Page 9 - 2020 Goodwill Benefits Guide
P. 9
2020
Goodwill Industries Benefits Enrollment
VISION Finding In-network
Your vision affects your life everyday and we want you to take good care Providers
of your eyesight so you can always enjoy the view. Goodwill provides two Remember to visit in-network
vision plans administered by BCBST’s Vision Blue Plan. You may elect provider to receive the deepest
to pay an additional premium in order to cover eligible family members, level of discount on your services.
and/or to purchase additional beneits under the buy-up vision plan.
Employees who enroll will receive an ID card. How Do I Find an
Beneit Services Base Plan Buy-Up Plan In-network Vision
(In-Network) Care Provider?
Eye Exam (every 12 $10 copay $10 copay You can ind an in-network
months) dentist by completing one of the
Frames (every 24 months) Purchased in the same Purchased in the same following:
transaction as lenses: transaction as lenses: Go to
35% of retail price $0 copay up to $120 bcbst.vitalschoice.com .
allowance, 20% of
Purchased separately: balance over allowance Under Please Select Network,
select Vision, then select Find
20% of retail price Vision Care. You can enter
Lenses (every 12 months) Purchased in the same You pay $25 for single, your ZIP Code to narrow your
transaction as frames: bifocal or trifocal lenses options
You pay
$50 for single lenses, $70 You pay additional $65 for Call Customer Service at
for bifocal lenses, $105 for standard progressive 877.342.0737
trifocal lenses, $135 for
standard progressive or You pay additional $65
20% of retail for premium for premium progressive
progressive and 20% of less $120
allowance
Purchased separately:
20% of retail price
Contacts (every 12 Contact lenses are Contact lenses are
months, in lieu of frames 15% of retail price; no covered in full up to $120;
and lenses) discount on disposable plus 15% discount of
balance over $120
Vision Plan Premiums (per pay period)
Base Plan Buy-Up Plan
Employee Only $0 .39 Employee Only $1 .92
Employee + One Person $0 .73 Employee + One Person $3 .58
Employee + Family $1 .11 Employee + Family $5 .42
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.
9
Goodwill Industries Benefits Enrollment
VISION Finding In-network
Your vision affects your life everyday and we want you to take good care Providers
of your eyesight so you can always enjoy the view. Goodwill provides two Remember to visit in-network
vision plans administered by BCBST’s Vision Blue Plan. You may elect provider to receive the deepest
to pay an additional premium in order to cover eligible family members, level of discount on your services.
and/or to purchase additional beneits under the buy-up vision plan.
Employees who enroll will receive an ID card. How Do I Find an
Beneit Services Base Plan Buy-Up Plan In-network Vision
(In-Network) Care Provider?
Eye Exam (every 12 $10 copay $10 copay You can ind an in-network
months) dentist by completing one of the
Frames (every 24 months) Purchased in the same Purchased in the same following:
transaction as lenses: transaction as lenses: Go to
35% of retail price $0 copay up to $120 bcbst.vitalschoice.com .
allowance, 20% of
Purchased separately: balance over allowance Under Please Select Network,
select Vision, then select Find
20% of retail price Vision Care. You can enter
Lenses (every 12 months) Purchased in the same You pay $25 for single, your ZIP Code to narrow your
transaction as frames: bifocal or trifocal lenses options
You pay
$50 for single lenses, $70 You pay additional $65 for Call Customer Service at
for bifocal lenses, $105 for standard progressive 877.342.0737
trifocal lenses, $135 for
standard progressive or You pay additional $65
20% of retail for premium for premium progressive
progressive and 20% of less $120
allowance
Purchased separately:
20% of retail price
Contacts (every 12 Contact lenses are Contact lenses are
months, in lieu of frames 15% of retail price; no covered in full up to $120;
and lenses) discount on disposable plus 15% discount of
balance over $120
Vision Plan Premiums (per pay period)
Base Plan Buy-Up Plan
Employee Only $0 .39 Employee Only $1 .92
Employee + One Person $0 .73 Employee + One Person $3 .58
Employee + Family $1 .11 Employee + Family $5 .42
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.
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