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2019 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 ​​$47.66​​$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

 

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     $16.12    $26.10 $36.56

 

SafeGuard

Table of State-Sponsored Dental Plans for SafeGuard.
Plan Type    Covered Persons    1-Party    2-Party    3-Party
​Standard ​Rank and File employees and their eligible dependents ​$16.05 ​$26.01 ​$36.42
​​Enhanced Excluded employees and their eligible dependents $16.38 ​$27.72 34.15

 

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*     $8.81    $8.81 $8.81   
​Premier ​Excluded and Rank and File employees and their eligible dependents* ​17.83 26.85 ​37.84

*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

SafeGuard Health Plans/MetLife

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

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

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