Page 15 - FY22_FOB_Guide_Final_Neat

FOCUS ON BENEFITS 2022

Goodwill-Easter Seals Minnesota

VISION PLAN SUMMARY

GESMN’s vision plan is offered through EyeMed.

This is a comprehensive plan for all vision services. You may use any
provider for your vision services; however, using an in-network provider
will reduce your out-of-pocket costs.

Features In-Network Out-of-Network Always use the Insight Network for in-network

Eye Exam You pay $10 Up to $30 provider to obtain the highest level of benefits.
Standard Contact Lens Fit & Up to $40 NA When accessing care out of network, you
Follow-Up receive an amount that the provider will pay up
Premium Contact Lens Fit & 10% off NA to. You are then responsible for the difference.
Follow-Up
Plastic Lenses Note: This is a voluntary plan, participation is
(1x/12 mos) optional. You may waive this coverage if you
Single Up to $25 don’t need eyeglasses or contacts.
Bifocal You pay $15 Up to $40
Trifocal Up to $60
Up to $60
Lenticular Preventive eye exams are covered at 100%
Frames You receive up to through either of the medical plans offered by
(1x/12 mos) $150 allowance and Up to $65 GESMN.
then you receive a
20% discount on
amounts over $150 Freedom pass: allows members

Contacts You receive up to to receive any frame, any price for $0 out-of-
pocket at Target Optical and Sears Optical. All
(1x/12 mos) $150 allowance and Up to $104
then you receive a
Elective, in lieu of glasses 15% discount on other vision plan services remain the same.
amounts over $150
Medically Necessary You pay $0 Up to $210

Vision plan premiums: This is a voluntary plan, meaning you pay 100% of
the premiums. Premiums are effective Jan. 1, 2022.

Status Per Payroll Rates
Employee only $3.06
Employee + Spouse $5.83
Employee + Child(ren) $6.13
Family $9.02 QUESTIONS?

Call customer service at 866-723-0513 or call
the phone number on the back of your ID card
or visit www.eyemedvisioncare.com.

Please review your plan summary document for more detailed coverage information.

14