Page 8 - Goodwill 2021 Annual Benefits Enrollment
P. 8
Goodwill Industries
Dental
Taking care of your mouth, gums, and teeth is important to your overall health. Goodwill provides dental insurance
so you can afford to care about your oral health. We offer two plans administered by BlueCross BlueShield of
Tennessee. 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 plan.
Base Plan Buy-Up Plan Finding In-Network Providers
Calendar Year Deductible Remember to visit in-network dentists to receive the
Individual $50 $0 deepest level of discount on your services.
Employee + 1 or $150 $0
Family
Calendar Year Maximum How Do I Find an In-Network Dental Care
$750 $1,500 Provider?
Coinsurance You can ind an in-network dentist by completing one
Preventive 100% no 100% no deductible of the following:
deductible
Basic 80% after 100% no deductible Go to bcbst.vitalschoice.com. Under Please
deductible Select Network, select Dental, then select Find
Major 50% after 60% no deductible Dental Care. You can enter your ZIP Code to
deductible narrow your options
This is a high level summary of your beneit coverage. Full coverage Call Customer Service at 800.523.1478
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 Contact your designated Human Resources
communicated in your SPD, the terms of your SPD will prevail.
Business Partner for assistance
Dental Plan Premiums (per pay period) Examples of Services
Base Plan Buy-Up Plan Preventive—exams, cleanings, luoride, x-rays, and
Employee Only $2.64 $8.50 sealants
Employee + One Person $9.21 $24.49 Basic—illings, extractions, periodontics, repairs,
Employee + Family $17.87 $42.06 and oral surgery
Major—crowns, inlays, dentures, and dental
implants
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Dental
Taking care of your mouth, gums, and teeth is important to your overall health. Goodwill provides dental insurance
so you can afford to care about your oral health. We offer two plans administered by BlueCross BlueShield of
Tennessee. 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 plan.
Base Plan Buy-Up Plan Finding In-Network Providers
Calendar Year Deductible Remember to visit in-network dentists to receive the
Individual $50 $0 deepest level of discount on your services.
Employee + 1 or $150 $0
Family
Calendar Year Maximum How Do I Find an In-Network Dental Care
$750 $1,500 Provider?
Coinsurance You can ind an in-network dentist by completing one
Preventive 100% no 100% no deductible of the following:
deductible
Basic 80% after 100% no deductible Go to bcbst.vitalschoice.com. Under Please
deductible Select Network, select Dental, then select Find
Major 50% after 60% no deductible Dental Care. You can enter your ZIP Code to
deductible narrow your options
This is a high level summary of your beneit coverage. Full coverage Call Customer Service at 800.523.1478
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 Contact your designated Human Resources
communicated in your SPD, the terms of your SPD will prevail.
Business Partner for assistance
Dental Plan Premiums (per pay period) Examples of Services
Base Plan Buy-Up Plan Preventive—exams, cleanings, luoride, x-rays, and
Employee Only $2.64 $8.50 sealants
Employee + One Person $9.21 $24.49 Basic—illings, extractions, periodontics, repairs,
Employee + Family $17.87 $42.06 and oral surgery
Major—crowns, inlays, dentures, and dental
implants
8
