Page 10 - Ally Office Solutions - 2024 Benefit Guide
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Dental Option:
Dental Select
2024 Rate — Per Pay Period
Per Pay-Period (26) Dependent Information
Employee Cost
Ally Office Solutions offers employees the op-
Employee Only $ 9.25 portunity to cover their spouse and de-
Employee + Spouse $31.54 pendent children. Children can join or
remain on a parent’s dental plan until age 26.
Employee + Child(ren) $40.78 When a child turns 26, they will lose dental
Employee + Family $60.92 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
Annual Maximum $1,500 per person (Calendar Year Max)
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
Annual Maximum Applies January 1 to December 31
NOTE: This is only a brief overview. Please see Benefit Summary for more details.
Website: www.dentalselect.com or Customer Service : 800-999-9789
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