2020

Dental Benefit Summaries 2020

Broker Resources

Benefit Summaries

When providing a benefit summary 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 PPO Plans with ADV

SmileSM Plus Gold 50/1500/Ortho/U80/ADV

English
Spanish

English
SmileSM Plus Gold 50/1500/No Ortho/U90/ADV

English
Spanish

English
SmileSM Plus Gold 50/1500/Ortho/U90/ADV

English
Spanish

English
SmileSM Plus Gold 50/2500/No Ortho/U90/ADV

English
Spanish

English
SmileSM Plus Gold 50/2500/Ortho/U90/ADV

English
Spanish

English

Dental PPO Plans without ADV

Plan Name Benefit Summaries Disclosures

SmileSM Value 50/1500/No Ortho/MAC/NR

English
Spanish

English

SmileSM 50/1500/No Ortho/Mac/NR

English 
Spanish

English
SmileSM Plus 50/1500/Ortho/Mac/NR

English
Spanish

English
SmileSM Basic 75/1000/No Ortho/Mac/NR

English
Spanish

English
SmileSM Basic 50/1000/No Ortho/MAC

English
Spanish

English
SmileSM Basic 50/1000/Ortho/U85

English
Spanish

English
SmileSM Plus 50/1500/No Ortho/MAC

English
Spanish

English
SmileSM Plus 50/1500/No Ortho/MAC/WP

English
Spanish

English
SmileSM Deluxe 50/1500/Ortho/MAC/NR

English
Spanish

English
SmileSM Deluxe 2000 50/2000/No Ortho/MAC/NR

English
Spanish

English
SmileSM Deluxe Plus 2000 50/2000/Ortho/MAC/NR

English
Spanish

English
SmileSM Deluxe Gold 50/1500/Ortho/U85/NR

English
Spanish

English
SmileSM Plus Gold 50/1500/Ortho/U85/NR

English
Spanish

English
SmileSM Plus Gold 50/1500/Ortho/U80

English
Spanish

English
SmileSM Plus Gold 50/1500/No Ortho/U80

English
Spanish

English
Ultimate Dental PPO for Small Business 50/2000/MAC/NR

English
Spanish

English
Ultimate Dental Plus PPO for Small Business 50/2000/MAC/NR

English
Spanish

English
Ultimate Dental PPO for Small Business 50/2000/No Ortho/U80

English
Spanish

English
Ultimate Dental PPO for Small Business 50/2000/Lifetime Ortho/U90

English
Spanish

English
Ultimate Dental PPO for Small Business 50/2000/No Ortho/U90

English
Spanish

English
SmileSM Basic Voluntary 75/1000/No Ortho/MAC/NR

English
Spanish

English
SmileSM Basic Voluntary 50/1000/No Ortho/MAC

English
Spanish

English
SmileSM Basic Voluntary 50/1500/Ortho/U80

English
Spanish

English

SmileSM Basic Voluntary 50/1000/No Ortho/U80/NWP

English
Spanish

English

 

 

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Plan Name Benefit Summaries Disclosures
Dental HMO Basic

English
Spanish

English
Dental HMO Standard

English
Spanish

English
Dental HMO Voluntary

English 
Spanish

English
Dental HMO Plus

English 
Spanish

English
Dental HMO Deluxe

English
Spanish

English
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Plan Name Benefit Summaries Disclosures

SmileSM Basic 75/1000/No Ortho/Mac

English 
Spanish

English
SmileSM Value 50/1500/No Ortho/MAC

English
Spanish

English
SmileSM 50/1500/No Ortho/Mac

English
Spanish

English
SmileSM Plus 50/1500/Ortho/Mac

English
Spanish

English
SmileSM Plus Gold 50/1500/Ortho/U85

English
Spanish

English
SmileSM Deluxe 2000 50/2000/No Ortho/MAC

English
Spanish

English
SmileSM Deluxe 50/1500/Ortho/MAC

English
Spanish

English
SmileSM Deluxe Plus 2000 50/2000/Ortho/MAC

English
Spanish

English
SmileSM Deluxe Gold 50/1500/Ortho/U85

English
Spanish

English
Ultimate Dental PPO for Small Business 50/2000/MAC

English
Spanish

English
Ultimate Dental Plus PPO for Small Business 50/2000/MAC

English
Spanish

English

SmileSM Basic Voluntary 75/1000/No Ortho/MAC

English
Spanish

English
SmileSM Basic Voluntary 75/1000/No Ortho/MAC - NWP

English
Spanish

English
SmileSM Basic 75/1000/No Ortho/MAC

English
Spanish

English
SmileSM Value 50/1500/No Ortho/MAC

English
Spanish

English
SmileSM 50/1500/No Ortho/MAC

English
Spanish

English
SmileSM Plus 50/1500/Ortho/MAC

English
Spanish

English
SmileSM Plus Gold 50/1500/Ortho/U85

English
Spanish

English
SmileSM Deluxe 2000 50/2000/No Ortho/MAC

English
Spanish

English
SmileSM Deluxe 50/1500/Ortho/MAC

English
Spanish

English
SmileSM Deluxe Plus 2000 50/2000/Ortho/MAC

English
Spanish

English
SmileSM Deluxe Gold 50/1500/Ortho/U85

English
Spanish

English
Ultimate Dental PPO for Small Business 50/2000/MAC

English
Spanish

English
Ultimate Dental Plus PPO for Small Business 50/2000/MAC

English
Spanish

English
SmileSM In-Network Only Dental Plan 50/2500/Endo-Perio 80%/Ortho

English
Spanish

English
SmileSM In-Network Only Dental Plan 50/2500/Endo-Perio 80%/No Ortho

English
Spanish

English
SmileSM In-Network Only Dental Voluntary Plan 50/2500/Endo-Perio 50%/Ortho

English
Spanish

English
SmileSM In-Network Only Dental Voluntary Plan 50/2500/Endo-Perio 50%/No Ortho

English
Spanish

English
SmileSM In-Network Only Dental Plan 50/1500/Endo-Perio 80%/Ortho

English
Spanish

English
SmileSM In-Network Only Dental Plan 50/1500/Endo-Perio 80%/No Ortho

English
Spanish

English
SmileSM INO Dental Voluntary Plan 50/1500/EndoPerio 50%/Ortho

English
Spanish

English
SmileSM INO Dental Voluntary Plan 50/1500/EndoPerio 50%/No Ortho

English
Spanish

English

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