Summary of Benefits 2027 - Dental
The following Summary of Benefits (SOB) 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, 254 KB) Spanish (PDF, 279 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum 50/1000/Ortho/MAC | English (PDF, 255KB) Spanish (PDF, 285 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum 50/1500/No Ortho/MAC | English (PDF, 253 KB) Spanish (PDF, 279 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum 50/1500/No Ortho/U90 | English (PDF, 254 KB) Spanish (PDF, 281 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum 50/1500/Ortho/MAC | English (PDF, 254 KB) Spanish (PDF, 285 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum 50/1500/Ortho/U90 | English (PDF, 256 KB) Spanish (PDF, 287 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/1000/Ortho/U90 | English (PDF, 256 KB) Spanish (PDF, 287 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/1500/Lifetime Ortho 1500/U80 | English (PDF, 257 KB) Spanish (PDF, 290 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 25/1500/Lifetime Ortho 1500/U80 | English (PDF, 257 KB) Spanish (PDF, 290 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/1500/No Ortho/MAC | English (PDF, 254 KB) Spanish (PDF, 279 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/1500/No Ortho/U90 | English (PDF, 254 KB) Spanish (PDF, 281 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/1500/Ortho/MAC | English (PDF, 255 KB) Spanish (PDF, 285 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/1500/Ortho/U90 | English (PDF, 256 KB) Spanish (PDF, 287 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/2000/No Ortho/U90 | English (PDF, 255 KB) Spanish (PDF, 281 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/2000/Ortho/MAC | English (PDF, 255 KB) Spanish (PDF, 285 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/2000/Ortho/U90 | English (PDF, 256 KB) Spanish (PDF, 287 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier D&P Waiver+Rollover 50/1500/Ortho/U90 | English (PDF, 180 KB) Spanish (PDF, 296 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 25/1500/No Ortho/U80 | English (PDF, 254 KB) Spanish (PDF, 280 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 25/2000/Lifetime Ortho 1500/U80 | English (PDF, 257 KB) Spanish (PDF, 290 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 25/2500/Lifetime Ortho 2000/U90 | English (PDF, 257 KB) Spanish (PDF, 290 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 25/2500/No Ortho/U90 | English (PDF, 254 KB) Spanish (PDF, 280 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/1000/Ortho/U90 | English (PDF, 256 KB) Spanish (PDF, 287 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/1000/No Ortho/MAC | English (PDF, 253 KB) Spanish (PDF, 278 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/1000/No Ortho/U90 | English (PDF, 254 KB) Spanish (PDF, 281 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/1000/Ortho/MAC | English (PDF, 256 KB) Spanish (PDF, 285 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/1500/No Ortho/MAC | English (PDF, 253 KB) Spanish (PDF, 278 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/1500/No Ortho/U90 | English (PDF, 254 KB) Spanish (PDF, 281 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/1500/Ortho/MAC | English (PDF, 255 KB) Spanish (PDF, 284 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/1500/Ortho/U90 | English (PDF, 256 KB) Spanish (PDF, 287 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/2000/No Ortho/MAC | English (PDF, 253 KB) Spanish (PDF, 278 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/2000/No Ortho/U90 | English (PDF, 254 KB) Spanish (PDF, 280 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/2000/Ortho/MAC | English (PDF, 255 KB) Spanish (PDF, 284 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/2000/Ortho/U90 | English (PDF, 256 KB) Spanish (PDF, 287 K)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/2500/Lifetime Ortho 2000/U80 | English (PDF, 257 KB) Spanish (PDF, 290 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus Rollover 50/1500/No Ortho/U90 | English (PDF, 258 KB) Spanish (PDF, 290 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Rollover 50/1500/No Ortho/U90 | English (PDF, 258 KB) Spanish (PDF, 290 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Rollover 50/1500/Ortho/U90 | English (PDF, 260 KB) Spanish (PDF, 296 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/2000/Lifetime Ortho 2000/U90 | English (PDF, 257 KB) Spanish (PDF, 290 KB)
