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

OPEN ACCESS PLUS

BENEFIT

IN-NETWORK

OUT-OF-NETWORK***

Annual Deductible

Individual: None Family: None

Individual: $1,000 Family: $2,000

Coinsurance*

100%

70%

Out-of-Pocket Maximum

Individual: $1,500 Family: $3,000

Individual: $2,500 Family: $5,000

Lifetime Maximum

Unlimited

Unlimited

Outpatient Care Primary care physician office visits Specialist office visits Outpatient facility surgery

100% after $20 copay 100% after $30 copay 100%

70% after deductible 70% after deductible 70% after deductible

Preventive Care

100%

70% deductible does not apply

Hospital Care

100%

70% after deductible

Emergency Care At hospital emergency room Urgent Care Prescriptions** Retail Pharmacy (30 day supply) Generic Preferred Brand Non-Preferred Brand Mail Order (90 day supply) Generic Preferred Brand Non-Preferred Brand

100% after $100 copay 100% after $50 copay

100% after $100 copay 100% after $50 copay

$15 copay $25 copay $50 copay $30 copay $50 copay $100 copay

70% deductible does not apply

Not covered

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