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 NameIBC Personal Choice PPO w/BlueCard $50/$80/$500 |
Plan NameKeystone POS $30/$60/100% |
Plan NameIBC Personal Choice PPO w/BlueCard $3000/$30/$60/$500 HSA |
Network AccessPPO BlueCard National Network Access. Out-of-network benefits included. |
Network AccessRegional Network Access. PCP & Referrals required. Self-Referred benefits available. |
Network AccessHigh 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 SpecialistsNo (Not required) |
Referrals for SpecialistsYes (Required) |
Referrals for SpecialistsNo (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 Copay0% 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 Coinsurance50% (Out-of-Network) |
Out-of-Network / Self-Referred Coinsurance50% (Self-Referred) |
Out-of-Network / Self-Referred Coinsurance50% (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 Drug50% ($500 copay max) |
Specialty Drug50% ($500 copay max) |
Specialty Drug50% ($500 copay max) after deductible |
Health Savings Account (HSA) - Employer ContributionNot Available |
Health Savings Account (HSA) - Employer ContributionNot Available |
Health Savings Account (HSA) - Employer Contribution$500 annual upfront employer HSA contribution |
Health Savings Account (HSA) - Voluntary Employee ContributionNot Available |
Health Savings Account (HSA) - Voluntary Employee ContributionNot Available |
Health Savings Account (HSA) - Voluntary Employee Contribution2026 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 NameKeystone POS $30/$60/100% |
Plan NameIBC Personal Choice PPO w/BlueCard $50/$80/$500 |
Plan NameIBC Personal Choice PPO w/BlueCard $3000/$30/$60/$500 HSA |
Network AccessRegional Network Access. PCP & Referrals required. Self-Referred benefits available. |
Network AccessPPO BlueCard National Network Access. Out-of-network benefits included. |
Network AccessHigh 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 SpecialistsYes (Required) |
Referrals for SpecialistsNo (Not required) |
Referrals for SpecialistsNo (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 Copay0% 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 Coinsurance50% (Self-Referred) |
Out-of-Network / Self-Referred Coinsurance50% (Out-of-Network) |
Out-of-Network / Self-Referred Coinsurance50% (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 Drug50% ($500 copay max) |
Specialty Drug50% ($500 copay max) |
Specialty Drug50% ($500 copay max) after deductible |
Health Savings Account (HSA) - Employer ContributionNot Available |
Health Savings Account (HSA) - Employer ContributionNot Available |
Health Savings Account (HSA) - Employer Contribution$500 annual upfront employer HSA contribution |
Health Savings Account (HSA) - Voluntary Employee ContributionNot Available |
Health Savings Account (HSA) - Voluntary Employee ContributionNot Available |
Health Savings Account (HSA) - Voluntary Employee Contribution2026 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 NameIBC Personal Choice PPO w/BlueCard $3000/$30/$60/$500 HSA |
Plan NameIBC Personal Choice PPO w/BlueCard $50/$80/$500 |
Plan NameKeystone POS $30/$60/100% |
Network AccessHigh Deductible Health Plan (HDHP). PPO BlueCard National Network Access. Out-of-network benefits included. Deductible applies to all expenses except preventive care. |
Network AccessPPO BlueCard National Network Access. Out-of-network benefits included. |
Network AccessRegional 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 SpecialistsNo (Not required) |
Referrals for SpecialistsNo (Not required) |
Referrals for SpecialistsYes (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 Copay0% 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 Coinsurance50% (Out-of-Network) |
Out-of-Network / Self-Referred Coinsurance50% (Out-of-Network) |
Out-of-Network / Self-Referred Coinsurance50% (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 Drug50% ($500 copay max) after deductible |
Specialty Drug50% ($500 copay max) |
Specialty Drug50% ($500 copay max) |
Health Savings Account (HSA) - Employer Contribution$500 annual upfront employer HSA contribution |
Health Savings Account (HSA) - Employer ContributionNot Available |
Health Savings Account (HSA) - Employer ContributionNot Available |
Health Savings Account (HSA) - Voluntary Employee Contribution2026 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 ContributionNot Available |
Health Savings Account (HSA) - Voluntary Employee ContributionNot 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 |