / Self-Referred Coinsurance

50% (Out-of-Network)

Out-of-Network / Self-Referred Coinsurance

50% (Out-of-Network)

Out-of-Network / Self-Referred Coinsurance

50% (Self-Referred)

Out-of-Network / Self-Referred Out-of-Pocket Max

$10,000 Individual / $20,000 Family (Out-of-Network)

Out-of-Network / Self-Referred Out-of-Pocket Max

$10,000 Individual / $20,000 Family (Out-of-Network)

Out-of-Network / Self-Referred Out-of-Pocket Max

$30,000 Individual / $60,000 Family (Self-Referred)

Routine Eye Exam (Medical Plan)

Not Covered (See Guardian Vision Plan)

Routine Eye Exam (Medical Plan)

$40

Routine Eye Exam (Medical Plan)

$40

Eyeglasses (Medical Plan)

Not Covered

Eyeglasses (Medical Plan)

Not Covered

Eyeglasses (Medical Plan)

Not Covered

Generic Prescription Copay

$3 / $20 after deductible

Generic Prescription Copay

$3 / $20

Generic Prescription Copay

$3 / $20

Preferred Brand Name Copay

$40 after deductible

Preferred Brand Name Copay

$40

Preferred Brand Name Copay

$40

Non-Preferred Brand Name Copay

$70 after deductible

Non-Preferred Brand Name Copay

$60

Non-Preferred Brand Name Copay

$60

Specialty Drug

50% ($500 copay max) after deductible

Specialty Drug

50% ($500 copay max)

Specialty Drug

50% ($500 copay max)

Health Savings Account (HSA) - Employer Contribution

$500 annual upfront employer HSA contribution

Health Savings Account (HSA) - Employer Contribution

Not Available

Health Savings Account (HSA) - Employer Contribution

Not Available

Health Savings Account (HSA) - Voluntary Employee Contribution

2026 gross maximum annual HSA pre-tax contribution: $4,400 Employee / $8,750 Employee + Dependents (Includes employer contribution). If over age 55, additional $1,000 catch-up contribution allowed. Employer + Employee voluntary HSA contributions cannot exceed the annual allowed IRS maximum limit.

Health Savings Account (HSA) - Voluntary Employee Contribution

Not Available

Health Savings Account (HSA) - Voluntary Employee Contribution

Not Available

Per Pay Deduction - Employee (52 pays)

$7.64

Per Pay Deduction - Employee (52 pays)

$33.59

Per Pay Deduction - Employee (52 pays)

$20.48

Per Pay Deduction - Employee/Child(ren) (52 pays)

$55.96

Per Pay Deduction - Employee/Child(ren) (52 pays)

$97.31

Per Pay Deduction - Employee/Child(ren) (52 pays)

$73.94

Per Pay Deduction - Employee/Spouse (52 pays)

$86.27

Per Pay Deduction - Employee/Spouse (52 pays)

$139.47

Per Pay Deduction - Employee/Spouse (52 pays)

$109.31

Per Pay Deduction - Family (52 pays)

$124.52

Per Pay Deduction - Family (52 pays)

$190.99

Per Pay Deduction - Family (52 pays)

$152.53