Page 13 - Ally Office Solutions - 2024 Benefit Guide

Vision Option:

Dental Select

2024 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 $10 Copay
Contact Lens Exam (fitting and evaluation) Up to $40 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 Copay
Lined Bifocal Covered in Full after Copay
Lined Trifocal Covered in Full after Copay
$75 Copay
Standard Progressive Lenses
Tier 1-3: $85 - $110 Copay
Premium Progressive Lenses
Tier 4: $65 Copay + 80% of charge lass $120 Allowance
Custom Progressive Lenses
any balance over $120
Frames:

Frames Allowance $100 Retail Allowance then 20% off any balance over $100

Contact Lenses in lieu of eye glasses, materials only:
Frequency Every 12 Months

Lens Allowance $115 Retail Allowance then 15% off any balance over $115

NOTE: This is only a brief overview. Please see Benefit Summary for more details.

Website: www.dental select.com or Customer Service : 800-999-9789
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