Page 10 - Goodwill 2021 Annual Benefits Enrollment
P. 10
Goodwill Industries
Vision
Your vision affects your life everyday and we want you to take good care of your eyesight so you can always enjoy
the view. Goodwill provides two vision plans administered by BCBST’s Vision Blue Plan. You may elect to pay an
additional premium in order to cover eligible family members, and/or to purchase additional beneits under the buy-
up vision plan. Employees who enroll will receive an ID card.
Beneit Services Base Plan Buy-Up Plan
(In-Network)
Eye Exam (every 12 months) $10 copay $10 copay
Frames (every 24 months) Purchased in the same transaction as Purchased in the same transaction as lenses:
lenses: 35% of retail price $0 copay up to $120 allowance, 20% of
balance over allowance
Purchased separately: 20% of retail price
Lenses (every 12 months) Purchased in the same transaction as You pay $25 for single, bifocal or trifocal
frames: lenses
You pay
$50 for single lenses, $70 for bifocal You pay additional $65 for standard
lenses, $105 for trifocal lenses, $135 for progressive
standard progressive or
20% of retail for premium progressive You pay additional $65 for premium
progressive and 20% of less $120 allowance
Purchased separately: 20% of retail price
Contacts (every 12 months, in lieu of Contact lenses are 15% of retail price; Contact lenses are covered in full up to
frames and lenses) no discount on disposable $120; plus 15% discount of balance over
$120
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In the event there is a
discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD will prevail.
Vision Plan Premiums (per pay period)
Base Plan Buy-Up Plan Finding In-Network Providers
Employee Only $0.39 $1.92 Remember to visit in-network provider to receive the
Employee + One Person $0.73 $3.58 deepest level of discount on your services.
Employee + Family $1.11 $5.42
How Do I Find an In-Network
Vision Care Provider?
You can ind an in-network dentist by completing one of the
following:
Go to bcbst.vitalschoice.com. Under Please Select
Network, select Vision, then select Find Vision Care.
You can enter your ZIP Code to narrow your options.
Call Customer Service at 877.342.0737.
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Vision
Your vision affects your life everyday and we want you to take good care of your eyesight so you can always enjoy
the view. Goodwill provides two vision plans administered by BCBST’s Vision Blue Plan. You may elect to pay an
additional premium in order to cover eligible family members, and/or to purchase additional beneits under the buy-
up vision plan. Employees who enroll will receive an ID card.
Beneit Services Base Plan Buy-Up Plan
(In-Network)
Eye Exam (every 12 months) $10 copay $10 copay
Frames (every 24 months) Purchased in the same transaction as Purchased in the same transaction as lenses:
lenses: 35% of retail price $0 copay up to $120 allowance, 20% of
balance over allowance
Purchased separately: 20% of retail price
Lenses (every 12 months) Purchased in the same transaction as You pay $25 for single, bifocal or trifocal
frames: lenses
You pay
$50 for single lenses, $70 for bifocal You pay additional $65 for standard
lenses, $105 for trifocal lenses, $135 for progressive
standard progressive or
20% of retail for premium progressive You pay additional $65 for premium
progressive and 20% of less $120 allowance
Purchased separately: 20% of retail price
Contacts (every 12 months, in lieu of Contact lenses are 15% of retail price; Contact lenses are covered in full up to
frames and lenses) no discount on disposable $120; plus 15% discount of balance over
$120
This is a high level summary of your beneit coverage. Full coverage details are available in your summary plan description (SPD). In the event there is a
discrepancy between what is relected in this guide and what is communicated in your SPD, the terms of your SPD will prevail.
Vision Plan Premiums (per pay period)
Base Plan Buy-Up Plan Finding In-Network Providers
Employee Only $0.39 $1.92 Remember to visit in-network provider to receive the
Employee + One Person $0.73 $3.58 deepest level of discount on your services.
Employee + Family $1.11 $5.42
How Do I Find an In-Network
Vision Care Provider?
You can ind an in-network dentist by completing one of the
following:
Go to bcbst.vitalschoice.com. Under Please Select
Network, select Vision, then select Find Vision Care.
You can enter your ZIP Code to narrow your options.
Call Customer Service at 877.342.0737.
10
