Summary of Benefits (SOB)
Dental PPO w/Ortho: Delta Dental
PPO Plus Premier Advantage 300 | $1500 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Advantage 300 | $2000 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 300 | $2000 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 300 | $2000 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Advantage 300 | $2000 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Advantage 300 | $2500 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 300 | $2500 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 300 | $2500 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Advantage 300 | $2500 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Advantage 300 Voluntary | $1000 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 300 Voluntary | $1000 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 300 Voluntary | $1500 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 300 Voluntary | $1500 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 300 Voluntary | $2000 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 300 Voluntary | $2000 Max | $1500 Ortho SOB
PPO Plus Premier Advantage 300 Voluntary | $2500 Max | $1000 Ortho SOB
PPO Plus Premier Advantage 300 Voluntary | $2500 Max | $1500 Ortho SOB
PPO Plus Premier Deluxe 100 | $1500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 | $1500 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 | $1500 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 | $1500 Max | D&P Max Waiver | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 | $2000 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 | $2000 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 | $2000 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 | $2000 Max | D&P Max Waiver | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 | $2500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 | $2500 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 | $2500 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 | $2500 Max | D&P Max Waiver | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 | $3000 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 | $3000 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 | $3000 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 | $3000 Max | D&P Max Waiver | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 Voluntary | $1500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 Voluntary | $1500 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 Voluntary | $2000 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 Voluntary | $2000 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 Voluntary | $2500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 Voluntary | $2500 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 100 Voluntary | $3000 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 100 Voluntary | $3000 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 | $1500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 | $1500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 | $1500 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 | $1500 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 | $1500 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 | $1500 Max | D&P Max Waiver | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 | $2000 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 | $2000 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 | $2000 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 | $2000 Max | D&P Max Waiver | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 | $2500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 | $2500 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 | $2500 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 | $3000 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 | $3000 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 | $3000 Max | D&P Max Waiver | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 | $3000 Max | D&P Max Waiver | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 Voluntary | $1500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 Voluntary | $1500 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 Voluntary | $2000 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 Voluntary | $2000 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 Voluntary | $2500 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 Voluntary | $2500 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 Voluntary | $3000 Max | $1500 Child and Adult Ortho SOB
PPO Plus Premier Deluxe 200 Voluntary | $3000 Max | $1500 Child Ortho SOB
PPO Plus Premier Deluxe 200 Voluntary | $3000 Max SOB
PPO Plus Premier Dual Choice 2 | $1500 Max | $1000 Ortho SOB
PPO Plus Premier Dual Choice 2 | $1500 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Dual Choice 2 | $2000 Max | $1000 Ortho SOB
PPO Plus Premier Dual Choice 2 | $2000 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Dual Choice 2 Voluntary | $1500 Max | $1000 Ortho SOB
PPO Plus Premier Dual Choice 2 Voluntary | $2000 Max | $1000 Ortho SOB
PPO Plus Premier Dual Choice 3 High | $1500 Max | $1500 Ortho SOB
PPO Plus Premier Dual Choice 3 High | $1500 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Dual Choice 3 High | $2500 Max | $1500 Ortho SOB
PPO Plus Premier Dual Choice 3 High | $2500 Max | D&P Max Waiver | $1500 Ortho SOB
PPO Plus Premier Dual Choice 3 Low | $1000 Max | $1000 Ortho SOB
PPO Plus Premier Dual Choice 3 Low | $1000 Max | $1000 Ortho SOB
PPO Plus Premier Dual Choice 3 Low | $1000 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Dual Choice 3 Low | $1500 Max | $1000 Ortho SOB
PPO Plus Premier Dual Choice 3 Low | $1500 Max | D&P Max Waiver | $1000 Ortho SOB
PPO Plus Premier Dual Choice 3 Voluntary | $1000 Max | $100 Ortho SOB - needs to be $1000 ortho
PPO Plus Premier Dual Choice 3 Voluntary | $1500 Max | $1000 Ortho SOB
PPO Plus Premier Dual Choice 3 Voluntary | $1500 Max | $1500 Ortho SOB
PPO Plus Premier Dual Choice 3 Voluntary | $2500 Max | $1500 Ortho SOB
PPO Plus Premier Dual Choice Buy-up | $1500 Max | $1500 Ortho SOB
PPO Plus Premier Dual Choice Buy-up | $2000 Max | $1500 Ortho SOB
PPO Plus Premier Dual Choice Core | $1000 Max | $1000 Ortho 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
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