CTR078198_Pricing_Document.xlsx
XLSX spreadsheet 309 KB Posted
- Attached to
- Master Agreement AZ|CTR078198
- Contract number
- CTR078198
- Issued by
- Arizona
About this file
This document is a Pricing Document for an Employee Vision Plan, issued by the Arizona Department of Administration State Procurement Office (Solicitation No. BPM006879). The contract is awarded to Avesis Insurance Inc. for a vision benefits program, covering state employees with various coverage options.
The contract spans five plan years with consistent monthly premium rates per employee: $3.97 for employee-only coverage, $13.26 for employee plus spouse, $13.07 for employee plus child, and $16.48 for family coverage. The fee schedule includes comprehensive vision benefits with low member cost shares, such as $10 for vision examinations, paid-in-full single/bifocal/trifocal lenses, $50 wholesale frames, $150 elective contact lens benefit, and a $750 lifetime LASIK surgery allowance. Additional options include 20% discounts on lens options and provider discounts up to 25% for various vision services. Non-participating provider fees are also detailed, with higher out-of-pocket costs for members who choose providers outside the network.
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Other files
| File | Type | Posted |
|---|---|---|
| CTR078198_Performance_Guarantees.xlsx | XLSX spreadsheet | |
| CTR078198_COI_2025-10-01_GL__AL__WC.pdf | ||
| CTR078198_COI_2025-10-01_Cyber.pdf |
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Text version
STANDARD BENEFIT (Pricing)
| Attachment 16 - Pricing Document | Arizona Department of Administration |
| Request for Proposal | State Procurement Office |
| Solicitation No. BPM006879 | 100 N 15th Avenue |
| Employee Vision Plan | Phoenix, AZ 85007 |
Offeror Name Avesis Insurance Inc.
Current Program - MINIMUM COVERAGE REQUIREMENTS
| Instructions: |
| APP Requirments: |
| Offeror shall put $1.00 for the pricing on the “Item (F)” tab in APP. |
| Section A Requirments: | |
| 1 | Offeror shall complete the pricing grid below. |
| 2 | All prices provided on this sheet shall be a firm, fixed price and include all services required within this solicitation unless specifically stated otherwise on this price sheet. |
| Section B Requirements: | |
| 1 | Offeror shall propose, if any, additional optional offerings and a firm, fixed price in the space provided. |
| Section C Requirements: | |
| 1 | Offeror provided with standard benefit copay amounts to assist with determining pricing in Section A. The cost sharing (copay) amount that a member would be responsible for each service is listed in the space provided. ADOA acknowledges that the member cost sharing (copay) amount will be part of the Certificate of Coverage upon award. |
A. Standard Benefit
| Monthly Premium Rate Guarantee | Employee only | Employee Plus Spouse | Employee Plus Child | Family |
| Plan Years 1 – 3 (PEPM) | 3.97 | 13.26 | 13.07 | 16.48 |
| Plan Year 4 (PEPM) | 3.97 | 13.26 | 13.07 | 16.48 |
| Plan Year 5 (PEPM) | 3.97 | 13.26 | 13.07 | 16.48 |
B. Other Optional Services
| OTHER Optional Services | ||||||||
| (Wellness Initiatives or other programs offered and what is included.) | Employee Only | Employee Plus Spouse | Employee Plus Child | Family | ||||
| COBRA Administration | $ | $ | $ | $ | ||||
| Direct Billing | $ | $ | $ | $ | ||||
| Includes: | $ | $ | $ | $ | ||||
| Includes: | $ | $ | $ | $ | ||||
| Other | $ | $ | $ | $ |
C. Fee Schedule
| Fee Schedule | Member Cost Share |
| Vision Examination | $10.00 |
| Single Vision Lens | Paid in full |
| Bifocal Lenses | Paid in full |
| Trifocal Lenses | Paid in full |
| Lenticular Lenses | Paid in full |
| Progressive Lenses | $20% off retail minus $50 allowance |
| Frames | $50.00 wholesale |
| Contact Lens Benefit - Elective | $150.00 |
| Contact Lens Benefit - Medically Necessary | Paid in full |
| LASIK Surgery | Onetime/lifetime $750 allowance |
Provider discount up to 25% Options(e.g. tinting, coatings, transitional lens) 20% discount on all lens options
| Non-Participating Fee Schedule | Member Cost Share |
| Vision Examination | $50.00 |
| Single Vision Lens | $33.00 |
| Bifocal Lenses | $50.00 |
| Trifocal Lenses | $60.00 |
| Lenticular Lenses | $110.00 |
| Progressive Lenses | $60.00 |
| Frames | $50.00 |
| Contact Lens Benefit - Elective | $150.00 |
| Contact Lens Benefit - Medically Necessary | $300.00 |
| LASIK Surgery | Onetime/lifetime $750 allowance |
| Options(e.g. tinting, coatings, transitional lens) | N/A |
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