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January 2022 Dental Summary of Benefits

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Summary of Benefits

The following summary of benefits 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, 1MB)

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Smile Spectrum PPO Dental Plans

Plan Name Summary of Benefits Disclosure
SmileSM Spectrum 50/1000/No Ortho/MAC English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum 50/1000/Ortho/MAC English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum 50/1500/No Ortho/MAC English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum 50/1500/No Ortho/U90 English  1.1MB        Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum 50/1500/Ortho/MAC English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum 50/1500/Ortho/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Advantage 50/1000/No Ortho/U80 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Advantage 50/1500/Ortho/U80 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Advantage 50/1500/Ortho/U80/In-Network English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Advantage 50/2000/Ortho/U80 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier 50/1000/No Ortho/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier 50/1000/Ortho/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier 50/1500/Lifetime Ortho 1500/U80 English 1.1MB         Spanish 1.8MB   Disclosure 1.3MB
SmileSM Spectrum Premier 50/1500/No Ortho/MAC English 1.1MB         Spanish 1.8MB   Disclosure 1.3MB
SmileSM Spectrum Premier 50/1500/No Ortho/U90 English 1.1MB         Spanish 1.8MB     Disclosure 1.3MB
SmileSM Spectrum Premier 50/1500/Ortho/MAC English 1.1MB         Spanish 1.8MB     Disclosure 1.3MB
SmileSM Spectrum Premier 50/1500/Ortho/U90 English 1.1MB         Spanish 1.8MB      Disclosure 1.3MB
SmileSM Spectrum Premier 50/2000/Lifetime Ortho 1500/U80 English 1.1MB         Spanish 1.8MB      Disclosure 1.3MB
SmileSM Spectrum Premier 50/2000/No Ortho/MAC English 1.1MB         Spanish 1.8MB  Disclosure 1.3MB
SmileSM Spectrum Premier 50/2000/No Ortho/U90 English 1.1MB         Spanish 1.8MB  Disclosure 1.3MB
SmileSM Spectrum Premier 50/2000/Ortho/MAC English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier 50/2000/Ortho/U90 English 1.1MB         Spanish 1.8MB  Disclosure 1.3MB
SmileSM Spectrum Premier D&P Waiver 50/1500/No Ortho/U90 English 1.1MB         Spanish 1.8MB    Disclosure 1.3MB
SmileSM Spectrum Premier D&P Waiver 50/1500/Ortho/U90 English 1.1MB         Spanish 1.8MB    Disclosure 1.3MB
SmileSM Spectrum Premier D&P Waiver+Rollover 50/1500/No Ortho/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier D&P Waiver+Rollover 50/1500/Ortho/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus 25/1500/Lifetime Ortho 1500/U80 English 1.1MB         Spanish 1.8MB   Disclosure 1.3MB
SmileSM Spectrum Premier Plus 25/1500/No Ortho/U80 English 1.1MB         Spanish 1.8MB    Disclosure 1.3MB
SmileSM Spectrum Premier Plus 25/2000/Lifetime Ortho 1500/U80 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus 25/2000/No Ortho/U80 English 1.1MB         Spanish 1.8MB   Disclosure 1.3MB
SmileSM Spectrum Premier Plus 25/2500/Lifetime Ortho 2000/U90 English 1.1MB         Spanish 1.8MB    Disclosure 1.3MB
SmileSM Spectrum Premier Plus 25/2500/No Ortho/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus 25/3000/Lifetime Ortho 2000/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus 25/3000/No Ortho/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus 50/1000/No Ortho/MAC English 1.1MB         Spanish 1.8MB   Disclosure 1.3MB
SmileSM Spectrum Premier Plus 50/1000/No Ortho/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus 50/1000/Ortho/MAC English 1.1MB         Spanish 1.8MB   Disclosure 1.3MB
SmileSM Spectrum Premier Plus 50/1000/Ortho/U90 English 1.1MB         Spanish 1.8MB    Disclosure 1.3MB
SmileSM Spectrum Premier Plus 50/1500/No Ortho/MAC English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus 50/1500/No Ortho/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus 50/1500/Ortho/MAC English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus 50/1500/Ortho/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus 50/2000/No Ortho/MAC English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus 50/2000/No Ortho/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus 50/2000/Ortho/MAC English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus 50/2000/Ortho/U90 English 1.1MB         Spanish 1.8MB  Disclosure 1.3MB
SmileSM Spectrum Premier Plus 50/2500/Lifetime Ortho 2000/U80 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus 50/2500/No Ortho/U80 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus 50/3000/Lifetime Ortho 2000/U80 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus 50/3000/No Ortho/U80 English 1.1MB         Spanish 1.8MB  Disclosure 1.3MB
SmileSM Spectrum Premier Plus D&P Waiver 50/1500/No Ortho/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus D&P Waiver 50/1500/Ortho/U90 English 1.1MB         Spanish 1.8MB  Disclosure 1.3MB
SmileSM Spectrum Premier Plus D&P Waiver 50/2000/No Ortho/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus D&P Waiver 50/2000/Ortho/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus D&P Waiver+Rollover 50/1500/No Ortho/U90 English 1.1MB         Spanish 1.8MB  Disclosure 1.3MB
SmileSM Spectrum Premier Plus D&P Waiver+Rollover 50/1500/Ortho/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus Rollover 50/1500/No Ortho/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus Rollover 50/1500/Ortho/U90 English 1.1MB         Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Rollover 50/1500/No Ortho/U90 English 1.1MB         Spanish 1.8MB   Disclosure 1.3MB
SmileSM Spectrum Premier Rollover 50/1500/Ortho/U90 English 1.1MB         Spanish 1.8MB  Disclosure 1.3MB
SmileSM Spectrum Premier Rollover 50/2000/No Ortho/U90 English 1.1MB         Spanish 1.8MB  Disclosure 1.3MB
SmileSM Spectrum Premier Rollover 50/2000/Ortho/U90 English 1.1MB         Spanish 1.8MB  Disclosure 1.3MB

Non-Marketed Smile Spectrum PPO Dental Plans

Plan Name   Benefit Summary / SOB Disclosure
SmileSM Spectrum Premier 50/1000/Ortho/MAC English  1.1MB      Spanish 1.8MB Disclosure 1.3MB
SmileSM Spectrum Premier Plus D&P Waiver+Rollover 50/2000/Ortho/U90 English  1.1MB      Spanish 1.8MB Disclosure 1.3MB
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Dental HMO Plans

Plan Name Summary of Benefits Disclosure
Dental HMO Basic English 1.1MB       Spanish 1.8MB Disclosure 1.3MB
Dental HMO Standard English 1.1MB       Spanish 1.8MB Disclosure 1.3MB
Dental HMO Plus English 1.1MB       Spanish 1.8MB Disclosure 1.3MB
Dental HMO Deluxe English 1.1MB       Spanish 1.8MB Disclosure 1.3MB
Dental HMO Elite 100 English 1.1MB       Spanish 1.9MB Disclosure 1.3MB
Dental HMO Elite 75 English 1.1MB       Spanish 1.9MB Disclosure 1.3MB
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Dental INO Plan (employer-paid)

Plan Name Summary of Benefits Disclosure
SmileSM D&P In-Network Only Dental PP​O English  794KB       Spanish  827KB Disclosure 1MB

Contact Us

  • Producer Services (800) 559-5905

    Employer Services (800) 325-5166

  • Blue Shield of California

    PO Box 272540

    Chico, CA 95927-2540

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