Thorlabs - 2024 Employee Benefit Guide - NJ New Hires (FINAL

MDG PLAN

PPO PLAN

BENEFIT

IN-NETWORK

OUT-OF-NETWORK*

IN-NETWORK ONLY

Annual Deductible (Waived for Preventive)

Individual: $0 Family: $0

Individual: $50 Family: $150

$5 Office visit copay

Benefit Maximum

Annual: $1,500 Combined In- and Out-of-Network

Unlimited

Preventive Services Cleaning (prophylaxis) Fluoride Treatments Oral Exams Sealants (per tooth) X-Rays Basic Services Fillings Perio Surgery Periodontal Maintenance Root Canal

100% no deductible 100% no deductible 100% no deductible 100% no deductible 100% no deductible 90% no deductible 90% no deductible 90% no deductible 90% no deductible 90% no deductible 90% no deductible

100% no deductible 100% no deductible 100% no deductible 100% no deductible 100% no deductible 80% after deductible 80% after deductible 80% after deductible 80% after deductible 80% after deductible 80% after deductible

No charge No charge No charge $6 No charge $13 $140 $16 $90-$140 $17 $37-$60

Simple Extractions Surgical Extractions

Major Services Bridges & Dentures Inlays, Onlays, Veneers Single Crowns

60% no deductible 60% no deductible 60% no deductible

50% after deductible 50% after deductible 50% after deductible

$330-$365 $225-$265 $275

Orthodontic Services

50% $1,500 lifetime maximum Combined In- and Out-of-Network Child coverage only up to the age of 19

$2,425 copay Adults & Children

15