Summary of Benefits 2023 – Dental

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, 1 MB)

Smile Spectrum PPO Dental plans

Plan name Summary of Benefits Disclosure
SmileSM Spectrum 50/1000/No Ortho/MAC

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum 50/1000/Ortho/MAC

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum 50/1500/No Ortho/MAC

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum 50/1500/No Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum 50/1500/Ortho/MAC

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum 50/1500/Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Advantage 50/1000/No Ortho/U80

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Advantage 50/1500/Ortho/U80

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Advantage 50/1500/Ortho/U80/In-Network

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Advantage 50/2000/Ortho/U80

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier 50/1000/No Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier 50/1000/Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier 50/1500/Lifetime Ortho 1500/U80

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier 50/1500/No Ortho/MAC

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier 50/1500/No Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier 50/1500/Ortho/MAC

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier 50/1500/Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier 50/2000/Lifetime Ortho 1500/U80

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier 50/2000/No Ortho/MAC

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier 50/2000/No Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier 50/2000/Ortho/MAC

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier 50/2000/Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier D&P Waiver 50/1500/No Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier D&P Waiver 50/1500/Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier D&P Waiver+Rollover 50/1500/No Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier D&P Waiver+Rollover 50/1500/Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 25/1500/Lifetime Ortho 1500/U80

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 25/1500/No Ortho/U80

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 25/2000/Lifetime Ortho 1500/U80

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 25/2000/No Ortho/U80

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 25/2500/Lifetime Ortho 2000/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 25/2500/No Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 25/3000/Lifetime Ortho 2000/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 25/3000/No Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 50/1000/No Ortho/MAC

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 50/1000/No Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 50/1000/Ortho/MAC

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 50/1000/Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 50/1500/No Ortho/MAC

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 50/1500/No Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 50/1500/Ortho/MAC

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 50/1500/Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 50/2000/No Ortho/MAC

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 50/2000/No Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 50/2000/Ortho/MAC

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 50/2000/Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 50/2500/Lifetime Ortho 2000/U80

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 50/2500/No Ortho/U80

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 50/3000/Lifetime Ortho 2000/U80

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus 50/3000/No Ortho/U80

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus D&P Waiver 50/1500/No Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus D&P Waiver 50/1500/Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus D&P Waiver 50/2000/No Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus D&P Waiver 50/2000/Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus D&P Waiver+Rollover 50/1500/No Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB) 

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus D&P Waiver+Rollover 50/1500/Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus Rollover 50/1500/No Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Plus Rollover 50/1500/Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Rollover 50/1500/No Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Rollover 50/1500/Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Rollover 50/2000/No Ortho/U90

English (PDF, 362 KB) Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)
SmileSM Spectrum Premier Rollover 50/2000/Ortho/U90

English (PDF, 362 KB)

Spanish (PDF, 370 KB)

Disclosure (PDF, 632 KB)

Dental HMO plans

Plan name Summary of Benefits Disclosure
Dental HMO Basic English (PDF, 354 KB)
Spanish (PDF, 395 KB)
 
Disclosure (PDF, 619 KB)
Dental HMO Standard English (PDF, 354 KB)
Spanish (PDF, 395 KB)
 
Disclosure (PDF, 619 KB)
Dental HMO Plus English (PDF, 354 KB)
Spanish (PDF, 395 KB)
Disclosure (PDF, 619 KB)
Dental HMO Deluxe English (PDF, 354 KB)
Spanish (PDF, 395 KB)
Disclosure (PDF, 619 KB)
Dental HMO Elite 75 English (PDF, 354KB 
Spanish (PDF, 359KB
Disclosure (PDF, 619 KB)
Dental HMO Elite 100 English (PDF, 354KB 
Spanish (PDF, 359KB
Disclosure (PDF, 619 KB)

Dental INO plan (employer-paid)

Plan name Summary of Benefits Disclosure
SmileSM D&P In-Network Only Dental PP​O English  (PDF, 325 KB)
Spanish  (PDF, 330 KB)
Disclosure (PDF, 502 KB)

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