COBRA Group Continuation Coverage for Dental and Vision Plan Premiums

Please refer to the Benefits Administration Manual (BAM) COBRA Section 400 for complete instructions on the completion and submission of COBRA documents.

Cobra participants are responsible for the total cost of the plan plus an additional 2%. This includes the amount you were paying as an employee as well as the portion of the cost paid by the State.

2027 State-Sponsored Dental Plans

Delta Dental

Plan Type	Covered Persons	Single	2-Party	Family
Delta Dental PPO Standard	Employees and Dependents	$50.16	$97.87	$147.44
Delta Dental PPO Essential	Represented Employees	$59.49	$104.16	$150.77
Delta Dental PPO Premium	Excluded Employees and Dependents	$59.55	$117.56	$165.31
DeltaCare USA	Employees and Dependents	$20.00	$32.82	$45.41

MetLife

Plan Type	Covered Persons	Single	2-Party	Family
MetLife PPO Access	Employees and Dependents	$53.18	$103.41	$155.57
MetLife PPO Core	Employees and Dependents	$61.57	$107.51	$155.37
MetLife PPO Plus	Excluded Employees and Dependents	$61.91	$121.87	$171.19
MetLife Select DHMO	Employees and Dependents	$15.17	$24.57	$34.41

2027 State-Sponsored Vision Plans

Vision Service Plan (VSP)

Plan Type	Covered Persons	Single	2-Party	Family
Basic	Excluded and Represented employees and their eligible dependents[1]	$8.26	$8.26	$8.26
Premier	Excluded and Represented employees and their eligible dependents[2]	$17.06	$25.69	$36.22

[1] Vision benefits for BU6 employees are provided through the CCPOA Health Benefits Trust.

[2] 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 or email the Dental Plan Enrollment Authorization (STD. 692) forms to the corresponding dental carrier’s COBRA unit:

Delta Dental of California/DeltaCare USA

iSolved Benefit Services – Enrollment Form Submission
P.O. Box 537011
Sacramento, CA 95853-7011

Email (preferred for fastest processing): IsolvedCobra@delta.org

Support for COBRA enrolled members:
Participants: 800-594-6957
Employers: 866-320-3040
Email: IsolvedCobra@delta.org

MetLife

MetLife Benefits
Attn: SOC COBRA Billing
P.O. Box 13724
Philadelphia, PA 19101-3724

Benefit questions: (800) 880-1800
Billing questions: (949) 471-2222

Please mail, email, or fax vision COBRA forms (STD. 700 for Basic COBRA and STD. 774 for Premier COBRA) to VSP directly:

Vision Service Plan (VSP)

Attn: CLIENT ADMINISTRATIVE SERVICES, MS 229
PO Box 997100
Sacramento, CA 95899-7100
Email: stateofca@vsp.com

Fax: 916-389-8304

Delta Dental

Plan Type	Covered Persons	Single	2-Party	Family
Preferred Provider Option (PPO)	Employees and Dependents	$48.66	$94.94	$143.03
PPO plus Premier Basic	Represented Employees	$57.71	$101.05	$146.26
PPO plus Premier Enhanced	Excluded Employees and Dependents	$57.77	$114.05	$160.37

DeltaCare USA

Plan Type	Covered Persons	Single	2-Party	Family
Standard	Employees and Dependents	$19.83	$32.54	$45.01

MetLife

Plan Type	Covered Persons	Single	2-Party	Family
Standard	Employees and Dependents	$14.13	$22.89	$32.05
Enhanced	Excluded Employees and Dependents	$16.38	$27.72	$34.15

Premier Access

Plan Type	Covered Persons	Single	2-Party	Family
Standard	Employees and Dependents	$14.49	$23.48	$32.88

Western Dental

Plan Type	Covered Persons	Single	2-Party	Family
Standard	Employees and Dependents	$16.09	$26.54	$37.65

Employees in BU6 should contact the California Correctional Peace Officers Association (CCPOA) Benefits Trust Fund at (916) 779-6300 or (800) 468-6486.

2026 State-Sponsored Vision Plans

Vision Service Plan (VSP)

Plan Type	Covered Persons	Single	2-Party	Family
Basic	Excluded and Represented employees and their eligible dependents[1]	$8.26	$8.26	$8.26
Premier	Excluded and Represented employees and their eligible dependents[2]	$17.06	$25.69	$36.22

[1] Vision benefits for BU6 employees are provided through the CCPOA Health Benefits Trust.

[2] Vision benefits for BU6 employees are provided through the CCPOA Health Benefits Trust.