Schedule F Plan Design.docx

This document is a Request for Proposal (RFP) No. 250000002307 for Schedule F Plan Design for Vision Care Services, detailing in-network and out-of-network member reimbursement rates and coverage. The proposal outlines comprehensive vision care benefits including routine eye exams, contact lens fittings, frames, and lens services with specific copayment and allowance structures. The plan provides coverage frequency of once every 12 months for exams, lenses/contacts, and frames, with a unique provision allowing members to choose between contact lenses or frames and lens services.

The pricing structure features tiered cost-sharing between in-network and out-of-network providers, with members paying modest copayments for services. In-network benefits include $10 copay for routine eye exams, $0 copay with $120 allowance for frames, and graduated copayments for different lens types ranging from $25 for standard lenses to $80-$135 for progressive lenses. Out-of-network reimbursement rates are significantly lower, providing up to limited dollar amounts for each service category, which incentivizes members to use in-network providers. The plan also differentiates between elective and medically necessary contact lenses, with consistent $25 copayments but varying allowance and reimbursement levels.