2022

Summary of Benefits 2022

Broker Resources

2021 Benefit Summaries for Dental Plans

Summary of Benefits

When providing a summary of benefits 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

Plan Names Summaries of Benefits Disclosures
Bronze DPPO/$1000/MAC

English
Spanish

English
Bronze DPPO/$1000/MAC/Child Only Ortho

English
Spanish

English
Bronze Voluntary DPPO/$1000/MAC

English
Spanish

English
Bronze Voluntary DPPO/$1000/MAC/Child Only Ortho

English
Spanish

English
Silver DPPO/$1500/MAC

English
Spanish

English
Silver DPPO/$1500/MAC/Adult+Child Ortho

English
Spanish

English
Silver DPPO/$1500/U90

English
Spanish

English
Silver DPPO/$1500/U90/Adult+Child Ortho

English
Spanish

English
Gold DPPO/$1500/U90

English
Spanish

English
Gold DPPO/$1500/U90/Adult+Child Ortho

English
Spanish

English
Gold DPPO/$2000/U90

English
Spanish

English
Gold DPPO/$2000/U90/Adult+Child Ortho

English
Spanish

English
Platinum DPPO/$2500/U90

English
Spanish

English
Platinum DPPO/$2500/U90/Adult+Child Ortho

English
Spanish

English
Platinum DPPO/$3000/U90

English
Spanish

English
Platinum DPPO/$3000/U90/Adult+Child Ortho

English
Spanish

English
Platinum DPPO/$5000/U90

English
Spanish

English
Platinum DPPO/$5000/U90/Adult+Child Ortho

English
Spanish

English
Diamond DPPO/$3000/U95

English
Spanish

English
Diamond DPPO/$3000/U95/Adult+Child Ortho

English
Spanish

English
Diamond DPPO/$5000/U95

English
Spanish

English
Diamond DPPO/$5000/U95/Adult+Child Ortho

English
Spanish

English

 

 

 

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Plan Names Summaries of Benefits Disclosures
Dental HMO Basic

English
Spanish

English
Dental HMO Standard

English
Spanish

English
Dental HMO Voluntary

English 
Spanish

English
Dental HMO Deluxe

English 
Spanish

English
Dental HMO Plus

English
Spanish

English
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Closed Dental Plans - 2022: for renewing groups only

Plan Names Summaries of Benefits Disclosures
SmileSM Basic Voluntary 75/1000/No Ortho/MAC

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 Plus PPO for Small Business 50/2000/Ortho/MAC

English
Spanish

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

English
Spanish

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

English
Spanish

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

English
Spanish

English
SmileSM Basic Voluntary 50/1500/Ortho/U80

English
Spanish

English
SmileSM Basic 50/1000/No Ortho/MAC

English
Spanish

English
SmileSM Basic 50/1000/Ortho/U85

English
Spanish

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

English
Spanish

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

English
Spanish

English
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/No Ortho/MAC

English
Spanish

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

English
Spanish

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

English
Spanish

English
SmileSM Plus Gold 50/1500/Ortho/U80

English
Spanish

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

English
Spanish

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

English
Spanish

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

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 Gold 50/1500/Ortho/U85/NR

English
Spanish

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

English
Spanish

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

English
Spanish

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

English
Spanish

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

English
Spanish

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

English
Spanish

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

English
Spanish

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

English
Spanish

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

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 Plus 50/1500/No Ortho/MAC

English
Spanish

English

Closed DINO Plans - 2022: for renewing groups only

Plan Names Summaries of Benefits Disclosures
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 In-Network Only Dental Voluntary Plan 50/1500/Endo-Perio 50%/Ortho

English
Spanish

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

English
Spanish

English

 

 

 

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