Summary of Benefits 2023 – Dental
The following Summary of Benefits (SOB) are for groups of 101 or more employees.
When providing a summary of benefit to an applicant or Blue Shield member, you must also include a Disclosure and a Notice of Language Assistance. (PDF, 1 MB)
Smile Spectrum PPO Dental plans
| Plan name | Summary of Benefits | Disclosure |
|---|---|---|
| SmileSM Spectrum 50/1000/No Ortho/MAC | English (PDF, 174 KB) Spanish (PDF, 367 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum 50/1000/Ortho/MAC | English (PDF, 175 KB) Spanish (PDF, 376 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum 50/1500/No Ortho/MAC | English (PDF, 174 KB) Spanish (PDF, 367 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum 50/1500/No Ortho/U90 | English (PDF, 175 KB) Spanish (PDF, 368 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum 50/1500/Ortho/MAC | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum 50/1500/Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Advantage 50/1000/No Ortho/U80 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Advantage 50/1500/Ortho/U80 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Advantage 50/1500/Ortho/U80/In-Network | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Advantage 50/2000/Ortho/U80 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier 50/1000/No Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier 50/1000/Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier 50/1500/Lifetime Ortho 1500/U80 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier 50/1500/No Ortho/MAC | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier 50/1500/No Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier 50/1500/Ortho/MAC | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier 50/1500/Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier 50/2000/Lifetime Ortho 1500/U80 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier 50/2000/No Ortho/MAC | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier 50/2000/No Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier 50/2000/Ortho/MAC | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier 50/2000/Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier D&P Waiver 50/1500/No Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier D&P Waiver 50/1500/Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier D&P Waiver+Rollover 50/1500/No Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier D&P Waiver+Rollover 50/1500/Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 25/1500/Lifetime Ortho 1500/U80 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 25/1500/No Ortho/U80 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 25/2000/Lifetime Ortho 1500/U80 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 25/2000/No Ortho/U80 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 25/2500/Lifetime Ortho 2000/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 25/2500/No Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 25/3000/Lifetime Ortho 2000/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 25/3000/No Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 50/1000/No Ortho/MAC | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 50/1000/No Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 50/1000/Ortho/MAC | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 50/1000/Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 50/1500/No Ortho/MAC | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 50/1500/No Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 50/1500/Ortho/MAC | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 50/1500/Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 50/2000/No Ortho/MAC | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 50/2000/No Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 50/2000/Ortho/MAC | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 50/2000/Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 50/2500/Lifetime Ortho 2000/U80 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 50/2500/No Ortho/U80 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 50/3000/Lifetime Ortho 2000/U80 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus 50/3000/No Ortho/U80 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus D&P Waiver 50/1500/No Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus D&P Waiver 50/1500/Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus D&P Waiver 50/2000/No Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus D&P Waiver 50/2000/Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus D&P Waiver+Rollover 50/1500/No Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus D&P Waiver+Rollover 50/1500/Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus Rollover 50/1500/No Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Plus Rollover 50/1500/Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Rollover 50/1500/No Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Rollover 50/1500/Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
| SmileSM Spectrum Premier Rollover 50/2000/No Ortho/U90 | Disclosure (PDF, 632 KB) | |
| SmileSM Spectrum Premier Rollover 50/2000/Ortho/U90 | English (PDF, 362 KB) Spanish (PDF, 370 KB) |
Disclosure (PDF, 632 KB) |
Dental HMO plans
| Plan name | Summary of Benefits | Disclosure |
|---|---|---|
| Dental HMO Basic | English (PDF, 354 KB) Spanish (PDF, 395 KB) |
Disclosure (PDF, 619 KB) |
| Dental HMO Standard | English (PDF, 354 KB) Spanish (PDF, 395 KB) |
Disclosure (PDF, 619 KB) |
| Dental HMO Plus | English (PDF, 354 KB) Spanish (PDF, 395 KB) |
Disclosure (PDF, 619 KB) |
| Dental HMO Deluxe | English (PDF, 354 KB) Spanish (PDF, 395 KB) |
Disclosure (PDF, 619 KB) |
| Dental HMO Elite 75 | English (PDF, 354KB Spanish (PDF, 359KB |
Disclosure (PDF, 619 KB) |
| Dental HMO Elite 100 | English (PDF, 354KB Spanish (PDF, 359KB |
Disclosure (PDF, 619 KB) |
Dental INO plan (employer-paid)
| Plan name | Summary of Benefits | Disclosure |
|---|---|---|
| SmileSM D&P In-Network Only Dental PPO | English (PDF, 325 KB) Spanish (PDF, 330 KB) |
Disclosure (PDF, 502 KB) |
