2025-2026 Support Staff Benefit Summary and Rates

Jay School Corporation Benefit Summary and Rates for Support Staff 2025-2026 Cost per pays are based on starting coverage with Payroll #1. If coverage is started after Payroll #1, costs will be calculated on the daily base rate of each plan. Plans 2 & 3 have an HSA option if you so choose. MEDICAL – PHP Plan 1 Plan 2 Plan 3 Deductible- in network Single / Family out of network Single / Family $2,000 / $4,000 $4,000 / $8,000 $3,500 / $7,000 $7,000 / $14,000 $6,000 / $12,000 $12,000 / $24,000 Max OOP- in network Single / Family out of network Single / Family $5,000 / $8,000 $10,000 / $16,000 $3,500 / $7,000 $10,500/$21,000 $8,050 / $16,100 $16,100 / $32,200 Prescription Drug Copays Tier I & II Tier III Tier IV $15 $30 $60 100% after Deductible 100% after Deductible Single School Contribution $8,000 $8,000 $8,000 Employee Contribution $6,165.04 $2,970.40 $2,069.92 Total Premium $14,165.04 $10,970.40 $10,069.92 Cost per pay 26 pays / 20 pays $237.12 / $308.25 $114.25 / $148.52 $79.61 / $103.50 Family School Contribution $17,200 $17,200 $17,200 Employee Contribution $15,160.76 $7,866.08 $5,808.80 Total Premium $32,360.76 $25,066.08 $23,008.80 Cost per pay 26 pays / 20 pays $583.11 / $758.04 $302.54/ $393.30 $223.42 / $290.44 Dental - Delta Dental Preventive, X-rays, sealants 100% Basic Oral surgery, simple restorative 80% Major restorative, orthodontics, endodontics 50% Maximum Benefit per year $500.00 per person Single Family Total Premium $342.48 $1,118.64 Employee Contribution $171.24 $559.32 Cost per pay (20 pays) $8.56 $27.97 Vision – EyeMed In/ Out of network Eye Exam 100% / up to $45.00 Single Lenses 100% / up to $35.00 Bifocal Lenses 100% / up to $55.00 Trifocal Lenses 100% / up to $80.00 Frames only Up to $150/up to $105 Contact Lenses (instead of glasses lenses) Up to $200/up to $170 Frequency – Exam and Lenses 12 months Frequency – Frames 24 months Single Family Total Premium $116.76 $288.00 Employee Contribution $58.38 $144.00 Cost per pay (20 pays) $2.92 $7.20 The benefit descriptions outlined in this presentation are intended to be a brief outline of coverage and are not intended to be a legal contract. The entire provisions of benefits and exclusions are contained in the Group Contract, Certificate and Schedule of Benefits. In the event of a conflict between the Group Contract and this description, the terms of the Group Contract will prevail.