Summary of Benefits 2025 – Dental
Broker resources
2024 Benefit Summaries for Dental Plans
Summary of Benefits
When providing a summary of benefits to an applicant or Blue Shield member, you must also include a Disclosure and a Notice of Language Assistance (PDF, 1 MB).
Dental PPO Plans – 2025
| Plan Names | Summaries of Benefits | Disclosures |
|---|---|---|
| Bronze DPPO/$1000/MAC | English (PDF, 295 KB) | |
| Bronze DPPO/$1000/MAC/Child Only Ortho | English (PDF, 295 KB) | |
| Bronze Voluntary DPPO/$1000/MAC | English (PDF, 295 KB) | |
| Bronze Voluntary DPPO/$1000/MAC/Child Only Ortho | English (PDF, 295 KB) | |
| Silver DPPO/$1500/MAC | English (PDF, 295 KB) | |
| Silver DPPO/$1500/MAC/Adult+Child Ortho | English (PDF, 295 KB) | |
| Silver DPPO/$1500/U90 | English (PDF, 295 KB) | |
| Silver DPPO/$1500/U90/Adult+Child Ortho | English (PDF, 295 KB) | |
| Gold DPPO/$1500/U90 | English (PDF, 295 KB) | |
| Gold DPPO/$1500/U90/Adult+Child Ortho | English (PDF, 295 KB) | |
| Gold DPPO/$2000/U90 | English (PDF, 295 KB) | |
| Gold DPPO/$2000/U90/Adult+Child Ortho | English (PDF, 295 KB) | |
| Platinum DPPO/$2500/U90 | English (PDF, 295 KB) | |
| Platinum DPPO/$2500/U90/Adult+Child Ortho | English (PDF, 295 KB) | |
| Platinum DPPO/$3000/U90 | English (PDF, 295 KB) | |
| Platinum DPPO/$3000/U90/Adult+Child Ortho | English (PDF, 295 KB) | |
| Platinum DPPO/$5000/U90 | English (PDF, 295 KB) | |
| Platinum DPPO/$5000/U90/Adult+Child Ortho | English (PDF, 295 KB) | |
| Diamond DPPO/$3000/U95 | English (PDF, 295 KB) | |
| Diamond DPPO/$3000/U95/Adult+Child Ortho | English (PDF, 295 KB) | |
| Diamond DPPO/$5000/U95 | English (PDF, 295 KB) | |
| Diamond DPPO/$5000/U95/Adult+Child Ortho | English (PDF, 295 KB) | |
| Bronze DPPO/$1500/MAC | English (PDF, 295 KB) | |
| Bronze DPPO/$1500/MAC/Child Only Ortho | English (PDF, 295 KB) | |
| Bronze Voluntary DPPO/$1500/MAC | English (PDF, 295 KB) | |
| Bronze Voluntary DPPO/$1500/MAC/Child Only Ortho | English (PDF, 295 KB) | |
| Gold DPPO/$1500/MAC | English (PDF, 295 KB) | |
| Gold DPPO/$1500/MAC/Adult+Child Ortho | English (PDF, 295 KB) | |
| Gold DPPO/$2000/MAC | English (PDF, 295 KB) | |
| Gold DPPO/$2000/MAC/Adult+Child Ortho | English (PDF, 295 KB) |
Dental HMO Plans – 2025
Closed Dental Plans – 2025: for renewing groups only
| Plan Names | Summaries of Benefits | Disclosures |
|---|---|---|
| Smile℠ Basic Voluntary 75/1000/No Ortho/MAC | English (PDF, 385 KB) | |
| Smile℠ Basic Voluntary 75/1000/No Ortho/MAC | English (PDF, 385 KB) | |
| Smile℠ Basic 75/1000/No Ortho/Mac | English (PDF, 385 KB) | |
| Smile℠ Value 50/1500/No Ortho/MAC | English (PDF, 385 KB) | |
| Smile℠ Plus 50/1500/Ortho/Mac | English (PDF, 385 KB) | |
| Smile℠ Deluxe Gold 50/1500/Ortho/U85 | English (PDF, 385 KB) | |
| Bronze Voluntary DPPO/$1000/MAC | English (PDF, 385 KB) | |
| Bronze Voluntary DPPO/$1000/MAC/Child Only Ortho | English (PDF, 385 KB) | |
| Smile℠ Basic Voluntary 50/1000/No Ortho/MAC | English (PDF, 385 KB) | |
| Smile℠ Value 50/1500/No Ortho/MAC/NR | English (PDF, 385 KB) | |
| Smile℠ Plus Gold 50/2500/No Ortho/U90/ADV | English (PDF, 385 KB) | |
| Smile℠ Basic 50/1000/No Ortho/MAC | English (PDF, 385 KB) | |
| Smile℠ Basic Voluntary 50/1000/No Ortho/U80 | English (PDF, 385 KB) | |
| Smile℠ Basic Voluntary 75/1000/No Ortho/MAC/NR | English (PDF, 385 KB) | |
| Smile℠ Plus Gold 50/1500/Ortho/U80 | English (PDF, 385 KB) | |
| Smile℠ 50/1500/No Ortho/Mac/NR | English (PDF, 385 KB) | |
| Smile℠ Basic 75/1000/No Ortho/Mac/NR | English (PDF, 385 KB) | |
| Smile℠ Plus 50/1500/Ortho/Mac/NR | English (PDF, 385 KB) | |
| Smile℠ Deluxe 50/1500/Ortho/MAC/NR | English (PDF, 385 KB) | |
| Smile℠ Plus Gold 50/2500/Ortho/U90/ADV | English (PDF, 385 KB) | |
| Smile℠ Basic Voluntary 75/1000/No Ortho/MAC/NR | English (PDF, 385 KB) | |
| Smile℠ Plus 50/1500/No Ortho/MAC/WP | English (PDF, 385 KB) | |
| Ultimate Dental PPO for Small Business 50/2000/No Ortho/U90 | English (PDF, 385 KB) | |
| Smile℠ Basic Voluntary 50/1000/No Ortho/MAC | English (PDF, 385 KB) | |
| Smile℠ Basic Voluntary 50/1500/Ortho/U80 | English (PDF, 385 KB) | |
| Smile℠ In-Network Only Dental Plan 50/1500/Endo-Perio 80%/Ortho | English (PDF, 530 KB) | |
| Smile℠ In-Network Only Dental Plan 50/1500/Endo-Perio 80%/No Ortho | English (PDF, 530 KB) | |
| Bronze Voluntary DPPO/$1500/MAC/NWP | English (PDF, 385 KB) | |
| Bronze Voluntary DPPO/$1500/MAC/Child Only Ortho/NWP | English (PDF, 385 KB) | |
| Smile℠ Basic Voluntary 50/1500/Ortho/U80 | English (PDF, 385 KB) |
