2023

January 2023 Dental Summary of Benefits

Related Links

2022 Benefit Summaries | Applications & Claim Forms | Dental Summary of Benefits FAQ

 

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 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum 50/1000/Ortho/MAC English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum 50/1500/No Ortho/MAC English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum 50/1500/No Ortho/U90 English  362KB        Spanish 370KB Disclosure 632KB
SmileSM Spectrum 50/1500/Ortho/MAC English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum 50/1500/Ortho/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Advantage 50/1000/No Ortho/U80 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Advantage 50/1500/Ortho/U80 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Advantage 50/1500/Ortho/U80/In-Network English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Advantage 50/2000/Ortho/U80 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier 50/1000/No Ortho/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier 50/1000/Ortho/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier 50/1500/Lifetime Ortho 1500/U80 English 362KB         Spanish 370KB   Disclosure 632KB
SmileSM Spectrum Premier 50/1500/No Ortho/MAC English 362KB         Spanish 370KB   Disclosure 632KB
SmileSM Spectrum Premier 50/1500/No Ortho/U90 English 362KB         Spanish 370KB     Disclosure 632KB
SmileSM Spectrum Premier 50/1500/Ortho/MAC English 362KB         Spanish 370KB     Disclosure 632KB
SmileSM Spectrum Premier 50/1500/Ortho/U90 English 362KB         Spanish 370KB      Disclosure 632KB
SmileSM Spectrum Premier 50/2000/Lifetime Ortho 1500/U80 English 362KB         Spanish 370KB      Disclosure 632KB
SmileSM Spectrum Premier 50/2000/No Ortho/MAC English 362KB         Spanish 370KB  Disclosure 632KB
SmileSM Spectrum Premier 50/2000/No Ortho/U90 English 362KB         Spanish 370KB  Disclosure 632KB
SmileSM Spectrum Premier 50/2000/Ortho/MAC English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier 50/2000/Ortho/U90 English 362KB         Spanish 370KB  Disclosure 632KB
SmileSM Spectrum Premier D&P Waiver 50/1500/No Ortho/U90 English 362KB         Spanish 370KB    Disclosure 632KB
SmileSM Spectrum Premier D&P Waiver 50/1500/Ortho/U90 English 362KB         Spanish 370KB    Disclosure 632KB
SmileSM Spectrum Premier D&P Waiver+Rollover 50/1500/No Ortho/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier D&P Waiver+Rollover 50/1500/Ortho/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus 25/1500/Lifetime Ortho 1500/U80 English 362KB         Spanish 370KB   Disclosure 632KB
SmileSM Spectrum Premier Plus 25/1500/No Ortho/U80 English 362KB         Spanish 370KB    Disclosure 632KB
SmileSM Spectrum Premier Plus 25/2000/Lifetime Ortho 1500/U80 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus 25/2000/No Ortho/U80 English 362KB         Spanish 370KB   Disclosure 632KB
SmileSM Spectrum Premier Plus 25/2500/Lifetime Ortho 2000/U90 English 362KB         Spanish 370KB    Disclosure 632KB
SmileSM Spectrum Premier Plus 25/2500/No Ortho/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus 25/3000/Lifetime Ortho 2000/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus 25/3000/No Ortho/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus 50/1000/No Ortho/MAC English 362KB         Spanish 370KB   Disclosure 632KB
SmileSM Spectrum Premier Plus 50/1000/No Ortho/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus 50/1000/Ortho/MAC English 362KB         Spanish 370KB   Disclosure 632KB
SmileSM Spectrum Premier Plus 50/1000/Ortho/U90 English 362KB         Spanish 370KB    Disclosure 632KB
SmileSM Spectrum Premier Plus 50/1500/No Ortho/MAC English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus 50/1500/No Ortho/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus 50/1500/Ortho/MAC English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus 50/1500/Ortho/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus 50/2000/No Ortho/MAC English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus 50/2000/No Ortho/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus 50/2000/Ortho/MAC English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus 50/2000/Ortho/U90 English 362KB         Spanish 370KB  Disclosure 632KB
SmileSM Spectrum Premier Plus 50/2500/Lifetime Ortho 2000/U80 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus 50/2500/No Ortho/U80 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus 50/3000/Lifetime Ortho 2000/U80 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus 50/3000/No Ortho/U80 English 362KB         Spanish 370KB  Disclosure 632KB
SmileSM Spectrum Premier Plus D&P Waiver 50/1500/No Ortho/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus D&P Waiver 50/1500/Ortho/U90 English 362KB         Spanish 370KB  Disclosure 632KB
SmileSM Spectrum Premier Plus D&P Waiver 50/2000/No Ortho/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus D&P Waiver 50/2000/Ortho/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus D&P Waiver+Rollover 50/1500/No Ortho/U90 English 362KB         Spanish 370KB  Disclosure 632KB
SmileSM Spectrum Premier Plus D&P Waiver+Rollover 50/1500/Ortho/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus Rollover 50/1500/No Ortho/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Plus Rollover 50/1500/Ortho/U90 English 362KB         Spanish 370KB Disclosure 632KB
SmileSM Spectrum Premier Rollover 50/1500/No Ortho/U90 English 362KB         Spanish 370KB   Disclosure 632KB
SmileSM Spectrum Premier Rollover 50/1500/Ortho/U90 English 362KB         Spanish 370KB  Disclosure 632KB
SmileSM Spectrum Premier Rollover 50/2000/No Ortho/U90 English 362KB         Spanish 370KB  Disclosure 632KB
SmileSM Spectrum Premier Rollover 50/2000/Ortho/U90 English 362KB         Spanish 370KB  Disclosure 632KB
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Dental HMO Plans

Plan Name Summary of Benefits Disclosure
Dental HMO Basic English 354KB       Spanish 359KB Disclosure 618KB
Dental HMO Standard English 354KB       Spanish 359KB Disclosure 618KB
Dental HMO Plus English 354KB       Spanish 359KB Disclosure 618KB
Dental HMO Deluxe English 354KB       Spanish 359KB Disclosure 618KB
Dental HMO Elite 75 English 354KB       Spanish 359KB Disclosure 618KB
Dental HMO Elite 100 English 354KB       Spanish 359KB Disclosure 618KB
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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  325KB       Spanish  330KB Disclosure 632KB

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