Summary of Benefits 2022 – Dental
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 – 2022
| Plan Names | Summaries of Benefits | Disclosures |
|---|---|---|
| Bronze DPPO/$1000/MAC | English | |
| Bronze DPPO/$1000/MAC/Child Only Ortho | English | |
| Bronze Voluntary DPPO/$1000/MAC | English | |
| Bronze Voluntary DPPO/$1000/MAC/Child Only Ortho | English | |
| Silver DPPO/$1500/MAC | English | |
| Silver DPPO/$1500/MAC/Adult+Child Ortho | English | |
| Silver DPPO/$1500/U90 | English | |
| Silver DPPO/$1500/U90/Adult+Child Ortho | English | |
| Gold DPPO/$1500/U90 | English | |
| Gold DPPO/$1500/U90/Adult+Child Ortho | English | |
| Gold DPPO/$2000/U90 | English | |
| Gold DPPO/$2000/U90/Adult+Child Ortho | English | |
| Platinum DPPO/$2500/U90 | English | |
| Platinum DPPO/$2500/U90/Adult+Child Ortho | English | |
| Platinum DPPO/$3000/U90 | English | |
| Platinum DPPO/$3000/U90/Adult+Child Ortho | English | |
| Platinum DPPO/$5000/U90 | English | |
| Platinum DPPO/$5000/U90/Adult+Child Ortho | English | |
| Diamond DPPO/$3000/U95 | English | |
| Diamond DPPO/$3000/U95/Adult+Child Ortho | English | |
| Diamond DPPO/$5000/U95 | English | |
| Diamond DPPO/$5000/U95/Adult+Child Ortho | English |
Dental HMO Plans – 2022
Closed Dental Plans – 2022: for renewing groups only
Closed Dental Plans - 2022: for renewing groups only
| Plan Names | Summaries of Benefits | Disclosures |
|---|---|---|
| SmileSM Basic 75/1000/No Ortho/Mac | English | |
| SmileSM Value 50/1500/No Ortho/MAC | English | |
| SmileSM 50/1500/No Ortho/Mac | English | |
| SmileSM Plus 50/1500/Ortho/Mac | English | |
| SmileSM Plus Gold 50/1500/Ortho/U85 | English | |
| SmileSM Deluxe 2000 50/2000/No Ortho/MAC | English | |
| SmileSM Deluxe 50/1500/Ortho/MAC | English | |
| SmileSM Deluxe Plus 2000 50/2000/Ortho/MAC | English | |
| SmileSM Deluxe Gold 50/1500/Ortho/U85 | English | |
| Ultimate Dental Plus PPO for Small Business 50/2000/Ortho/MAC | English | |
| Ultimate Dental PPO for Small Business 50/2000/No Ortho/MAC | English | |
| SmileSM Basic Voluntary 50/1000/No Ortho/MAC | English | |
| SmileSM Basic Voluntary 50/1000/No Ortho/U80 | English | |
| SmileSM Basic Voluntary 50/1500/Ortho/U80 | English | |
| SmileSM Basic 50/1000/No Ortho/MAC | English | |
| SmileSM Basic 50/1000/Ortho/U85 | English | |
| SmileSM Basic Voluntary 75/1000/No Ortho/MAC/NR | English | |
| SmileSM Basic 75/1000/No Ortho/Mac/NR | English | |
| SmileSM Value 50/1500/No Ortho/MAC/NR | English | |
| SmileSM 50/1500/No Ortho/MAC/NR | English | |
| SmileSM Plus 50/1500/No Ortho/MAC | English | |
| SmileSM Plus 50/1500/Ortho/Mac/NR | English | |
| SmileSM Plus 50/1500/No Ortho/MAC/WP | English | |
| SmileSM Plus Gold 50/1500/Ortho/U80 | English | |
| SmileSM Plus Gold 50/1500/Ortho/U80/ADV | English | |
| SmileSM Plus Gold 50/1500/No Ortho/U80 | English | |
| SmileSM Plus Gold 50/1500/Ortho/U85/NR | English | |
| SmileSM Deluxe 50/1500/Ortho/MAC/NR | English | |
| SmileSM Deluxe 2000 50/2000/No Ortho/MAC/NR | English | |
| SmileSM Deluxe Gold 50/1500/Ortho/U85/NR | English | |
| SmileSM Deluxe Plus 2000 50/2000/Ortho/MAC/NR | English | |
| Ultimate Dental PPO for Small Business 50/2000/No Ortho/MAC/NR | English | |
| Ultimate Dental PPO for Small Business 50/2000/No Ortho/U80 | English | |
| Ultimate Dental Plus PPO for Small Business 50/2000/Ortho/MAC/NR | English | |
| SmileSM Plus Gold 50/1500/Ortho/U90/ADV | English | |
| SmileSM Plus Gold 50/1500/No Ortho/U90/ADV | English | |
| SmileSM Plus Gold 50/2500/Ortho/U90/ADV | English | |
| SmileSM Plus Gold 50/2500/No Ortho/U90/ADV | English | |
| Ultimate Dental PPO for Small Business 50/2000/Lifetime Ortho/U90 | English | |
| Ultimate Dental PPO for Small Business 50/2000/No Ortho/U90 | English | |
| SmileSM Plus 50/1500/No Ortho/MAC | 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 | |
| SmileSM In-Network Only Dental Plan 50/2500/Endo-Perio 80%/No Ortho | English | |
| SmileSM In-Network Only Dental Voluntary Plan 50/2500/Endo-Perio 50%/Ortho | English | |
| SmileSM In-Network Only Dental Voluntary Plan 50/2500/Endo-Perio 50%/No Ortho | English | |
| SmileSM In-Network Only Dental Plan 50/1500/Endo-Perio 80%/Ortho | English | |
| SmileSM In-Network Only Dental Plan 50/1500/Endo-Perio 80%/No Ortho | English | |
| SmileSM In-Network Only Dental Voluntary Plan 50/1500/Endo-Perio 50%/Ortho | English | |
| SmileSM In-Network Only Dental Voluntary Plan 50/1500/Endo-Perio 50%/No Ortho | English |