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2016 Dental and Vision Plan COBRA Premiums

State-Sponsored Dental Plans

Delta Dental

Delta Dental

Plan Type

Covered Persons   

1-Party   

2-Party   

3-Party   
​Basic Rank and File Employees ​$53.08 ​$92.95 ​$134.51
​Enhanced​Excluded employees and their eligible dependents $​55.22​$109.05 $​153.33
​PPO​Excluded and Rank and File employees and their eligible dependents ​$48.47​$94.58​$142.51
​Basic Dependents​Eligible dependents of Rank and File employees ​$45.53​$68.23​$89.22

 

DeltaCare USA

DeltaCare USA
Plan Type    Covered Persons    1-Party    2-Party3-Party
StandardExcluded and Rank and File employees and their eligible dependents $18.35 $30.11 $41.65   

 

Premier Access

Premier Access
Plan Type    Covered Persons    1-Party2-Party    3-Party   
Standard    Excluded and Rank and File employees and their eligible dependents     $16.96     $27.48     $38.48   

 

SafeGuard

SafeGuard
Plan Type    Covered Persons    1-Party    2-Party    3-Party
​Standard​Rank and File employees and their eligible dependents ​$16.91​$27.40 ​$38.37
​​EnhancedExcluded employees and their eligible dependents $​17.26​$29.20$35.98

 

Western Dental

Western Dental
Plan Type    Covered Persons    1-Party    2-Party    3-Party   
Standard    Excluded and Rank and File employees and their eligible dependents $15.46 $25.52     $36.20    

State-Sponsored Vision Plans

Vision Service Plan (VSP)

Vision Service Plan (VSP)
Plan Type    Covered Persons    1-Party2-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
1-800-296-0192 

DeltaCare USA

Wolfpack Insurance Services, Inc.
P.O. Box 833
Belmont, CA 94002-0833
1-800-296-0192 

Premier Access

Attn: COBRA Unit
8890 Cal Center Drive
Sacramento, CA 95826
1-888-534-3466 

SafeGuard Health Plans

Attn: COBRA Billing
P.O. Box 30910
Laguna Hills, CA 92654
1-800-880-1800 

Western Dental

Attn: COBRA Unit
530 South Main Street, 6th Floor
Orange, CA 92868
1-866-859-7525 

Vision Service Plan (VSP)

Attn: COBRA Unit
P.O. Box 997100
Sacramento, CA 95899-7100
1-800-852-7600 Ext. 4636   

  Updated: 2/4/2016
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