Schedule F Plan Design.docx

This document is a Request for Proposal (RFP) No. 250000002307 for Schedule F Plan Design for Vision Care Services. The proposal outlines in-network and out-of-network member reimbursement rates for various vision care services, including routine eye exams, contact lens fittings, frames, and lens services. The plan specifies a 12-month frequency for exams, lenses, and frames, with members able to choose between contact lenses or frames and lens services in a given period.

The pricing structure includes copayments and allowances for different vision services. In-network benefits feature $10 copay for routine eye exams, $0 copay with a $120 allowance for frames, and copays ranging from $25 to $80 for various lens types, including standard and progressive lenses. Out-of-network reimbursement rates are significantly lower, with maximum reimbursement amounts for exams, frames, and lenses. The plan also covers both elective and medically necessary contact lenses, with a $25 copay and varying allowance amounts.