Page 13 - Ally Office Solutions - Benefit Guide 2025

Vision Option:

HUMANA

2025 Rate — Per Pay Period (26)
Dependent Information
Per Pay-Period (26)
Ally Office Solutions offers employees the op-
Employee Cost
portunity to cover their spouse and depend-
Employee Only $ 1.33 ent children.

Employee + Spouse $ 3.34 Children can join or remain on a parent’s
dental plan until age 26. When a child turns
Employee + Child(ren) $ 3.56 26, they will lose dental coverage on the last
day of their birth month.
Employee + Family $ 6.46

Benefits (In-Network) Plan Coverage

Copays:
Well Vision Exam $10 Copay

Materials $15 Copay
Contact Lens Exam (fitting and evaluation) Up to $39 Copay
Frequency: (January 1st through December 31st)
Exams Every 12 Months

Lenses Every 12 Months
Frames Every 24 Months
Contact Lenses Every 12 Months
Standard Lenses:

Single Vision Covered in Full after Materials Copay
Lined Bifocal Covered in Full after Materials Copay
Lined Trifocal Covered in Full after Materials Copay

Standard Progressive Lenses
Premium Progressive Lenses Tier 1: $57 Copay / Tier 2: $68 Copay / Tier 3: $90 Copay
Custom Progressive Lenses Tier 4: $90 Copay + 80% of charge less $120 Allowance
Frames:

Frames Allowance $130 Retail Allowance then 20% off any balance over $130

Contact Lenses in lieu of eye glasses, materials only:

Frequency Every 12 Months
Lens Allowance $130 Retail Allowance then 15% off any balance over $130

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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