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Dental and Vision Package

Plan Name Benefit Summary Disclosure

Specialty DuoSM Dental (benefit summary)

(must be purchased with Specialty Duo Vision)

English          Spanish Disclosure

Duo Combined Disclosure
 
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Smile Spectrum PPO Dental Plans

Plan Name Summary of Benefits Disclosure
SmileSM Spectrum 50/1000/No Ortho/MAC English          Spanish Disclosure
SmileSM Spectrum 50/1000/Ortho/MAC English          Spanish Disclosure
SmileSM Spectrum 50/1500/No Ortho/MAC English          Spanish Disclosure
SmileSM Spectrum 50/1500/No Ortho/U90 English          Spanish Disclosure
SmileSM Spectrum 50/1500/Ortho/MAC English          Spanish  Disclosure
SmileSM Spectrum 50/1500/Ortho/U90 English          Spanish  Disclosure
SmileSM Spectrum Advantage 50/1000/No Ortho/U80 English          Spanish  Disclosure
SmileSM Spectrum Advantage 50/1500/Ortho/U80 English          Spanish  Disclosure
SmileSM Spectrum Advantage 50/1500/Ortho/U80/In-Network English          Spanish  Disclosure
SmileSM Spectrum Advantage 50/2000/Ortho/U80 English          Spanish  Disclosure
SmileSM Spectrum Premier 50/1000/No Ortho/U90 English          Spanish  Disclosure
SmileSM Spectrum Premier 50/1000/Ortho/U90 English          Spanish  Disclosure
SmileSM Spectrum Premier 50/1500/Lifetime Ortho 1500/U80 English          Spanish   Disclosure
SmileSM Spectrum Premier 50/1500/No Ortho/MAC English          Spanish   Disclosure
SmileSM Spectrum Premier 50/1500/No Ortho/U90 English          Spanish     Disclosure
SmileSM Spectrum Premier 50/1500/Ortho/MAC English          Spanish      Disclosure
SmileSM Spectrum Premier 50/1500/Ortho/U90 English          Spanish      Disclosure
SmileSM Spectrum Premier 50/2000/Lifetime Ortho 1500/U80 English          Spanish      Disclosure
SmileSM Spectrum Premier 50/2000/No Ortho/MAC English          Spanish  Disclosure
SmileSM Spectrum Premier 50/2000/No Ortho/U90 English          Spanish  Disclosure
SmileSM Spectrum Premier 50/2000/Ortho/MAC English          Spanish Disclosure
SmileSM Spectrum Premier 50/2000/Ortho/U90 English          Spanish  Disclosure
SmileSM Spectrum Premier D&P Waiver 50/1500/No Ortho/U90 English          Spanish    Disclosure
SmileSM Spectrum Premier D&P Waiver 50/1500/Ortho/U90 English          Spanish    Disclosure
SmileSM Spectrum Premier D&P Waiver+Rollover 50/1500/No Ortho/U90 English          Spanish  Disclosure
SmileSM Spectrum Premier D&P Waiver+Rollover 50/1500/Ortho/U90 English          Spanish Disclosure
SmileSM Spectrum Premier Plus 25/1500/Lifetime Ortho 1500/U80 English          Spanish   Disclosure
SmileSM Spectrum Premier Plus 25/1500/No Ortho/U80 English          Spanish    Disclosure
SmileSM Spectrum Premier Plus 25/2000/Lifetime Ortho 1500/U80 English          Spanish  Disclosure
SmileSM Spectrum Premier Plus 25/2000/No Ortho/U80 English          Spanish   Disclosure
SmileSM Spectrum Premier Plus 25/2500/Lifetime Ortho 2000/U90 English          Spanish    Disclosure
SmileSM Spectrum Premier Plus 25/2500/No Ortho/U90 English          Spanish Disclosure
SmileSM Spectrum Premier Plus 25/3000/Lifetime Ortho 2000/U90 English          Spanish Disclosure
SmileSM Spectrum Premier Plus 25/3000/No Ortho/U90 English          Spanish Disclosure
SmileSM Spectrum Premier Plus 50/1000/No Ortho/MAC English          Spanish   Disclosure
SmileSM Spectrum Premier Plus 50/1000/No Ortho/U90 English          Spanish  Disclosure
SmileSM Spectrum Premier Plus 50/1000/Ortho/MAC English          Spanish   Disclosure
SmileSM Spectrum Premier Plus 50/1000/Ortho/U90 English          Spanish    Disclosure
SmileSM Spectrum Premier Plus 50/1500/No Ortho/MAC English          Spanish Disclosure
SmileSM Spectrum Premier Plus 50/1500/No Ortho/U90 English          Spanish Disclosure
SmileSM Spectrum Premier Plus 50/1500/Ortho/MAC English          Spanish Disclosure
SmileSM Spectrum Premier Plus 50/1500/Ortho/U90 English          Spanish Disclosure
SmileSM Spectrum Premier Plus 50/2000/No Ortho/MAC English          Spanish Disclosure
SmileSM Spectrum Premier Plus 50/2000/No Ortho/U90 English          Spanish Disclosure
SmileSM Spectrum Premier Plus 50/2000/Ortho/MAC English          Spanish Disclosure
SmileSM Spectrum Premier Plus 50/2000/Ortho/U90 English          Spanish  Disclosure
SmileSM Spectrum Premier Plus 50/2500/Lifetime Ortho 2000/U80 English          Spanish Disclosure
SmileSM Spectrum Premier Plus 50/2500/No Ortho/U80 English          Spanish Disclosure
SmileSM Spectrum Premier Plus 50/3000/Lifetime Ortho 2000/U80 English          Spanish Disclosure
SmileSM Spectrum Premier Plus 50/3000/No Ortho/U80 English          Spanish  Disclosure
SmileSM Spectrum Premier Plus D&P Waiver 50/1500/No Ortho/U90 English          Spanish Disclosure
SmileSM Spectrum Premier Plus D&P Waiver 50/1500/Ortho/U90 English          Spanish  Disclosure
SmileSM Spectrum Premier Plus D&P Waiver 50/2000/No Ortho/U90 English          Spanish  Disclosure
SmileSM Spectrum Premier Plus D&P Waiver 50/2000/Ortho/U90 English          Spanish  Disclosure
SmileSM Spectrum Premier Plus D&P Waiver+Rollover 50/1500/No Ortho/U90 English          Spanish  Disclosure
SmileSM Spectrum Premier Plus D&P Waiver+Rollover 50/1500/Ortho/U90 English          Spanish Disclosure
SmileSM Spectrum Premier Plus Rollover 50/1500/No Ortho/U90 English          Spanish  Disclosure
SmileSM Spectrum Premier Plus Rollover 50/1500/Ortho/U90 English          Spanish Disclosure
SmileSM Spectrum Premier Rollover 50/1500/No Ortho/U90 English          Spanish   Disclosure
SmileSM Spectrum Premier Rollover 50/1500/Ortho/U90 English          Spanish  Disclosure
SmileSM Spectrum Premier Rollover 50/2000/No Ortho/U90 English          Spanish  Disclosure
SmileSM Spectrum Premier Rollover 50/2000/Ortho/U90 English          Spanish  Disclosure

Non-Marketed Smile Spectrum PPO Dental Plans

Plan Name   Benefit Summary / SOB Disclosure
SmileSM Spectrum Premier 50/1000/Ortho/MAC English          Spanish Disclosure
SmileSM Spectrum Premier Plus D&P Waiver+Rollover 50/2000/Ortho/U90 English          Spanish Disclosure