Summary of Benefits 2024 – 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, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum 50/1000/Ortho/MAC

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum 50/1500/No Ortho/MAC

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum 50/1500/No Ortho/U90

English  (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum 50/1500/Ortho/MAC

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum 50/1500/Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Advantage 50/1500/Ortho/U80

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Advantage 50/2000/Ortho/U80

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier 50/1000/Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier 50/1500/Lifetime Ortho 1500/U80

English (PDF, 180 KB)

Spanish (PDF, 195 KB)  

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier 50/1500/No Ortho/MAC

English (PDF, 180 KB)

Spanish (PDF, 195 KB)  

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier 50/1500/No Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)  

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier 50/1500/Ortho/MAC

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier 50/1500/Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB) 

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier 50/2000/No Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB) 

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier 50/2000/Ortho/MAC

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier 50/2000/Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB) 

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier D&P Waiver+Rollover 50/1500/Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 25/1500/No Ortho/U80

English (PDF, 180 KB)

Spanish (PDF, 195 KB)   

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 25/2000/Lifetime Ortho 1500/U80

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 25/2500/Lifetime Ortho 2000/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB) 

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 25/2500/No Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/1000/No Ortho/MAC

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/1000/No Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/1000/Ortho/MAC

English (PDF, 180 KB)

Spanish (PDF, 195 KB)  

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/1500/No Ortho/MAC

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/1500/No Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/1500/Ortho/MAC

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/1500/Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/2000/No Ortho/MAC

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/2000/No Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/2000/Ortho/MAC

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/2000/Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB) 

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/2500/Lifetime Ortho 2000/U80

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus Rollover 50/1500/No Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Rollover 50/1500/No Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)  

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Rollover 50/1500/Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB) 

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/2000/Lifetime Ortho 2000/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/1500/Lifetime Ortho 1500/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB) 

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier 50/2000/Lifetime Ortho 2000/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier 50/1500/Lifetime Ortho 1500/U90 English (PDF, 180 KB)

Spanish (PDF, 195 KB)
Disclosure (PDF, 305 KB)

Non-Marketed Smile Spectrum PPO Dental plans

Plan name   Benefit Summary / SOB Disclosure
SmileSM Spectrum Premier Plus 50/2000/No Ortho/MAC

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/1000/Ortho/U90 English (PDF, 180 KB) 

 Spanish (PDF, 195 KB)  
Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier 50/1000/No Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier D&P Waiver 50/1500/No Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB) 

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier D&P Waiver 50/1500/Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB) 

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus D&P Waiver 50/1500/No Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus D&P Waiver 50/1500/Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus D&P Waiver 50/2000/No Ortho/U90

English (PDF, 180 KB)

 Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus D&P Waiver 50/2000/Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Rollover 50/2000/No Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Rollover 50/2000/Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus Rollover 50/1500/Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier D&P Waiver+Rollover 50/1500/No Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus D&P Waiver+Rollover 50/1500/No Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus D&P Waiver+Rollover 50/1500/Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Advantage 50/1000/No Ortho/U80

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Advantage 50/1500/Ortho/U80/In-Network

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 25/1500/Lifetime Ortho 1500/U80

English (PDF, 180 KB)

Spanish (PDF, 195 KB) 

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 25/2000/No Ortho/U80

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier 50/2000/Lifetime Ortho 1500/U80

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 25/3000/Lifetime Ortho 2000/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 25/3000/No Ortho/U90

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/2500/No Ortho/U80

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/3000/Lifetime Ortho 2000/U80

English (PDF, 180 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 305 KB)
SmileSM Spectrum Premier Plus 50/3000/No Ortho/U80

English (PDF, 180 KB)

Spanish (PDF, 195 KB) 

Disclosure (PDF, 305 KB)

Dental HMO plans

Plan name Summary of Benefits Disclosure
Dental HMO Basic

English (PDF, 1.1MB)

Spanish (PDF, 1.8MB)

Disclosure (PDF, 1.3 MB)
Dental HMO Standard

English (PDF, 1.1MB)

Spanish (PDF, 1.8MB)

Disclosure (PDF, 1.3 MB)
Dental HMO Plus

English (PDF, 1.1MB)

Spanish (PDF, 1.8MB)

Disclosure (PDF, 1.3 MB)
Dental HMO Deluxe

English (PDF, 1.1MB)

Spanish (PDF, 1.8MB)

Disclosure (PDF, 1.3 MB)
Dental HMO Elite 75

English (PDF, 1.1MB)

Spanish (PDF, 1.8MB)

Disclosure (PDF, 1.3 MB)
Dental HMO Elite 100

English (PDF, 1.1MB)

Spanish (PDF, 1.8MB)

Disclosure (PDF, 1.3 MB)

Dental INO plans

Plan name Summary of Benefits Disclosure
SmileSM D&P In-Network Only Dental PP​O

English (PDF, 175 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 275 KB)
SmileSM Dental In-Network Only (DINO) 50/2000/Lifetime Ortho 2000

English (PDF, 175 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 275 KB)
SmileSM Dental In-Network Only (DINO) 50/1500/Lifetime Ortho 1500

English (PDF, 175 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 275 KB)
SmileSM Dental In-Network Only (DINO) 50/2000/No Ortho

English (PDF, 175 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 275 KB)
SmileSM Dental In-Network Only (DINO) 50/1500/No Ortho

English (PDF, 175 KB)

Spanish (PDF, 195 KB)

Disclosure (PDF, 275 KB)

© California Physicians' Service DBA Blue Shield of California 1999-2024. All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.

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