print logo
Main Content Anchor

2021 Dental and Vision COBRA Premiums

State-Sponsored Dental Plans

Delta Dental

Table of State-Sponsored Dental Plans for Delta Dental.

Plan Type

Covered Persons   

1-Party   

2-Party   

3-Party   
PPO Plus Premier Basic * Represented Employees ​​$52.19 ​​$91.39 ​​$132.25
​​PPO plus Premier Basic (dependents)* ​Eligible dependents of Represented employees ​​$47.76 ​​$67.09 ​$87.73
​Enhanced           ​Excluded employees and their eligible dependents ​$54.30  $107.22 ​​$150.76
​PPO ​Excluded and Rank and File employees and their eligible dependents ​​$47.66 ​​$93.00 ​$140.12

 *Dependents of Represented employees have a lower level of coverage under the Delta Premier Basic Plan, and pay a lower premium for dependent only coverage.

DeltaCare USA

Table of State-Sponsored Dental Plans for DeltaCare USA.
Plan Type    Covered Persons    1-Party    2-Party 3-Party
Standard Excluded and Rank and File employees and their eligible dependents  $19.83  ​$32.54 $45.01

MetLife*

Plan Type    Covered Persons    1-Party    2-Party 3-Party

Standard

Rank-and-file employees and their eligible dependents

$16.05

$26.01

$16.42

​Enhanced

​Excluded employees and their eligible dependents

​$16.38

​$27.72

$​34.15

 *Benefits Provided by SafeGuard Health Plans, Inc., a MetLife company

Premier Access

Table of State-Sponsored Dental Plans for Premier Access.
Plan Type    Covered Persons    1-Party 2-Party    3-Party   
Standard    Excluded and Rank and File employees and their eligible dependents     $15.79    $25.58 $35.82

Note: Dental benefits for Bargaining Unit 6 (BU6) employees are provided through the CCPOA Health Benefits Trust. Exception: BU6 employees who are non-CCPOA members may only enroll into Western Dental.

Western Dental

Table of State-Sponsored Dental Plans for Western Dental.
Plan Type    Covered Persons    1-Party    2-Party    3-Party   
Standard    Excluded and Rank and File employees and their eligible dependents $16.09      $26.54      $37.65  

​ 

​State-Sponsored Vision Plans

Vision Service Plan (VSP)

Table of State-Sponsored Vision Plans for Vision Service Plan (VSP).
Plan Type    Covered Persons    1-Party 2-Party    3-Party   
Basic     Excluded and Rank and File employees and their eligible dependents*     $8.43    $8.43 $8.43   
​Premier ​Excluded and Rank and File employees and their eligible dependents* ​$17.06 $25.69 $​36.22

*Vision benefits for BU6 employees are provided through the CCPOA Health Benefits Trust.

​COBRA Carrier Contact Information for State-Sponsored Dental and Vision Plans

Please mail the Dental Plan Enrollment Authorization (STD. 692) forms to the corresponding dental carrier’s COBRA unit, and the Vision Plan Direct Payment Authorization (STD. 703) forms to VSP: 

Delta Dental

Wolfpack Insurance Services, Inc.
P.O. Box 833
Belmont, CA 94002-0833
(888) 837-7511

DeltaCare USA

Wolfpack Insurance Services, Inc.
P.O. Box 833
Belmont, CA 94002-0833
(888) 837-7511

Premier Access

Attn: COBRA Unit
8890 Cal Center Drive
Sacramento, CA 95826
(888) 534-3466

 

MetLife*

Attn: SOC COBRA Billing
P.O. Box 13724
Philadelphia, PA 19101-3724
(800) 880-1800

*Benefits provided by SafeGuard Health Plans, Inc., a MetLife company.

Western Dental

Attn: Group Services
530 South Main Street, 1st Floor
Orange, CA 92868
(866) 859-7525

Vision Service Plan (VSP)

Attn: COBRA Unit MS 422
P.O. Box 997100
Sacramento, CA 95899-7100
(800) 400-4569

Supporting Page
Link Back to Top