Forms & Documents

Summary of Benefits (SOB)

Dental PPO: Delta Dental

	PPO Plus Premier Advantage 100 | $2500 Max | D&P Max Waiver SOB
	PPO Plus Premier Advantage 100 | $2500 Max SOB
	PPO Plus Premier Advantage 100 Voluntary | $1000 Max SOB
	PPO Plus Premier Advantage 100 Voluntary | $1500 Max SOB
	PPO Plus Premier Advantage 100 Voluntary | $2000 Max SOB
	PPO Plus Premier Advantage 100 Voluntary | $2500 Max SOB
	PPO Plus Premier Advantage 200 | $1000 Max SOB
	PPO Plus Premier Advantage 200 | $1000 Max SOB
	PPO Plus Premier Advantage 200 | $1500 Max | D&P Max Waiver SOB
	PPO Plus Premier Advantage 200 | $1500 Max SOB
	PPO Plus Premier Advantage 200 | $2000 Max | D&P Max Waiver SOB
	PPO Plus Premier Advantage 200 | $2000 Max SOB
	PPO Plus Premier Advantage 200 | $2500 Max | D&P Max Waiver SOB
	PPO Plus Premier Advantage 200 | $2500 Max SOB
	PPO Plus Premier Advantage 200 Voluntary | $1000 Max SOB
	PPO Plus Premier Advantage 200 Voluntary | $1500 Max SOB
	PPO Plus Premier Advantage 200 Voluntary | $2000 Max SOB
	PPO Plus Premier Advantage 200 Voluntary | $2500 Max SOB
	PPO Plus Premier Advantage 300 | $1000 Max | D&P Max Waiver SOB
	PPO Plus Premier Advantage 300 | $1000 Max SOB
	PPO Plus Premier Advantage 300 | $1500 Max | D&P Max Waiver SOB
	PPO Plus Premier Advantage 300 | $1500 Max SOB
	PPO Plus Premier Advantage 300 | $2000 Max | D&P Max Waiver SOB
	PPO Plus Premier Advantage 300 | $2000 Max SOB
	PPO Plus Premier Advantage 300 | $2500 Max | D&P Max Waiver SOB
	PPO Plus Premier Advantage 300 | $2500 Max SOB
	PPO Plus Premier Advantage 300 Voluntary | $1000 Max SOB
	PPO Plus Premier Advantage 300 Voluntary | $1500 Max SOB
	PPO Plus Premier Advantage 300 Voluntary | $2000 Max SOB
	PPO Plus Premier Advantage 300 Voluntary | $2500 Max SOB
	PPO Plus Premier Deluxe 100 | $1500 Max | D&P Max Waiver SOB
	PPO Plus Premier Deluxe 100 | $1500 Max SOB
	PPO Plus Premier Deluxe 100 | $2000 Max | D&P Max Waiver SOB
	PPO Plus Premier Deluxe 100 | $2000 Max SOB
	PPO Plus Premier Deluxe 100 | $2500 Max | D&P Max Waiver SOB
	PPO Plus Premier Deluxe 100 | $2500 Max SOB
	PPO Plus Premier Deluxe 100 | $3000 Max | D&P Max Waiver SOB
	PPO Plus Premier Deluxe 100 | $3000 Max SOB
	PPO Plus Premier Deluxe 100 Voluntary | $1500 Max SOB
	PPO Plus Premier Deluxe 100 Voluntary | $2000 Max SOB
	PPO Plus Premier Deluxe 100 Voluntary | $2500 Max SOB
	PPO Plus Premier Deluxe 100 Voluntary | $3000 Max SOB
	PPO Plus Premier Deluxe 200 | $1500 Max | D&P Max Waiver SOB
	PPO Plus Premier Deluxe 200 | $1500 Max SOB
	PPO Plus Premier Deluxe 200 | $1500 Max SOB
	PPO Plus Premier Deluxe 200 | $2000 Max | D&P Max Waiver SOB
	PPO Plus Premier Deluxe 200 | $2000 Max SOB
	PPO Plus Premier Deluxe 200 | $2500 Max | D&P Max Waiver SOB
	PPO Plus Premier Deluxe 200 | $2500 Max SOB
	PPO Plus Premier Deluxe 200 | $3000 Max | D&P Max Waiver SOB
	PPO Plus Premier Deluxe 200 | $3000 Max SOB
	PPO Plus Premier Deluxe 200 Voluntary | $1500 Max SOB
	PPO Plus Premier Deluxe 200 Voluntary | $2000 Max SOB
	PPO Plus Premier Deluxe 200 Voluntary | $2500 Max SOB
	PPO Plus Premier Dual Choice 2 | $1500 Max | D&P Max Waiver SOB
	PPO Plus Premier Dual Choice 2 | $1500 Max SOB
	PPO Plus Premier Dual Choice 2 | $2000 Max | D&P Max Waiver SOB
	PPO Plus Premier Dual Choice 2 | $2000 Max SOB
	PPO Plus Premier Dual Choice 2 Voluntary | $1500 Max SOB
	PPO Plus Premier Dual Choice 2 Voluntary | $2000 Max SOB
	PPO Plus Premier Dual Choice 3 High | $1500 Max | D&P Max Waiver SOB
	PPO Plus Premier Dual Choice 3 High | $1500 Max SOB
	PPO Plus Premier Dual Choice 3 High | $2500 Max | D&P Max Waiver SOB
	PPO Plus Premier Dual Choice 3 High | $2500 Max SOB
	PPO Plus Premier Dual Choice 3 Low | $1000 Max SOB
	PPO Plus Premier Dual Choice 3 Low | $1500 Max | $1000 Ortho SOB
	PPO Plus Premier Dual Choice 3 Low | $1500 Max SOB
	PPO Plus Premier Dual Choice 3 Voluntary | $1000 Max SOB
	PPO Plus Premier Dual Choice 3 Voluntary | $1500 Max SOB
	PPO Plus Premier Dual Choice 3 Voluntary | $2500 Max SOB
	PPO Plus Premier Dual Choice Buy-up | $1500 Max SOB
	PPO Plus Premier Dual Choice Buy-up | $2000 Max SOB
	PPO Plus Premier Dual Choice Core | $1000 Max SOB

