Page 10 - Ally Office Solutions - Benefit Guide 2025

Dental Option:

HUMANA

2025 Rate — Per Pay Period

Per Pay-Period (26) Dependent Information

Employee Cost
Ally Office Solutions offers employees the op-
Employee Only $ 7.78 portunity to cover their spouse and de-

Employee + Spouse $23.33 pendent children. Children can join or
remain on a parent’s dental plan until age 26.
Employee + Child(ren) $34.77 When a child turns 26, they will lose dental

Employee + Family $50.90 coverage on the last day of their birth month.

(In-Network) Amount Paid
Type of Service (Out of Network Paid at the 90th Percentile of
Routine & Customary costs)

Preventive Services Covered at 100%; No Deductible Does count toward CY Max.

Basic Services Covered at 80% after Calendar Year Deductible
Major Services Covered at 50% after Calendar Year Deductible

Calendar Year Deductible $50 Individual / $150 Family

*Extended Annual Maximum $1,500 per person (Calendar Year Max) *Extended
Orthodontic Services to age 19 $1,000 (lifetime Max) Covered at 50%

Waiting Period None

Type of Service Benefit Description

Preventive Services Oral Exams, Cleanings, X-rays, Sealants, Fluoride Treatment

Surgical Extractions/ Restorative Amalgams / Restorative Compo-
Basic Services sites / Endodontics (nonsurgical) / Periodontics (nonsurgical) / En-
dodontics (surgical) / Periodontics (surgical) / Simple Extractions

Major Services Crowns, Bridges, Dentures, Ortho

Applies January 1 to December 31 *Extended Annual Max provides
*Extended Annual Maximum additional coverage for preventive, basic and major services after the
annual max is met (excludes ortho).

NOTE: This is only a brief overview. Please see Benefit Summary for more details.
Website: www.Humana.com or Customer Service : 800-457-4708
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