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FOCUS ON BENEFITS 2021

Goodwill-Easter Seals Minnesota

VISION PLAN SUMMARY

Our 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 an in-network provider to obtain
the highest level of benefits.
Eye Exam You pay $10 Up to $30
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
Lenticular Up to $60
Frames You receive up to Freedom pass: allows members
(1x/12 mos) $150 allowance and
then you receive a Up to $65 to receive any frame, any price for $0 out-of-
20% discount on
amounts over $150 pocket at Target Optical and Sears Optical. All
other vision plan services remain the same.
Contacts You receive up to
(1x/12 mos) $150 allowance and
Elective, in lieu of glasses then you receive a Up to $104
15% discount on
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, 2021.

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

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