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)
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 |
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 |
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 |
Plan Name | Summary of Benefits | Disclosure |
---|---|---|
SmileSM D&P In-Network Only Dental PPO | English 794KB Spanish 827KB | Disclosure 1MB |
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