Summary of Benefits 2024 – Dental

Broker resources

2023 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, 1 MB).

Dental PPO Plans – 2024

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
Bronze DPPO/$1500/MAC

English
Spanish

English
Bronze DPPO/$1500/MAC/Child Only Ortho

English
Spanish

English
Bronze Voluntary DPPO/$1500/MAC

English
Spanish

English
Bronze Voluntary DPPO/$1500/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
Gold DPPO/$1500/MAC

English
Spanish

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

English
Spanish

English
Gold DPPO/$2000/MAC

English
Spanish

English
Gold DPPO/$2000/MAC/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

 

 

Dental HMO Plans – 2024

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

Closed Dental Plans – 2024: for renewing groups only

Plan Names Summaries of Benefits Disclosures
Smile℠ 50/1500/No Ortho/MAC/NR

English
Spanish

English
Smile℠ Basic 50/1000/No Ortho/MAC

English
Spanish

English
Smile℠ Basic 75/1000/No Ortho/Mac

English
Spanish

English
Smile℠ Basic 75/1000/No Ortho/Mac/NR

English
Spanish

English
Smile℠ Basic Voluntary 50/1000/No Ortho/MAC

English
Spanish

English
Smile℠ Basic Voluntary 50/1000/No Ortho/U80

English
Spanish

English
Smile℠ Basic Voluntary 50/1500/Ortho/U80

English
Spanish

English
Smile℠ Basic Voluntary 75/1000/No Ortho/MAC

English
Spanish

English
Smile℠ Basic Voluntary 75/1000/No Ortho/MAC/NR

English
Spanish

English
Smile℠ Deluxe 50/1500/Ortho/MAC

English
Spanish

English
Smile℠ Deluxe 50/1500/Ortho/MAC/NR

English
Spanish

English
Smile℠ Deluxe Gold 50/1500/Ortho/U85

English
Spanish

English
Smile℠ Deluxe Gold 50/1500/Ortho/U85/NR

English
Spanish

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

English
Spanish

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

English
Spanish

English
Smile℠ Plus 50/1500/No Ortho/MAC/WP

English
Spanish

English
Smile℠ Plus 50/1500/Ortho/Mac

English
Spanish

English
Smile℠ Plus 50/1500/Ortho/Mac/NR

English
Spanish

English
Smile℠ Plus Gold 50/1500/Ortho/U80

English
Spanish

English
Smile℠ Plus Gold 50/2500/Ortho/U90/ADV

English
Spanish

English
Smile℠ Plus Gold 50/2500/No Ortho/U90/ADV

English
Spanish

English
Smile℠ Value 50/1500/No Ortho/MAC

English
Spanish

English
Smile℠ Value 50/1500/No Ortho/MAC/NR

English
Spanish

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

English
Spanish

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

English
Spanish

English

© California Physicians' Service DBA Blue Shield of California 1999-2024. All rights reserved. California Physicians’ Service DBA Blue Shield of California is an independent member of the Blue Shield Association. Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.

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