|
Disclosure (PDF, 747 KB) |
| Smile℠ Spectrum Premier Plus Rollover 50/1500/Ortho/U90 | English (PDF, 260 KB) Spanish (PDF, 296 KB) |
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/1500/Lifetime Ortho 1500/U90 | English (PDF, 257 KB) Spanish (PDF, 290 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/2000/Lifetime Ortho 2000/U90 | English (PDF, 257 KB) Spanish (PDF, 290 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/1500/Lifetime Ortho 1500/U90 | English (PDF, 257 KB) Spanish (PDF, 290 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/2500/Ortho/U90 | English (PDF, 256 KB) Spanish (DF, 287 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/2500/No Ortho/U90 | English (PDF, 254 KB) Spanish (PDF, 287 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/3000/Ortho/U90 | English (PDF, 256 KB) Spanish (PDF, 287 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/3000/No Ortho/U90 | English (PDF, 256 KB) Spanish (PDF, 281 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/2500/Ortho/U90 | English (PDF, 256 KB) Spanish (PDF, 287 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/3000/Ortho/U90 | English (PDF, 256 KB) Spanish (PDF, 287 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/2500/No Ortho/U90 | English (PDF, 254 KB) Spanish (PDF, 281 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/3000/No Ortho/U90 | English (PDF, 254 KB) Spanish (PDF, 281 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/5000/Ortho/U90 | English (PDF, 256 KB) Spanish (PDF, 287 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/5000/No Ortho/U90 | English (PDF, 254 KB) Spanish (PDF, 281 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/5000/Ortho/U90 | English (PDF, 256 KB) Spanish (PDF, 257 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/5000/No Ortho/U90 | English (PDF, 254 KB) Spanish (PDF, 281 KB) |
Disclosure (PDF, 747 KB) |
Not Marketed Smile Spectrum PPO Dental plans
| Plan name | Benefit Summary / SOB | Disclosure |
|---|---|---|
| SmileSM Spectrum Premier 50/1000/No Ortho/U90 | English (PDF, 254 KB) Spanish (PDF, 281 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/2000/Lifetime Ortho 1500/U80 | English (PDF, 257 KB) Spanish (PDF, 290 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier 50/2000/No Ortho/MAC | English (PDF, 254 KB) Spanish (PDF, 279 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier D&P Waiver 50/1500/Ortho/U90 | English (PDF, 256 KB) Spanish (PDF, 287 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Premier Plus 50/3000/Lifetime Ortho 2000/U80 | English (PDF, 257 KB) Spanish (PDF, 290 KB)
|
Disclosure (PDF, 747 KB) |
| SmileSM Spectrum Advantage 50/2000/Ortho/U80 | English (PDF, 257 KB) Spanish (PDF, 291 KB)
|
Disclosure (PDF, 747 KB) |
Dental HMO plans
| Plan name | Summary of Benefits | Disclosure |
|---|---|---|
| Dental HMO Basic | English (PDF, 318 KB) Spanish (PDF, 430 KB)
|
Disclosure (PDF, 745 KB) |
| Dental HMO Standard | English (PDF, 318 KB) Spanish (PDF, 430 KB)
|
Disclosure (PDF, 745 KB) |
| Dental HMO Plus | English (PDF, 318 KB) Spanish (PDF, 430 KB)
|
Disclosure (PDF, 745 KB) |
| Dental HMO Deluxe | English (PDF, 318 KB) Spanish (PDF, 430 KB)
|
Disclosure (PDF, 745 KB) |
| Dental HMO Elite 75 | English (PDF, 328 KB) Spanish (PDF, 463 KB)
|
Disclosure (PDF, 745 KB) |
| Dental HMO Elite 100 | English (PDF, 328 KB) Spanish (PDF, 463 KB)
|
Disclosure (PDF, 745 KB) |
Dental INO plans
| Plan name | Summary of Benefits | Disclosure |
|---|---|---|
| SmileSM D&P In-Network Only Dental PPO | English (PDF, 228 KB) Spanish (PDF, 224 KB)
|
Disclosure (PDF, 757 KB) |
| SmileSM Dental In-Network Only (DINO) 50/2000/Lifetime Ortho 2000 | English (PDF, 225 KB) Spanish (PDF, 247 KB)
|
Disclosure (PDF, 757 KB) |
| SmileSM Dental In-Network Only (DINO) 50/1500/Lifetime Ortho 1500 | English (PDF, 225 KB) Spanish (PDF, 246 KB)
|
Disclosure (PDF, 757 KB) |
| SmileSM Dental In-Network Only (DINO) 50/2000/No Ortho | English (PDF, 241 KB) Spanish (PDF, 241 KB)
|
Disclosure (PDF, 757 KB) |
| SmileSM Dental In-Network Only (DINO) 50/1500/No Ortho | English (PDF, 241 KB) Spanish (PDF, 241 KB)
|
Disclosure (PDF, 757 KB) |