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, 1MB).
Plan Names | Summaries of Benefits | Disclosures |
---|---|---|
Bronze DPPO/$1000/MAC | English | |
Bronze DPPO/$1000/MAC/Child Only Ortho | English | |
Bronze Voluntary DPPO/$1000/MAC | English | |
Bronze Voluntary DPPO/$1000/MAC/Child Only Ortho | English | |
Bronze DPPO/$1500/MAC | English | |
Bronze DPPO/$1500/MAC/Child Only Ortho | English | |
Bronze Voluntary DPPO/$1500/MAC | English | |
Bronze Voluntary DPPO/$1500/MAC/Child Only Ortho | English | |
Silver DPPO/$1500/MAC | English | |
Silver DPPO/$1500/MAC/Adult+Child Ortho | English | |
Silver DPPO/$1500/U90 | English | |
Silver DPPO/$1500/U90/Adult+Child Ortho | English | |
Gold DPPO/$1500/U90 | English | |
Gold DPPO/$1500/U90/Adult+Child Ortho | English | |
Gold DPPO/$2000/U90 | English | |
Gold DPPO/$2000/U90/Adult+Child Ortho | English | |
Gold DPPO/$1500/MAC | English | |
Gold DPPO/$1500/MAC/Adult+Child Ortho | English | |
Gold DPPO/$2000/MAC | English | |
Gold DPPO/$2000/MAC/Adult+Child Ortho | English | |
Platinum DPPO/$2500/U90 | English | |
Platinum DPPO/$2500/U90/Adult+Child Ortho | English | |
Platinum DPPO/$3000/U90 | English | |
Platinum DPPO/$3000/U90/Adult+Child Ortho | English | |
Platinum DPPO/$5000/U90 | English | |
Platinum DPPO/$5000/U90/Adult+Child Ortho | English | |
Diamond DPPO/$3000/U95 | English | |
Diamond DPPO/$3000/U95/Adult+Child Ortho | English | |
Diamond DPPO/$5000/U95 | English | |
Diamond DPPO/$5000/U95/Adult+Child Ortho | English |
Plan Names | Summaries of Benefits | Disclosures |
---|---|---|
SmileSM 50/1500/No Ortho/Mac | English | |
SmileSM 50/1500/No Ortho/MAC/NR | English | |
SmileSM Basic 50/1000/No Ortho/MAC | English | |
SmileSM Basic 50/1000/Ortho/U85 | English | |
SmileSM Basic 75/1000/No Ortho/Mac | English | |
SmileSM Basic 75/1000/No Ortho/Mac/NR | English | |
SmileSM Basic Voluntary 50/1000/No Ortho/MAC | English | |
SmileSM Basic Voluntary 50/1000/No Ortho/MAC/NR | English | |
SmileSM Basic Voluntary 50/1000/No Ortho/U80 | English | |
SmileSM Basic Voluntary 50/1500/Ortho/U80 | English | |
SmileSM Basic Voluntary 75/1000/No Ortho/MAC | English | |
SmileSM Basic Voluntary 75/1000/No Ortho/MAC/NR | English | |
SmileSM Deluxe 2000 50/2000/No Ortho/MAC/NR | English | |
SmileSM Deluxe 50/1500/Ortho/MAC | English | |
SmileSM Deluxe 50/1500/Ortho/MAC/NR | English | |
SmileSM Deluxe Gold 50/1500/Ortho/U85 | English | |
SmileSM Deluxe Gold 50/1500/Ortho/U85/NR | English | |
SmileSM Deluxe Plus 2000 50/2000/Ortho/MAC/NR | English | |
SmileSM In-Network Only Dental Plan 50/1500/Endo-Perio 80%/No Ortho | English | |
SmileSM In-Network Only Dental Plan 50/1500/Endo-Perio 80%/Ortho | English | |
SmileSM In-Network Only Dental Voluntary Plan 50/1500/Endo-Perio 50%/Ortho | English | |
SmileSM Plus 50/1500/No Ortho/MAC | English | |
SmileSM Plus 50/1500/No Ortho/MAC/WP | English | |
SmileSM Plus 50/1500/Ortho/Mac | English | |
SmileSM Plus 50/1500/Ortho/Mac/NR | English | |
SmileSM Plus Gold 50/1500/No Ortho/U80 | English | |
SmileSM Plus Gold 50/1500/No Ortho/U90/ADV | English | |
SmileSM Plus Gold 50/1500/Ortho/U80 | English | |
SmileSM Plus Gold 50/1500/Ortho/U80/ADV | English | |
SmileSM Plus Gold 50/1500/Ortho/U85/NR | English | |
SmileSM Plus Gold 50/1500/Ortho/U90/ADV | English | |
SmileSM Plus Gold 50/2500/No Ortho/U90/ADV | English | |
SmileSM Plus Gold 50/2500/Ortho/U90/ADV | English | |
SmileSM Value 50/1500/No Ortho/MAC | English | |
SmileSM Value 50/1500/No Ortho/MAC/NR | English | |
Ultimate Dental Plus PPO for Small Business 50/2000/Ortho/MAC/NR | English | |
Ultimate Dental PPO for Small Business 50/2000/Lifetime Ortho/U90 | English | |
Ultimate Dental PPO for Small Business 50/2000/No Ortho/MAC/NR | English | |
Ultimate Dental PPO for Small Business 50/2000/No Ortho/U80 | English | |
Ultimate Dental PPO for Small Business 50/2000/No Ortho/U90 | English |
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