Vision: VSP

	CoPower VSP EasyOptions Plan Summary
	VSP Basic Choice Enhanced Plan B $130, $25 with Retail
	VSP Basic Choice Plan A $20 with Retail
	VSP Choice Plan A $20
	VSP Choice Plan A $25 $25
	VSP Choice Plan A $25 $25 with Retail
	VSP Choice Plan B $150 $20 $20
	VSP Choice Plan B $180 $10
	VSP Choice Plan C $150 $10 $25
	VSP Choice Plan C $180 $10
	VSP Choice Plan C $200 $300 $10 $25 EZO
	VSP Easy Option 5 Choice Plan C $10 $25
	VSP Elite Choice Enhanced Plan B $25 with Retail
	VSP Elite Choice Plan C $25 with Retail
	VSP Signature Enhanced Plan B $0 $20
	VSP Signature Enhanced Plan B $0 $20 with Retail
	VSP Signature Enhanced Plan B $25
	VSP Signature Plan A $25
	VSP Signature Plan A $25 with Retail
	VSP Signature Plan C $0 $20
	VSP Signature Plan C $0 $20 with Retail
	VSP Signature Plan C $10
	VSP Signature Plan C $10 with Retail
	VSP Standard Choice Plan C $130, $25 with Retail
	VSP Standard Signature Health Plan B $25 with Retail
	VSP Vol Choice Enhanced Plan B $150, $10 $25 with Retail
	VSP Vol Choice Enhanced Plan B $180, $10 $25 with Retail