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-Party	3-Party
Standard	Excluded and Rank and File employees and their eligible dependents	$18.35	$30.11	$41.65

Premier Access

Premier Access
Plan Type	Covered Persons	1-Party	2-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
Enhanced	Excluded 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-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
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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