Level C
Benefit Levels & Rates

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Level C Benefits for 2024

 

Professional Musicians Local 47 and Employers Health and Welfare Fund offers one Kaiser Permanente plan to Level C eligible participants, and their dependents, who reside in California.

Participants that qualify for Level C may waive the Kaiser Permanente medical plan and enroll in the Dental/Vision Only plan.

Review the benefit summary carefully.

The following Summary of Benefits & Coverages (“SBC”) contain the same information as the Benefit Summaries. However, they are provided in a different format that is required by the Affordable Care Act (“ACA”) to allow members to compare various plans.

 
 

Level C Benefit Summaries

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Medical Coverage


 
 

Life and Accidental Death and Dismemberment Coverage


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Prudential Financial

Prudential Financial underwrites life and Accidental Death and Dismemberment coverage. This benefit covers the participant only. Dependents are not eligible for this benefit.

Prudential Life Certificate
Life Application/Beneficiary Form

 
 

Dental & Vision Coverage Only Plan


 
 

CALIFORNIA RESIDENTS ONLY

EyeMed

Benefit Summary - coming soon

 

Level C Rates

Rates are valid through December 31, 2024

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Kaiser Permanente
High Deductible HMO - HSA Qualified Plan


$30 Office Visit co-pay / $3,200 / $6,400 Deductible – 30% of some services


Kaiser Permanente HD HMO

Member Only
$155.00 

Member +1
$706.00 

Family
$1,220.00 


 

Dental & Vision Coverage Only


THE RATES LISTED BELOW ARE ANNUAL


DeltaCare HMO + EyeMed Vision

Member Only
$60

Member +1
$288.00 

Family
$516.00 


Delta Dental PPO + EyeMed Vision

Member Only
$600

Member +1
$1,308.00 

Family
$2,148.00 


 
 

Level C Enrollment Form

 

If you have been notified that you are eligible for benefits, please print and complete this form. Enrollment forms are accepted at the Administrator’s office at Open Enrollment (November 20th through December 20th).

NOTE: Submitting an enrollment application is not proof of enrollment.