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VSP Proprietary & Confidential Member Out-of-Pocket Buy-Up Plan, Progressive (no line bifocal) Lenses Signature Plan C Services Retail CostMember Cost with VSP Signature Plan Exam (copay applied) $ $ Frame - Jones of New York J107$ $ Bifocal Lens (material copay applied) $ $ Hoyalux Summit Progressive Lens$ $ Super HiVision A/R Coating$ $ Annualized Premium ($9.98 / month) N/A$ Total Out-of-Pocket Cost$ $ VSP saves $ or 56%
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VSP Proprietary & Confidential
Member Out-of-PocketBasic Plan, Progressive (no line bifocal) Lenses
Signature Plan A Services Retail Cost Member Cost with VSP
Signature Plan
Exam (copay applied) $ 173.80 $ 10.00
Frame - Jones of New York J107 $ 165.00 $ 28.00
Bifocal Lens (material copay applied) $ 127.00 $ 10.00
Hoyalux Summit Progressive Lens $ 146.00 $ 93.00
Super HiVision A/R Coating $ 115.00 $ 61.00
Annualized Premium ($6.72 / month) N/A $ 80.64
Total Out-of-Pocket Cost $ 726.80 $ 282.64
VSP saves $444.16 or 61%
VSP Proprietary & Confidential
Member Out-of-PocketBasic Plan, Single Vision Lenses
Signature Plan A Services Retail Cost Member Cost with VSP
Signature Plan
Exam (copay applied) $ 173.80 $ 10.00
Frame – Sigrid Olsen SO105 $ 126.00 $ 0.00
Single Vision Lens (material copay applied) $ 75.00 $ 10.00
Super HiVision A/R Coating $ 115.00 $ 61.00
Polycarbonate (under 18) $ 50.00 $ 0.00
Annualized Premium ($6.72 / month) N/A $ 80.64
Total Out-of-Pocket Cost $ 539.80 $ 161.64
VSP saves $378.16 or 70%
VSP Proprietary & Confidential
Member Out-of-PocketBuy-Up Plan, Progressive (no line bifocal) Lenses
Signature Plan C Services Retail Cost Member Cost with VSP
Signature Plan
Exam (copay applied) $ 173.80 $ 10.00
Frame - Jones of New York J107 $ 165.00 $ 28.00
Bifocal Lens (material copay applied) $ 127.00 $ 10.00
Hoyalux Summit Progressive Lens $ 146.00 $ 93.00
Super HiVision A/R Coating $ 115.00 $ 61.00
Annualized Premium ($9.98 / month) N/A $ 119.76
Total Out-of-Pocket Cost $ 726.80 $ 321.76
VSP saves $405.04 or 56%
VSP Proprietary & Confidential
Member Out-of-PocketBuy Up Plan, Single Vision Lenses
Signature Plan C Services Retail Cost Member Cost with VSP
Signature Plan
Exam (copay applied) $ 173.80 $ 10.00
Frame – Sigrid Olsen SO105 $ 126.00 $ 0.00
Single Vision Lens (material copay applied) $ 75.00 $ 10.00
Super HiVision A/R Coating $ 115.00 $ 61.00
Polycarbonate (under 18) $ 50.00 $ 0.00
Annualized Premium ($9.98 / month) N/A $ 119.76
Total Out-of-Pocket Cost $ 539.80 $200.76
VSP saves $339.04 or 63%
