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January 2021 Dental Benefit Summaries / Summary of Benefits

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Benefit Summary/Summary of Benefits

The following benefit summary/summary of benefits are for groups of 101 or more employees.

When providing a benefit summary/summary of benefit to an applicant or Blue Shield member, you must also include a Disclosure and a Notice of Language Assistance. (PDF, 1MB)

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Dental HMO Plans

Plan Name Summary of Benefits Disclosure
Dental HMO Basic English        Spanish Disclosure
Dental HMO Standard English        Spanish Disclosure
Dental HMO Plus English        Spanish Disclosure
Dental HMO Deluxe English        Spanish Disclosure
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Dental INO Plan (employer-paid)

Plan Name Benefit Summary Disclosure
SmileSM D&P In-Network Only Dental PPO English          Spanish  Disclosure
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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

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