2021

January 2021 Dental Summary of Benefits

Related Links

2020 Benefit Summaries | Applications & Claim Forms  | Dental Summary of Benefits FAQ

 

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)

Show full contents

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
Show full contents

Dental INO Plan (employer-paid)

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

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

Contact Us

  • Producer Services (800) 559-5905

    Employer Services (800) 325-5166

  • Blue Shield of California

    PO Box 272540

    Chico, CA 95927-2540

© California Physicians’ Service DBA Blue Shield of California 1999-2022. All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association.

Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.