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

OPEN ACCESS PLUS H.S.A.

BENEFIT

IN-NETWORK

OUT-OF-NETWORK***

Health Savings Account Employer Funded (Funded on a weekly basis during your employment)

Annual Benefit Amount per Calendar Year Individual: $1,600 ($30.77 per week) Family: $3,200 ($61.54 per week) Due to IRS regulations, the annual benefit and deductible amounts are subject to change each calendar year.

Annual Deductible

Individual: $1,600 Family: $3,200

Individual: $3,000 Family: $6,000

Coinsurance*

100%

70%

Out-of-Pocket Maximum

Individual: $3,000 Family: $6,000

Individual: $4,500 Family: $9,000

Lifetime Maximum

Unlimited

Unlimited

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

100% after deductible 100% after deductible 100% after deductible

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

Preventive Care

100%

70% after deductible

Hospital Care

100% after deductible

70% after deductible

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

100% after deductible 100% after deductible Copays apply after Medical deductible has been met.

100% after deductible 100% after deductible Copays apply after Medical deductible has been met.

$10 copay $20 copay $35 copay $20 copay $40 copay $70 copay

70% after deductible

Mail Order (90 day supply) Generic Preferred Brand Non-Preferred Brand

Not covered

Diabetes • Farxiga

Diabetes / Insulins

• Basaglar • Humalog • Humalog Mix

• Glyxambi • Jardiance • Ozempic • Rybelsus • Synjardy • Synjardy XR • Trulicity • Xigduo XR

• Humulin • Levemir • Lyumjev

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